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Can Alcohol Cause Ketoacidosis?

Low-carbers Beware The Breathalyzer

Low-carbers Beware The Breathalyzer

A recent article in the International Journal of Obesity should give low-carbers cause for a little alarm. Here is what happened to a man in Sweden on a low-carb diet: We report a case of a 59-year-old man, body mass index 26.6 kg/m2, who began a weight reduction program, partly because of knee pains but also because he was a glider pilot where weight is important. He used a Swedish textbook on obesity treatment written by S Rössner together with the commonly used Swedish VLCD [very low calorie diet] Nutrilett (Cederroths, Stockholm, Sweden), 5 packets/day for 3 weeks, which is an approved standard regimen. This treatment resulted in a weight loss of 7 kg. During dieting, the man discovered that an alcohol ignition interlock device, installed in an official company car, indicated that he had consumed alcohol and the vehicle failed to start. This was confusing because the man was a life-long teetotaller and was therefore both surprised and upset by the result. As he had been supervising private aviation he had access to a second breath-alcohol analyzer, which indicated a simultaneous BAC ranging from 0.01 to 0.02 g/100 ml. A VLCD diet (very-low-calorie diet, a protein-sparing modified fast) contains mainly protein along with a small amount of carbohydrate and very few calories, usually fewer than 1000 per day. Just about anyone going on one of these diets will soon be in producing ketone bodies at a pretty high rate. But the same goes for a more traditional low-carb diet as well. If carbs are kept at a low level, ketosis will occur. In fact, it’s desired. Ketone bodies are water-soluble products of fat metabolism. The body has three ways of dealing with ketones: it can burn them for energy (which it does with great success), it can release them in the urine (which is Continue reading >>

Alcoholic Ketoacidosis

Alcoholic Ketoacidosis

Ketoacidosis - alcoholic; Alcohol use - alcoholic ketoacidosis Alcoholic ketoacidosis is the buildup of ketones in the blood. Ketones are a type of acid that form when the body breaks down fat for energy. The condition is an acute form of metabolic acidosis , a condition in which there is too much acid in body fluids. Acute means sudden or severe. Acute symptoms appear, change, or worsen rapidly. It is the opposite of chronic. Metabolic acidosis is a condition in which there is too much acid in the body fluids. Alcoholic ketoacidosis is caused by very heavy alcohol use. It most often occurs in a malnourished person who drinks large amounts of alcohol every day. Malnutrition is the condition that occurs when your body does not get enough nutrients. Symptoms of alcoholic ketoacidosis include: Agitation is an unpleasant state of extreme arousal. An agitated person may feel stirred up, excited, tense, confused, or irritable. Confusion is the inability to think as clearly or quickly as you normally do. You may feel disoriented and have difficulty paying attention, remembe... Changed level of alertness, which may lead to coma Fatigue is a feeling of weariness, tiredness, or lack of energy. Hyperventilation is rapid and deep breathing. It is also called overbreathing, and it may leave you feeling breathless. Symptoms of dehydration , such as dizziness, lightheadedness, and thirst Dehydration occurs when your body does not have as much water and fluids as it should. Dehydration can be mild, moderate, or severe, based on how muc... Arterial blood gases (measures the acid/base balance and oxygen level in blood) Blood gasesare a measurement of how much oxygen and carbon dioxideare in your blood. They also determine the acidity (pH) of your blood. Blood chemistries, and liver func Continue reading >>

