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How Are Ketones Produced In Dka?

Ketones — The 6 Must-knows

Ketones — The 6 Must-knows

WRITTEN BY: Kyla Schmieg, BSN, RN Editor’s Note: Kyla Schmieg (BSN, RN) is a practicing pediatric endocrinology nurse in Cincinnati, OH, USA, and Type 1 Diabetic, working on the same unit she was diagnosed at 26 years ago. 1 – What are ketones? Ketones are chemicals that build up when your body starts to burn fat for energy. The most common cause of ketones in diabetics is insulin deficiency. Without enough insulin, glucose builds up in the blood stream and can’t enter cells. The cells then burn fat instead of glucose. This results in ketones forming in the blood and eventually spilling into urine. 2 – Why can ketones be dangerous? Having ketones can indicate that your body needs more insulin. (Always monitor your blood sugar levels to know how much insulin you need.) If you have a build up of ketones, this can lead to Diabetic Ketoacidosis (DKA). Signs of DKA include moderate or large ketones, nausea, vomiting, abdominal pain, fruity or acetone (think nail polish remover) breath, rapid breathing, flushed skin, and lack of energy. If left untreated, it can lead to a serious and life-threatening diabetic coma or death. High levels of ketones are toxic to the body and if you’re experiencing these, you should seek out medical attention. 3 – When should you check for ketones? You should be checked anytime your blood sugar is above 240 mg/dl (13.3 mmol/l) or any time you are sick. This includes any minor illness such as a cold. 4 – Can you get ketones with a high blood sugar? Ketones typically accompany high blood sugar. They indicate that your body needs more insulin. Most often if your body needs more insulin, it means you probably have a high blood sugar. Also, when an illness is present, your body releases hormones in response to the stress. These hormones Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Diabetic Ketoacidosis Definition Diabetic ketoacidosis is a dangerous complication of diabetes mellitus in which the chemical balance of the body becomes far too acidic. Description Diabetic ketoacidosis (DKA) always results from a severe insulin deficiency. Insulin is the hormone secreted by the body to lower the blood sugar levels when they become too high. Diabetes mellitus is the disease resulting from the inability of the body to produce or respond properly to insulin, required by the body to convert glucose to energy. In childhood diabetes, DKA complications represent the leading cause of death, mostly due to the accumulation of abnormally large amounts of fluid in the brain (cerebral edema). DKA combines three major features: hyperglycemia, meaning excessively high blood sugar kevels; hyperketonemia, meaning an overproduction of ketones by the body; and acidosis, meaning that the blood has become too acidic. Insulin deficiency is responsible for all three conditions: the body glucose goes largely unused since most cells are unable to transport glucose into the cell without the presence of insulin; this condition makes the body use stored fat as an alternative source instead of the unavailable glucose for energy, a process that produces acidic ketones, which build up because they require insulin to be broken down. The presence of excess ketones in the bloodstream in turn causes the blood to become more acidic than the body tissues, which creates a toxic condition. Causes and symptoms DKA is most commonly seen in individuals with type I diabetes, under 19 years of age and is usually caused by the interruption of their insulin treatment or by acute infection or trauma. A small number of people with type II diabetes also experience ketoacidosis, but this is rare give 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 >>

Understanding The Presentation Of Diabetic Ketoacidosis

Understanding The Presentation Of Diabetic Ketoacidosis

Hypoglycemia, diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar nonketotic syndrome (HHNS) must be considered while forming a differential diagnosis when assessing and managing a patient with an altered mental status. This is especially true if the patient has a history of diabetes mellitus (DM). However, be aware that the onset of DKA or HHNS may be the first sign of DM in a patient with no known history. Thus, it is imperative to obtain a blood glucose reading on any patient with an altered mental status, especially if the patient appears to be dehydrated, regardless of a positive or negative history of DM. In addition to the blood glucose reading, the history — particularly onset — and physical assessment findings will contribute to the formulation of a differential diagnosis and the appropriate emergency management of the patient. Pathophysiology of DKA The patient experiencing DKA presents significantly different from one who is hypoglycemic. This is due to the variation in the pathology of the condition. Like hypoglycemia, by understanding the basic pathophysiology of DKA, there is no need to memorize signs and symptoms in order to recognize and differentiate between hypoglycemia and DKA. Unlike hypoglycemia, where the insulin level is in excess and the blood glucose level is extremely low, DKA is associated with a relative or absolute insulin deficiency and a severely elevated blood glucose level, typically greater than 300 mg/dL. Due to the lack of insulin, tissue such as muscle, fat and the liver are unable to take up glucose. Even though the blood has an extremely elevated amount of circulating glucose, the cells are basically starving. Because the blood brain barrier does not require insulin for glucose to diffuse across, the brain cells are rece Continue reading >>

