Starvation Ketoacidosis
Eating disorders, prolonged fasting, severely calorie-restricted diets, restricted access to food (low socioeconomic and elderly patients) may be causes of starvation ketoacidosis. When insulin levels are low and glucagon levels are high (such as in a fasting state), long chain fatty acids and glycerol from triglycerides are released from peripheral fat stores and are transported to the liver. The fatty acids undergo beta-oxidation and generate acetyl-CoA. However, with excessive amounts of acetyl-CoA, the Krebs cycle may become oversaturated, and instead the acetyl-CoA enter the ketogenic pathway resulting in production of ketone bodies. Mild ketosis (1mmol/L) results after fasting for approximately 12 to 14 hours. However, the ketoacid concentration rises with continued fasting and will peak after 20 to 30 days (8-10mmol/L). Clinical Features Nausea and vomiting Abdominal pain Dehydration Altered mental status Fatigue Kussmaul breathing Differential Diagnosis Evaluation Serum chemistry (elevated anion gap) Glucose (usually euglycemic or hypoglycemic) Urinalysis (ketonuria) Serum beta-hydroxybutyrate Lactate Salicylate level (if overdose suspected) Serum osmolality (if toxic alcohol ingestion suspected) Management Dextrose and saline solutions Dextrose Will cause increase in insulin and decrease in glucagon secretion, which will reduce ketone production and increase ketone metabolism Beta-hydroxybutyrate and acetoacetate will regenerate bicarbonate, causing partial correction of metabolic acidosis Saline or lactated ringer Will provide volume resuscitation and will in turn reduce secretion of glucagon (which promotes ketogenesis) Considerations Rate of infusion dependent on volume status If hypokalemic, need to correct before administering glucose (as glucose stimulate Continue reading >>
Starvation Ketoacidosis: A Cause Of Severe Anion Gap Metabolic Acidosis In Pregnancy
Copyright © 2014 Nupur Sinha 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. Pregnancy is a diabetogenic state characterized by relative insulin resistance, enhanced lipolysis, elevated free fatty acids and increased ketogenesis. In this setting, short period of starvation can precipitate ketoacidosis. This sequence of events is recognized as “accelerated starvation.” Metabolic acidosis during pregnancy may have adverse impact on fetal neural development including impaired intelligence and fetal demise. Short periods of starvation during pregnancy may present as severe anion gap metabolic acidosis (AGMA). We present a 41-year-old female in her 32nd week of pregnancy, admitted with severe AGMA with pH 7.16, anion gap 31, and bicarbonate of 5 mg/dL with normal lactate levels. She was intubated and accepted to medical intensive care unit. Urine and serum acetone were positive. Evaluation for all causes of AGMA was negative. The diagnosis of starvation ketoacidosis was established in absence of other causes of AGMA. Intravenous fluids, dextrose, thiamine, and folic acid were administered with resolution of acidosis, early extubation, and subsequent normal delivery of a healthy baby at full term. Rapid reversal of acidosis and favorable outcome are achieved with early administration of dextrose containing fluids. 1. Introduction A relative insulin deficient state has been well described in pregnancy. This is due to placentally derived hormones including glucagon, cortisol, and human placental lactogen which are increased in periods of stress [1]. The insulin resistance increases with gestational age Continue reading >>
Euglycaemic Ketoacidosis In Patients With And Without Diabetes
Euglycaemic ketoacidosis in patients with and without diabetes Gladstone Centre, Maelor Hospital, Wrexham LL13 7TD, UK Search for more papers by this author Please review our Terms and Conditions of Use and check box below to share full-text version of article. I have read and accept the Wiley Online Library Terms and Conditions of Use Use the link below to share a full-text version of this article with your friends and colleagues. Learn more. Get access to the full version of this article. View access options below. You previously purchased this article through ReadCube. View access options below. Unlimited viewing of the article/chapter PDF and any associated supplements and figures. Ketoacidosis in individuals with diabetes is usually associated with a raised plasma glucose concentration. However, ketoacidosis in diabetes can occur with normal (11mmol/L) plasma glucose levels. Ketoacidosis is also seen in patients who do not have diabetes, most commonly in pregnancy or following alcoholic binges, rarely with starvation, anorexia nervosa or inborn errors of metabolism. The aim of this review is to compare the clinical features, pathophysiology and management of these conditions. Common clinical features due to a raised anion gap metabolic acidosis are seen. Reduced carbohydrate intake is a usual contributor to ketogenesis. Treatment is primarily with intravenous glucose, insulin if there is insulin deficiency and potassium as needed. The value of using bedside monitors to measure hydroxybutyrate levels both for diagnosis and monitoring of response to treatment is emphasised. Early recognition of ketoacidosis and treatment with glucose rather than saline is important for optimum outcome. Copyright 2013 John Wiley & Sons. Practical Diabetes 2013; 30(4): 167171 Continue reading >>
Starvation Ketoacidosis: A Cause Of Severe Anion Gap Metabolic Acidosis In Pregnancy