Ketoacidosis

Ketoacidosis

Ketoacidosis is a metabolic state associated with high concentrations of ketone bodies, formed by the breakdown of fatty acids and the deamination of amino acids. The two common ketones produced in humans are acetoacetic acid and β-hydroxybutyrate. Ketoacidosis is a pathological metabolic state marked by extreme and uncontrolled ketosis. In ketoacidosis, the body fails to adequately regulate ketone production causing such a severe accumulation of keto acids that the pH of the blood is substantially decreased. In extreme cases ketoacidosis can be fatal.[1] Ketoacidosis is most common in untreated type 1 diabetes mellitus, when the liver breaks down fat and proteins in response to a perceived need for respiratory substrate. Prolonged alcoholism may lead to alcoholic ketoacidosis. Ketoacidosis can be smelled on a person's breath. This is due to acetone, a direct by-product of the spontaneous decomposition of acetoacetic acid. It is often described as smelling like fruit or nail polish remover.[2] Ketosis may also give off an odor, but the odor is usually more subtle due to lower concentrations of acetone. Treatment consists most simply of correcting blood sugar and insulin levels, which will halt ketone production. If the severity of the case warrants more aggressive measures, intravenous sodium bicarbonate infusion can be given to raise blood pH back to an acceptable range. However, serious caution must be exercised with IV sodium bicarbonate to avoid the risk of equally life-threatening hypernatremia. Cause[edit] Three common causes of ketoacidosis are alcohol, starvation, and diabetes, resulting in alcoholic ketoacidosis, starvation ketoacidosis, and diabetic ketoacidosis respectively.[3] In diabetic ketoacidosis, a high concentration of ketone bodies is usually accomp Continue reading >>

Emergent Treatment Of Alcoholic Ketoacidosis

Emergent Treatment Of Alcoholic Ketoacidosis

Exenatide extended-release causes an increased incidence in thyroid C-cell tumors at clinically relevant exposures in rats compared to controls. It is unknown whether BYDUREON BCise causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as the human relevance of exenatide extended-release-induced rodent thyroid C-cell tumors has not been determined BYDUREON BCise is contraindicated in patients with a personal or family history of MTC or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Counsel patients regarding the potential risk of MTC with the use of BYDUREON BCise and inform them of symptoms of thyroid tumors (eg, mass in the neck, dysphagia, dyspnea, persistent hoarseness). Routine monitoring of serum calcitonin or using thyroid ultrasound is of uncertain value for detection of MTC in patients treated with BYDUREON BCise Acute Pancreatitis including fatal and non-fatal hemorrhagic or necrotizing pancreatitis has been reported. After initiation, observe patients carefully for symptoms of pancreatitis. If suspected, discontinue promptly and do not restart if confirmed. Consider other antidiabetic therapies in patients with a history of pancreatitis Acute Kidney Injury and Impairment of Renal Function Altered renal function, including increased serum creatinine, renal impairment, worsened chronic renal failure, and acute renal failure, sometimes requiring hemodialysis and kidney transplantation have been reported. Not recommended in patients with severe renal impairment or end-stage renal disease. Use caution in patients with renal transplantation or moderate renal impairment Gastrointestinal Disease Because exenatide is commonly associated with gastrointestinal adverse reactions, not recommended in patients with sev Continue reading >>

Ketoacidosis

Ketoacidosis

GENERAL ketoacidosis is a high anion gap metabolic acidosis due to an excessive blood concentration of ketone bodies (keto-anions). ketone bodies (acetoacetate, beta-hydroxybutyrate, acetone) are released into the blood from the liver when hepatic lipid metabolism has changed to a state of increased ketogenesis. a relative or absolute insulin deficiency is present in all cases. CAUSES The three major types of ketosis are: (i) Starvation ketosis (ii) Alcoholic ketoacidosis (iii) Diabetic ketoacidosis STARVATION KETOSIS when hepatic glycogen stores are exhausted (eg after 12-24 hours of total fasting), the liver produces ketones to provide an energy substrate for peripheral tissues. ketoacidosis can appear after an overnight fast but it typically requires 3 to 14 days of starvation to reach maximal severity. typical keto-anion levels are only 1 to 2 mmol/l and this will usually not alter the anion gap. the acidosis even with quite prolonged fasting is only ever of mild to moderate severity with keto-anion levels up to a maximum of 3 to 5 mmol/l and plasma pH down to 7.3. ketone bodies also stimulate some insulin release from the islets. patients are usually not diabetic. ALCOHOLIC KETOSIS Presentation a chronic alcoholic who has a binge, then stops drinking and has little or no oral food intake for a few days (ethanol and fasting) volume depletion is common and this can result in increased levels of counter regulatory hormones (eg glucagon) levels of free fatty acids (FFA) can be high (eg up to 3.5mM) providing plenty of substrate for the altered hepatic lipid metabolism to produce plenty of ketoanions GI symptoms are common (eg nausea, vomiting, abdominal pain, haematemesis, melaena) acidaemia may be severe (eg pH down to 7.0) plasma glucose may be depressed or normal or Continue reading >>