Diabetic, Alcoholic And Starvation Ketoacidosis

Diabetic, Alcoholic And Starvation Ketoacidosis

Copious amounts of ketones which are generated in insulin-deficient or insulin-unresponsive patients will give rise to a high anion gap metabolic acidosis. Ketones are anions, and they form the high anion gap. Management of DKA and HONK is discussed elsewhere. Meet the ketones Chemically speaking, a ketone is anything with a carbonyl group between a bunch of other carbon atoms. The above are your three typical ketoacidosis-associated ketone bodies. The biochemistry nerds among us will hasten to add that the beta-hydroxybutyrate is in fact not a ketone but a carboxylic acid, but - because it is associated with ketoacidosis, we will continue to refer to it as a ketone for the remainder of this chapter, in the spirit of convention. In the same spirit, we can suspend our objections to acetone being included in a discussion of ketoacidosis, which (though a true ketone) is in fact not acidic or basic, as it does not ionise at physiological pH (its pKa is 20 or so). So really, the only serious ketone acid is acetoacetate, which has a pKa of 3.77. However, beta-hydroxybutyrate is the prevalent ketone in ketoacidosis; the normal ratio of beta-hydroxybutyrate and acetoacetate is 3:1, and it can rise to 10:1 in diabetic ketoacidosis. Acetone is the least abundant. The metabolic origin of ketones The generation of ketones is a normal response to fasting, which follows the depletion of hepatic glycogen stores. Let us discuss normal physiology for a change. You, a healthy adult without serious alcohol problems, are fasting from midnight for a routine elective hernia repair. You will go to be after dinner with a few nice lumps of undigested food in your intestine, as well as about 75g of hepatic glycogen. As you sleep, you gradually digest the food and dip into the glycogen store. At Continue reading >>

Hyperglycemia Dka (ketoacidosis) & Ketones - Danii Foundation

Hyperglycemia Dka (ketoacidosis) & Ketones - Danii Foundation

Hyperglycemia DKA (Ketoacidosis) & Ketones Diabetic ketoacidosis (DKA) is a serious condition that can lead to diabetic coma (passing out for a long time) or even death. When your cells dont get the glucose they need for energy, your body begins to burn fat for energy, which produces ketones. Ketones are chemicals that the body creates when it breaks down fat to use for energy. The body does this when it doesnt have enough insulin to use glucose, the bodys normal source of energy. When ketones build up in the blood, they make it more acidic. They are a warning sign that your diabetes is out of control or that you are getting sick. High levels of ketones can poison the body. When levels get too high, you can develop DKA. DKA may happen to anyone with diabetes, though it is rare in people with type 2. Treatment for DKA usually takes place in the hospital. But you can help prevent it by learning the warning signs and checking your urine and blood regularly. DKA usually develops slowly. But when vomiting occurs, this life-threatening condition can develop in a few hours. Early symptoms include the following: Nausea, vomiting, or abdominal pain (Vomiting can be caused by many illnesses, not just ketoacidosis. If vomiting continues for more than 2 hours, contact your health care provider.) A hard time paying attention, or confusion Ketoacidosis (DKA) is dangerous and serious. If you have any of the above symptoms, contact your health care provider IMMEDIATELY, or go to the nearest emergency room of your local hospital. You can detect ketones with a simple urine test using a test strip, similar to a blood testing strip. Ask your health care provider when and how you should test for ketones. Many experts advise to check your urine for ketones when your blood glucose is more th Continue reading >>

