From the Guidelines
The presence of 2+ ketones in urine along with hyperglycemia in an elderly patient indicates a high risk of diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar state (HHS), and requires immediate medical attention. The significance of ketonuria with a level of 2+ in an elderly patient with hyperglycemia is a critical indicator of potential diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar state (HHS), both of which are life-threatening conditions if not promptly managed 1.
Key Considerations
- DKA is characterized by the presence of ketones in the urine or blood, hyperglycemia, and metabolic acidosis, and its management involves IV fluids, insulin therapy, and electrolyte replacement 1.
- The presence of ketones in the urine, as indicated by a level of 2+, is a significant finding that warrants further evaluation and immediate intervention to prevent complications of DKA or HHS.
- Elderly patients are at increased risk of complications from DKA or HHS due to age-related changes, comorbidities, and polypharmacy, and require careful monitoring and management 1.
Management Approach
- Treatment should involve IV fluids, insulin therapy, and electrolyte replacement, with careful monitoring of blood glucose, electrolytes, and fluid status.
- The use of specific measurement of b-hydroxybutyrate in blood is recommended for diagnosis and monitoring of DKA 1.
- Blood ketone determinations that rely on the nitroprusside reaction should not be used to monitor treatment of DKA 1.
Prioritizing Morbidity, Mortality, and Quality of Life
- The management approach should prioritize the prevention of complications, such as fluid overload, electrolyte imbalances, and hyping glycemia, to minimize morbidity and mortality.
- The goal of treatment is to rapidly correct hyperglycemia, metabolic acidosis, and fluid and electrolyte imbalances, while minimizing the risk of complications and improving quality of life.
From the Research
Significance of Ketonuria in Elderly Patients with Hyperglycemia
The presence of ketones in urine, also known as ketonuria, is a significant indicator of diabetic ketoacidosis (DKA) in patients with hyperglycemia. A level of 2+ in an elderly patient with hyperglycemia may indicate a high risk of DKA, which is a life-threatening condition if left untreated 2.
Diagnosis and Management of DKA
DKA is characterized by the presence of high urinary or blood ketoacids, elevated blood glucose levels, and a high anion gap metabolic acidosis 2. The mainstays of treatment include restoration of circulating volume, insulin therapy, electrolyte replacement, and treatment of any underlying precipitating event 2. Early diagnosis and management are crucial to improve patient outcomes.
Ketone Body Kinetics in DKA
The hyperglycemia and hyperketonemia of DKA are initiated primarily by overproduction of these substrates, and subsequent maintenance of hyperglycemia occurs due to impaired utilization of glucose, whereas overproduction of ketone bodies continues to be the major mechanism for maintenance of hyperketonemia 3. Insulin deficiency results in increased rates of lipolysis and provides increased substrate for ketogenesis.
Urine Ketone Dip Test as a Screen for Ketonemia
The urine ketone dip test (UKDT) is a highly sensitive test for the detection of ketonemia in patients with DKA and diabetic ketosis, with a sensitivity of 97% (95% CI, 94% to 99%) 4. However, the test may not detect the most prevalent ketone body moiety, 3beta-hydroxybutyrate (3HB), which is in equilibrium with acetoacetate (up to 10:1 ratio) 5.
Blood Ketone Body Evaluation
Blood 3HB evaluation is a better indicator of metabolic control compared to urine KB detection and is useful to predict the time required for blood KB clearing 5. Further studies are needed to assess its use in the early detection and management of DKA.
Key Points
- Ketonuria is a significant indicator of DKA in patients with hyperglycemia 2.
- DKA is characterized by the presence of high urinary or blood ketoacids, elevated blood glucose levels, and a high anion gap metabolic acidosis 2.
- The UKDT is a highly sensitive test for the detection of ketonemia in patients with DKA and diabetic ketosis 4.
- Blood 3HB evaluation is a better indicator of metabolic control compared to urine KB detection 5.