Alcoholic Ketoacidosis

Alcoholic Ketoacidosis

Alcoholic ketoacidosis is a metabolic complication of alcohol use and starvation characterized by hyperketonemia and anion gap metabolic acidosis without significant hyperglycemia. Alcoholic ketoacidosis causes nausea, vomiting, and abdominal pain. Diagnosis is by history and findings of ketoacidosis without hyperglycemia. Treatment is IV saline solution and dextrose infusion. Alcoholic ketoacidosis is attributed to the combined effects of alcohol and starvation on glucose metabolism. Alcohol diminishes hepatic gluconeogenesis and leads to decreased insulin secretion, increased lipolysis, impaired fatty acid oxidation, and subsequent ketogenesis, causing an elevated anion gap metabolic acidosis. Counter-regulatory hormones are increased and may further inhibit insulin secretion. Plasma glucose levels are usually low or normal, but mild hyperglycemia sometimes occurs. Diagnosis requires a high index of suspicion; similar symptoms in an alcoholic patient may result from acute pancreatitis, methanol or ethylene glycol poisoning, or diabetic ketoacidosis (DKA). In patients suspected of having alcoholic ketoacidosis, serum electrolytes (including magnesium), BUN and creatinine, glucose, ketones, amylase, lipase, and plasma osmolality should be measured. Urine should be tested for ketones. Patients who appear significantly ill and those with positive ketones should have arterial blood gas and serum lactate measurement. The absence of hyperglycemia makes DKA improbable. Those with mild hyperglycemia may have underlying diabetes mellitus, which may be recognized by elevated levels of glycosylated Hb (HbA1c). Typical laboratory findings include a high anion gap metabolic acidosis, ketonemia, and low levels of potassium, magnesium, and phosphorus. Detection of acidosis may be com Continue reading >>

Metabolic Acidosis

Metabolic Acidosis

Patient professional reference Professional Reference articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use. You may find one of our health articles more useful. See also separate Lactic Acidosis and Arterial Blood Gases - Indications and Interpretations articles. Description Metabolic acidosis is defined as an arterial blood pH <7.35 with plasma bicarbonate <22 mmol/L. Respiratory compensation occurs normally immediately, unless there is respiratory pathology. Pure metabolic acidosis is a term used to describe when there is not another primary acid-base derangement - ie there is not a mixed acid-base disorder. Compensation may be partial (very early in time course, limited by other acid-base derangements, or the acidosis exceeds the maximum compensation possible) or full. The Winter formula can be helpful here - the formula allows calculation of the expected compensating pCO2: If the measured pCO2 is >expected pCO2 then additional respiratory acidosis may also be present. It is important to remember that metabolic acidosis is not a diagnosis; rather, it is a metabolic derangement that indicates underlying disease(s) as a cause. Determination of the underlying cause is the key to correcting the acidosis and administering appropriate therapy[1]. Epidemiology It is relatively common, particularly among acutely unwell/critical care patients. There are no reliable figures for its overall incidence or prevalence in the population at large. Causes of metabolic acidosis There are many causes. They can be classified according to their pathophysiological origin, as below. The table is not exhaustive but lists those that are most common or clinically important to detect. Increased acid Continue reading >>

Help Me - Alcoholic Ketoacidosis?

Help Me - Alcoholic Ketoacidosis?

I have fried my brain today trying to figure out this concept and have had no luck. I am hoping to get some clarity from anyone here on the forum. In alcoholics, there is an increase in NADH (metabolism of ethanol puts out NADH), causing the following: - inhibition of pyruvate hydrogenase thus an increase in lactate - inhibition of gluconeogenis (OAA gets converted to malate) - increase in Glycerol 3 phosphate from DHAP A high NADH state also favors an increase in glycerol 3 phosphate. This can therefore cause inappropriate fatty acids to be stored in the liver. Also, when ethanol is metabolized from acetate it turns into Acetyl Co causing it to favor more fatty acid synthesis resulting in fatty liver over time. Finally, high NADH states will also inhibit fatty acid B-oxidation via various mechanisms that we do not need to be concerned about. Up until here I am able to understand this. However, the part that confuses me is what causes alcoholic ketoacidosis? Here is my problem that I cant seem to wrap my head about. In a non-alcoholic person, low levels of energy will trigger Ketone bodies synthesis by the break down of fatty acids via B-oxidation. The acetyl- CoA has two pathways it can traveleither make ketone bodies or enter into the TCA cycle. Both yielding energy that the body can use during periods of fasting. But in an alcoholic, the B-oxidation of fatty acids is inhibited. So how do alcoholics get ketoacidosis? Or do they? How is it possible to have ketoacidosis when the B-oxidation of Fatty acids is inhibited? I dont know if Im confusing myself.or if I made any sense. I have searched online and all I get is that alcoholic ketoacidosis is due to the low energy state (hypoglycemia) and then on other websites it says that the increase in NADH will inhibit B-oxida Continue reading >>