Hyperglycaemic Crises And Lactic Acidosis In Diabetes Mellitus

Hyperglycaemic Crises And Lactic Acidosis In Diabetes Mellitus

Hyperglycaemic crises are discussed together followed by a separate section on lactic acidosis. DIABETIC KETOACIDOSIS (DKA) AND HYPERGLYCAEMIC HYPEROSMOLAR STATE (HHS) Definitions DKA has no universally agreed definition. Alberti proposed the working definition of “severe uncontrolled diabetes requiring emergency treatment with insulin and intravenous fluids and with a blood ketone body concentration of >5 mmol/l”.1 Given the limited availability of blood ketone body assays, a more pragmatic definition comprising a metabolic acidosis (pH <7.3), plasma bicarbonate <15 mmol/l, plasma glucose >13.9 mmol/l, and urine ketostix reaction ++ or plasma ketostix ⩾ + may be more workable in clinical practice.2 Classifying the severity of diabetic ketoacidosis is desirable, since it may assist in determining the management and monitoring of the patient. Such a classification is based on the severity of acidosis (table 1). A caveat to this approach is that the presence of an intercurrent illness, that may not necessarily affect the level of acidosis, may markedly affect outcome: a recent study showed that the two most important factors predicting mortality in DKA were severe intercurrent illness and pH <7.0.3 HHS replaces the older terms, “hyperglycaemic hyperosmolar non-ketotic coma” and “hyperglycaemic hyperosmolar non-ketotic state”, because alterations of sensoria may be present without coma, and mild to moderate ketosis is commonly present in this state.4,5 Definitions vary according to the degree of hyperglycaemia and elevation of osmolality required. Table 1 summarises the definition of Kitabchi et al.5 Epidemiology The annual incidence of DKA among subjects with type 1 diabetes is between 1% and 5% in European and American series6–10 and this incidence appear Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Diabetic Ketoacidosis (DKA) is a serious condition that can be life threatening. It most commonly occurs when a diagnosis of Type 1 diabetes is first made. It can occur when a person with known Type 1 diabetes becomes unwell or has very high blood glucose levels (BGLs) resulting from a lack of insulin. It can even occur in the presence of normal glucose levels in children and young people with known diabetes. Type 1 diabetes is the most common form of diabetes affecting children and adolescents in Australia. The condition occurs when the body does not have enough insulin (a hormone which helps glucose move from the blood into the cells). Insulin is also responsible for controlling the level of glucose in the blood. Without insulin, glucose levels will build up in the blood. Type 1 diabetes is treated by replacing the body’s missing insulin, with injectable insulin. Some of the signs and symptoms of Type 1 diabetes include nausea, vomiting and/or abdominal pain, dehydration, deep breathing or breathlessness, extreme drowsiness and/or a fruity odour to the breath. What causes DKA? DKA occurs when there is an accumulation of toxic substances called ketones. Ketones are produced when there is not enough insulin in the body. Glucose cannot enter the cells to provide energy which results in a breakdown of fat as an energy source which then results in ketones being produced. Ketones are a form of pollution in the blood. They make the blood too acidic and this can result in the person becoming seriously unwell very quickly. This condition requires immediate medical management. Managing Type 1 diabetes Everyday illnesses, infection, or missed doses of insulin will nearly always cause a rise in BGLs in someone with Type 1 diabetes. Therefore, at the earliest sign of any form of Continue reading >>

Diabetic Ketoacidosis (dka)

Diabetic Ketoacidosis (dka)

Also see Pet Diabetes Wiki: Ketoacidosis A Ketone Primer by an FDMB user What are Ketones? Ketones or ketone bodies (acetone, acetoacetic acid, and beta-hydroxybutyric acid) are waste products of fatty acid breakdown in the body. This is the result of burning fat, rather than glucose, to fuel the body. The body tries to dispose of excess ketones as quickly as possible when they are present in the blood. The kidneys filter out ketones and excrete them into the urine. Should you care about ketones? YES! If they build up, they can lead to very serious energy problems in the body, resulting in diabetic ketoacidosis, a true medical emergency. If the condition is not reversed and other systemic stresses are present, ketones may continue to rise and a condition known as diabetic ketoacidosis (DKA) may occur. This condition can progress very quickly and cause severe illness. It is potentially fatal even when treated. Recognition of DKA and rapid treatment by your veterinarian can save your cat's life. Signs of Diabetic Ketoacidosis (DKA) Drinking excessive amounts of water OR no water Excessive urination Diminished activity Not eating for over 12 hours Vomiting Lethargy and depression Weakness Breathing very fast Dehydration Ketone odor on breath (smells like nail-polish remover or fruit) Causes of Diabetic Ketoacidosis (DKA) Insulin dependent diabetes mellitus Inadequate insulin dosing or production Infection Concurrent diseas that stresses the animal Estrus Medication noncompliance Lethargy and depression Stress Surgery Idiopathic (unknown causes) Risk Factors for DKA Any condition that causes an insulin deficiency History of corticosteroid or beta-blocker administration Diagnosis Laboratory tests performed by your vet are necessary for diagnosis. Depending on how sick your c Continue reading >>