How To Avoid Diabetic Ketoacidosis

How To Avoid Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is a possible complication of diabetes caused by extreme hyperglycemia, or high blood glucose. It is a serious and potentially life-threatening complication, one that you should work hard to avoid when you have diabetes. Diabetic ketoacidosis mainly affects people with type 1 diabetes, but it is a very rare possible complication for people with type 2 diabetes. Your doctor and certified diabetes educator will teach you how to recognize and manage diabetic ketoacidosis. It's critical to know and recognize the signs and symptoms of DKA, as well as how to treat it. What Is Diabetic Ketoacidosis? Diabetic ketoacidosis happens when your blood glucose level gets too high—usually higher than 300 mg/dL. Because people with type 1 diabetes do not have the insulin to process this extra glucose, their body cannot break down this glucose to create energy. To create energy for itself, the body starts to aggressively break down fat. Ketones or ketoacids are a byproduct of this process. Your body can handle a small amount of ketones circulating in your blood. However, the sizeable amounts from DKA are toxic. Diabetic Ketoacidosis Causes Illness, infections, stress, injuries, neglecting diabetes care (not properly taking your insulin, for example), and alcohol consumption can cause DKA. Diabetic Ketoacidosis Symptoms Initial symptoms of DKA include a stomach ache, nausea, and vomiting. One problem with DKA is that people could mistake it for an illness that typically gets better over time like the flu or food poisoning. Other symptoms of diabetic ketoacidosis include: fruity breath (when fat is broken down by the body, it creates a chemical called acetone that smells fruity) fatigue frequent urination intense thirst headache If you feel any of these sympto Continue reading >>

Alcoholic Ketoacidosis

Alcoholic Ketoacidosis

Workup When a chronic alcoholic presents with signs of AKA, the clinician should carefully evaluate the patient, obtain a history, perform a physical exam, and order the appropriate laboratory tests. Laboratory tests and results A comprehensive metabolic profile will allow the medical team to determine the overall clinical picture of the patient. This includes measurement of serum electrolytes, glucose, blood urea nitrogen (BUN), creatinine, lipase, amylase, and plasma osmolality. Also, urinalysis is helpful to detect ketones. Another useful tool is the blood alcohol level [8]. Finally, critically ill patients with positive ketones must have an analysis of their arterial blood gas (ABG) and serum lactate levels. With regards to expected findings, all patients demonstrate ketonuria and a majority display ketonemia. Also common are electrolyte imbalances such as hypokalemia, hyponatremia, hypophosphatemia, and hypomagnesemia. Additionally, the serum glucose may range from low to modest elevation while another abnormality is an increased osmolar gap (secondary to increased acetone and possibly ethanol). Most importantly, AKA is typically characterized by a high anion gap metabolic acidosis, which may be complicated by metabolic alkalosis secondary to concurrent vomiting. In cases where the pH is normal, the increased anion gap is an indicator of ketoacidosis. If there is a normal gap, this is the result of the excretion of ketoacid ions. Additionally, lactic acidosis is observed in more than 50% of cases due to hypoperfusion [9]. Differential diagnoses Differentials include diabetic ketoacidosis (DKA),however, the absence of hyperglycemia excludes this. Pancreatitis may also present similar to AKA and should be ruled out. If alcohol intoxication is not conclusive, serum me Continue reading >>

Alcoholic Ketoacidosis

Alcoholic Ketoacidosis

Increased production of ketone bodies due to: Dehydration (nausea/vomiting, ADH inhibition) leads to increased stress hormone production leading to ketone formation Depleted glycogen stores in the liver (malnutrition/decrease carbohydrate intake) Elevated ratio of NADH/NAD due to ethanol metabolism Increased free fatty acid production Elevated NADH/NAD ratio leads to the predominate production of β–hydroxybutyrate (BHB) over acetoacetate (AcAc) Dehydration Fever absent unless there is an underlying infection Tachycardia (common) due to: Dehydration with associated orthostatic changes Concurrent alcohol withdrawal Tachypnea: Common Deep, rapid, Kussmaul respirations frequently present Nausea and vomiting Abdominal pain (nausea, vomiting, and abdominal pain are the most common symptoms): Usually diffuse with nonspecific tenderness Epigastric pain common Rebound tenderness, abdominal distension, hypoactive bowel sounds uncommon Mandates a search for an alternative, coexistent illness Decreased urinary output from hypovolemia Mental status: Minimally altered as a result of hypovolemia and possibly intoxication Altered mental status mandates a search for other associated conditions such as: Head injury, cerebrovascular accident (CVA), or intracranial hemorrhage Hypoglycemia Alcohol withdrawal Encephalopathy Toxins Visual disturbances: Reports of isolated visual disturbances with AKA common History Chronic alcohol use: Recent binge Abrupt cessation Physical Exam Findings of dehydration most common May have ketotic odor Kussmaul respirations Palmar erythema (alcoholism) Lab Acid–base disturbance: Increased anion gap metabolic acidosis hallmark Mixed acid–base disturbance common: Respiratory alkalosis Metabolic alkalosis secondary to vomiting and dehydration Hyperchlorem Continue reading >>

Ketosis And Alcohol

Ketosis And Alcohol

When it comes to the ketogenic lifestyle, there are lots of confusing and conflicting opinions floating around, and they can lead to all kinds of mistakes. One of those confusing areas is how alcohol fits into a ketogenic lifestyle. Hopefully, after you read this, you’ll have a pretty good understanding and some tools to use to make informed decisions along the way. First off, not all alcoholic beverages are the same. Alcohol is the same across the board; it’s a macronutrient with seven calories per gram, so that’s the starting point. It’s a byproduct of fermentation. Essentially, a sugar compound is acted upon by yeast and the yeast produces alcohol and carbon dioxide. Depending on the type of sugar compound, you get different kinds of alcoholic beverages. Hard liquor, or spirits, takes the process a little further and adds distillation. That is, essentially, the process of “boiling off” the alcohol and then re-condensing (as it cools) it into more a more concentrated form. When you something marketed as “Distilled 9 times”, that just means they went through the boiling and condensing process nine times. Okay, so that’s where alcohol comes from, but that’s not all there is to it. Like said, the type of sugar compound determines the type of alcohol. For example, beer is made with, basically four ingredients. Barley, hops, water, and yeast. Barley is the primary ingredient, it’s where the sugar (maltose) comes from for the yeast. It’s also very similar to wheat. It’s a very bad carb. And it’s the reason that some people call beer “liquid bread”. It is far too rich in carbohydrates, not just the sugars, but the other “glutenous carbs”. So it’s a definite no for Ketovangelists. Beer does not fit into a ketogenic lifestyle. (Sidenote: A Continue reading >>