Ketone Testing: What You Need To Know

Ketone Testing: What You Need To Know

What are ketones? Ketones are produced when the body burns fat for energy or fuel. They are also produced when you lose weight or if there is not enough insulin to help your body use sugar for energy. Without enough insulin, glucose builds up in the blood. Since the body is unable to use glucose for energy, it breaks down fat instead. When this occurs, ketones form in the blood and spill into the urine. These ketones can make you very sick. How can I test for ketones? You can test to see if your body is making any ketones by doing a simple urine test. There are several products available for ketone testing and they can be purchased, without a prescription, at your pharmacy. The test result can be negative, or show small, moderate, or large quantities of ketones. When should I test for ketones? Anytime your blood glucose is over 250 mg/dl for two tests in a row. When you are ill. Often illness, infections, or injuries will cause sudden high blood glucose and this is an especially important time to check for ketones. When you are planning to exercise and the blood glucose is over 250 mg/dl. If you are pregnant, you should test for ketones each morning before breakfast and any time the blood glucose is over 250 mg/dl. If ketones are positive, what does this mean? There are situations when you might have ketones without the blood glucose being too high. Positive ketones are not a problem when blood glucose levels are within range and you are trying to lose weight. It is a problem if blood glucose levels are high and left untreated. Untreated high blood glucose with positive ketones can lead to a life-threatening condition called diabetic ketoacidosis (DKA). What should I do if the ketone test is positive? Call your diabetes educator or physician, as you may need additional Continue reading >>

Breath Ketone Testing: A New Biomarker For Diagnosis And Therapeutic Monitoring Of Diabetic Ketosis

Breath Ketone Testing: A New Biomarker For Diagnosis And Therapeutic Monitoring Of Diabetic Ketosis

BioMed Research International Volume 2014 (2014), Article ID 869186, 5 pages 1Department of Endocrinology, The Second Hospital of Jilin University, 218 Ziqiang Road, Changchun, Jilin 130041, China 2Research Center of Analytical Instrumentation, Analytical & Testing Center, Sichuan University, 29 Wangjiang Road, Chengdu 610064, China Academic Editor: Cheng Hu Copyright © 2014 Yue Qiao et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. Acetone, β-hydroxybutyric acid, and acetoacetic acid are three types of ketone body that may be found in the breath, blood, and urine. Detecting altered concentrations of ketones in the breath, blood, and urine is crucial for the diagnosis and treatment of diabetic ketosis. The aim of this study was to evaluate the advantages of different detection methods for ketones, and to establish whether detection of the concentration of ketones in the breath is an effective and practical technique. Methods. We measured the concentrations of acetone in the breath using gas chromatography-mass spectrometry and β-hydroxybutyrate in fingertip blood collected from 99 patients with diabetes assigned to groups 1 (−), 2 (±), 3 (+), 4 (++), or 5 (+++) according to urinary ketone concentrations. Results. There were strong relationships between fasting blood glucose, age, and diabetic ketosis. Exhaled acetone concentration significantly correlated with concentrations of fasting blood glucose, ketones in the blood and urine, LDL-C, creatinine, and blood urea nitrogen. Conclusions. Breath testing for ketones has a high sensitivity and specificity and appears to be a noninvas Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

As fat is broken down, acids called ketones build up in the blood and urine. In high levels, ketones are poisonous. This condition is known as ketoacidosis. Diabetic ketoacidosis (DKA) is sometimes the first sign of type 1 diabetes in people who have not yet been diagnosed. It can also occur in someone who has already been diagnosed with type 1 diabetes. Infection, injury, a serious illness, missing doses of insulin shots, or surgery can lead to DKA in people with type 1 diabetes. People with type 2 diabetes can also develop DKA, but it is less common. It is usually triggered by uncontrolled blood sugar, missing doses of medicines, or a severe illness. Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

What is diabetic ketoacidosis? Diabetic ketoacidosis (DKA) is a life-threatening condition caused by a build-up of waste products called ketones in the blood. It occurs in people with diabetes mellitus when they have no, or very low levels of, insulin. DKA mostly occurs in people with type 1 diabetes, but it can also occur in some people with type 2 diabetes and pregnant women with gestational diabetes. Causes Glucose is an essential energy source for the body's cells. When food containing carbohydrates is eaten, it is broken down into glucose that travels around the body in the blood, to be absorbed by cells that use it for energy. Insulin works to help glucose pass into cells. Without insulin, the cells cannot absorb glucose to use for energy. This leads to a series of changes in metabolism that can affect the whole body. The liver attempts to compensate for the lack of energy in the cells by producing more glucose, leading to increased levels of glucose in the blood, also known as hyperglycaemia. The body switches to burning its stores of fat instead of glucose to produce energy. This leads to a build-up of acidic waste products called ketones in the blood and urine. This is known as ketoacidosis, and it can cause heart rhythm abnormalities, breathing changes and abdominal pain. The kidneys try to remove some of the excess glucose and ketones. However, this requires taking large amounts of fluid from the body, which leads to dehydration. This can cause: Increased concentration of ketones in the blood, worsening the ketoacidosis; Loss of electrolytes such as potassium and salt that are vital for the normal function of the body's cells, and; Signs and symptoms Symptoms of DKA can develop over the course of hours. They can include: Increased thirst; Increased frequency Continue reading >>

Is Ketosis Dangerous?

Is Ketosis Dangerous?

You may have heard from your doctor that ketosis is a life-threatening condition. If so, your doctor is confusing diabetic ketoacidosis (DKA) with nutritional ketosis, or keto-adaptation. First, some semantics. Our body can produce, from fat and some amino acids, three ketone bodies (a “ketone” refers to the chemical structure where oxygen is double-bonded to carbon sandwiched between at least 2 other carbons). These ketone bodies we produce are: acetone, acetoacetone, and beta-hydroxybutyrate (B-OHB). [For anyone who is interested, they are the 3 most right structures on the figure, below.] Why do we make ketones? For starters, it’s a vital evolutionary advantage. Our brain can only function with glucose and ketones. Since we can’t store more than about 24 hours’ worth of glucose, we would all die of hypoglycemia if ever forced to fast for more than a day. Fortunately, our liver can take fat and select amino acids (the building blocks of proteins) and turn them into ketones, first and foremost to feed our brains. Hence, our body’s ability to produce ketones is required for basic survival. What is diabetic ketoacidosis? When diabetics (usually Type I diabetics, but sometimes this occurs in very late-stage, insulin-dependent, Type II diabetics) fail to receive enough insulin, they go into an effective state of starvation. While they may have all the glucose in the world in their bloodstream, without insulin, they can’t get any into their cells. Hence, they are effectively going into starvation. The body does what it would do in anyone – it starts to make ketones out of fat and proteins. Here’s the problem: the diabetic patient in this case can’t produce any insulin, so there is no feedback loop and they continue to produce more and more ketones withou Continue reading >>

Diabetic Ketoacidosis (dka) And Ketone Strips

Diabetic Ketoacidosis (dka) And Ketone Strips

Diabetic Ketoacidosis (DKA) can be a life-threatening complication of diabetes. People with Type 1, or those on insulin pumps can experience DKA more frequently due to a lack of endogenous (internally produced) insulin. People with gestational diabetes can experience ketone production and DKA as well. Those with Type 2 diabetes rarely get DKA except when they have severe infections or trauma. DKA can occur when ketones form; your blood becomes acidic from ketone production and cause acidosis. What Are Ketones? Ketones are a toxic by-product of fat breakdown which can occur during times of severe stress, injury or illness in people with diabetes. The body’s blood sugar rises during illness and since there is not enough insulin, the body breaks down fat as an energy source. Ketones will accumulate in the blood and urine which can cause multiple systemic problems and eventual acidosis. Dietary ketones form from strict low carbohydrate diets, yet they are benign and do not cause acidosis. When Do I Test for Ketones? When your blood sugar exceeds 240 mg/dL and you are ill, you should be testing for ketones. If you exceed 240 mg/dL and have ketones you may require insulin. If you are pregnant and your glucose drops below 60 mg/dl, you should check for ketones; if you have low glucose and find ketones, you may need more carbohydrates in the diet. How Do I Test for Ketones? Certain meters such as the Nova Max Plus can test blood for ketones with a different colored strip. Using urine ketone strips are another fast, reliable and affordable way to test. The vial has a lining that helps preserve the strips so close the bottle as soon as you remove a strip. The strips are sensitive to heat, humidity, and light. It is easy and convenient to use. Your fingers should be clean and dr Continue reading >>

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