Alcoholic Ketoacidosis: Causes, Symptoms, Treatment, Prognosis

Alcoholic Ketoacidosis: Causes, Symptoms, Treatment, Prognosis

Ketoacidosis is a medical condition in which the food that is ingested by an individual is either metabolized or converted into acid. Alcoholic Ketoacidosis is a condition in which there is development of Ketoacidosis as a result of excessive alcohol intake for a long period of time and less ingestion of food resulting in malnutrition. Drinking excessive alcohol causes the individual to be able to eat less food. Additionally, if excess alcohol is ingested then it may lead to vomiting which further worsens the nutritional status of the individual which results in formation of excess acids resulting in Alcoholic Ketoacidosis. The symptoms caused by Alcoholic Ketoacidosis include abdominal pain, excessive fatigue, persistent vomiting, and the individual getting dehydrated due to frequent vomiting episodes and less fluid intake. If an individual has a history of alcohol abuse and experiences the above mentioned symptoms then it is advised that the individual goes to the nearest emergency room to get evaluated and if diagnosed treated for Alcoholic Ketoacidosis. As stated above, the root cause of Alcoholic Ketoacidosis is drinking excessive amounts of alcohol for a prolonged period of time. When an individual indulges in binge drinking he or she is not able to take in enough food that is required by the body to function. This eventually results in malnourishment. Additionally, vomiting caused by excessive drinking also results in loss of vital nutrients and electrolytes from the body such that the body is not able to function normally. This results in the insulin that is being produced by the body becoming less and less. All of these ultimately results in the development of Alcoholic Ketoacidosis. An individual may develop symptoms within a day after binge drinking, dependin Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Print Overview Diabetic ketoacidosis is a serious complication of diabetes that occurs when your body produces high levels of blood acids called ketones. The condition develops when your body can't produce enough insulin. Insulin normally plays a key role in helping sugar (glucose) — a major source of energy for your muscles and other tissues — enter your cells. Without enough insulin, your body begins to break down fat as fuel. This process produces a buildup of acids in the bloodstream called ketones, eventually leading to diabetic ketoacidosis if untreated. If you have diabetes or you're at risk of diabetes, learn the warning signs of diabetic ketoacidosis — and know when to seek emergency care. Symptoms Diabetic ketoacidosis signs and symptoms often develop quickly, sometimes within 24 hours. For some, these signs and symptoms may be the first indication of having diabetes. You may notice: Excessive thirst Frequent urination Nausea and vomiting Abdominal pain Weakness or fatigue Shortness of breath Fruity-scented breath Confusion More-specific signs of diabetic ketoacidosis — which can be detected through home blood and urine testing kits — include: High blood sugar level (hyperglycemia) High ketone levels in your urine When to see a doctor If you feel ill or stressed or you've had a recent illness or injury, check your blood sugar level often. You might also try an over-the-counter urine ketones testing kit. Contact your doctor immediately if: You're vomiting and unable to tolerate food or liquid Your blood sugar level is higher than your target range and doesn't respond to home treatment Your urine ketone level is moderate or high Seek emergency care if: Your blood sugar level is consistently higher than 300 milligrams per deciliter (mg/dL), or 16.7 mill Continue reading >>

Emdocs.net Emergency Medicine Educationtoxcards: Alcoholic Ketoacidosis - Emdocs.net - Emergency Medicine Education

Emdocs.net Emergency Medicine Educationtoxcards: Alcoholic Ketoacidosis - Emdocs.net - Emergency Medicine Education

Author: Cynthia Santos, MD (Senior Medical Toxicology Fellow, Emory University School of Medicine) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit) A 45 year old male presents intoxicated, smelling of alcohol and appears disheveled with vomit on his clothes. He is sleepy but arousable to noxious stimuli. His serum ethanol level is 143 mg/dL. Na 135, K 3.9, Cl 97, CO2 20, BUN 33, Cr 1.1. Lactate 3.1. pH 7.35, CO2 28, HCO3 15. His urine is negative for ketones. His vitals are HR 103, RR 30, BP 115/65, O2 98% RA. Could these laboratory results be consistent with alcohol ketoacidosis (AKA)? The classic laboratory findings in patients with AKA include an elevated anion gap metabolic acidosis and an elevated lactate. Early in AKA patients may be negative for ketones when the nitroprusside test is used because it does not detect beta-hydroxybutyrate. As patients recover, the nitroprusside test will become positive as beta-hydroxybutyrate gets converted to acetone and acetate. Patients with AKA typically have elevated anion gap metabolic acidosis. However, vomiting may cause a primary metabolic alkalosis and a compensatory respiratory alkalosis which may result in a normal or even elevated pH. AKA patients, as compared to DKA patients, typically have higher pH, lower K and Cl, and higher HCO3 in their blood tests. As ethanol is metabolized by ADH and ALDH to acetaldehyde and acetate, respectively, an increased amount of NADH forms which causes a high redox state and excess of reducing potential (increased NADH:NAD+ ratio). Increased lactate due to pyruvate shunting: Reduced caloric intake, decreased glycogen stores, and thiamine depletion results in amino acids being c Continue reading >>

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