Abstract Pregnancy is a diabetogenic state characterized by relative insulin resistance, enhanced lipolysis, elevated free fatty acids and increased ketogenesis. In this setting, short period of starvation can precipitate ketoacidosis. This sequence of events is recognized as "accelerated starvation." Metabolic acidosis during pregnancy may have adverse impact on fetal neural development including impaired intelligence and fetal demise. Short periods of starvation during pregnancy may present as severe anion gap metabolic acidosis (AGMA). We present a 41-year-old female in her 32nd week of pregnancy, admitted with severe AGMA with pH 7.16, anion gap 31, and bicarbonate of 5 mg/dL with normal lactate levels. She was intubated and accepted to medical intensive care unit. Urine and serum acetone were positive. Evaluation for all causes of AGMA was negative. The diagnosis of starvation ketoacidosis was established in absence of other causes of AGMA. Intravenous fluids, dextrose, thiamine, and folic acid were administered with resolution of acidosis, early extubation, and subsequent normal delivery of a healthy baby at full term. Rapid reversal of acidosis and favorable outcome are achieved with early administration of dextrose containing fluids. Discover the world's research 14+ million members 100+ million publications 700k+ research projects Join for free Starvation Ketoacidosis: A Cause of Severe Anion Gap Metabolic Nupur Sinha, Sindhaghatta Venkatram, and Gilda Diaz-Fuentes Division of Pulmonary and Critical Care Medicine, Bronx Lebanon Hospital Center and Albert Einstein College of Medicine, Correspondence should be addressed to Nupur Sinha; [email protected] Received February ; Revised May ; Accepted May ; Published Continue reading >>
Ketosis
Not to be confused with Ketoacidosis. Ketosis is a metabolic state in which some of the body's energy supply comes from ketone bodies in the blood, in contrast to a state of glycolysis in which blood glucose provides energy. Ketosis is a result of metabolizing fat to provide energy. Ketosis is a nutritional process characterised by serum concentrations of ketone bodies over 0.5 mM, with low and stable levels of insulin and blood glucose.[1][2] It is almost always generalized with hyperketonemia, that is, an elevated level of ketone bodies in the blood throughout the body. Ketone bodies are formed by ketogenesis when liver glycogen stores are depleted (or from metabolising medium-chain triglycerides[3]). The main ketone bodies used for energy are acetoacetate and β-hydroxybutyrate,[4] and the levels of ketone bodies are regulated mainly by insulin and glucagon.[5] Most cells in the body can use both glucose and ketone bodies for fuel, and during ketosis, free fatty acids and glucose synthesis (gluconeogenesis) fuel the remainder. Longer-term ketosis may result from fasting or staying on a low-carbohydrate diet (ketogenic diet), and deliberately induced ketosis serves as a medical intervention for various conditions, such as intractable epilepsy, and the various types of diabetes.[6] In glycolysis, higher levels of insulin promote storage of body fat and block release of fat from adipose tissues, while in ketosis, fat reserves are readily released and consumed.[5][7] For this reason, ketosis is sometimes referred to as the body's "fat burning" mode.[8] Ketosis and ketoacidosis are similar, but ketoacidosis is an acute life-threatening state requiring prompt medical intervention while ketosis can be physiological. However, there are situations (such as treatment-resistant Continue reading >>
Starvation Ketoacidosis In Pregnancy - Sciencedirect
Volume 167, Issue 1 , March 2013, Pages 1-7 Author links open overlay panel Charlotte J.Frisea LucyMackillopa KarenJoashb CatherineWilliamsonc Get rights and content Starvation ketosis outside pregnancy is rare and infrequently causes a severe acidosis. Placental production of hormones, including glucagon and human placental lactogen, leads to the insulin resistance that is seen in pregnancy, which in turn increases susceptibility to ketosis particularly in the third trimester. Starvation ketoacidosis in pregnancy has been reported and is usually precipitated by a period of severe vomiting. Ketoacidosis is likely to have important implications for fetal survival as ketoacidosis in women with type 1 diabetes mellitus is associated with intrauterine death. This article features four cases of women with vomiting in the third trimester of pregnancy associated with a severe metabolic acidosis. The mechanism underlying ketogenesis, the evidence for accelerated ketogenesis in pregnancy and other similar published cases are reviewed. A proposed strategy for management of these women is presented. Continue reading >>
Ketoacidosis Versus Ketosis
Some medical professionals confuse ketoacidosis, an extremely abnormal form of ketosis, with the normal benign ketosis associated with ketogenic diets and fasting states in the body. They will then tell you that ketosis is dangerous. Testing Laboratory Microbiology - Air Quality - Mold Asbestos - Environmental - Lead emsl.com Ketosis is NOT Ketoacidosis The difference between the two conditions is a matter of volume and flow rate*: Benign nutritional ketosis is a controlled, insulin regulated process which results in a mild release of fatty acids and ketone body production in response to either a fast from food, or a reduction in carbohydrate intake. Ketoacidosis is driven by a lack of insulin in the body. Without insulin, blood sugar rises to high levels and stored fat streams from fat cells. This excess amount of fat metabolism results in the production of abnormal quantities of ketones. The combination of high blood sugar and high ketone levels can upset the normal acid/base balance in the blood and become dangerous. In order to reach a state of ketoacidosis, insulin levels must be so low that the regulation of blood sugar and fatty acid flow is impaired. *See this reference paper. Here's a table of the actual numbers to show the differences in magnitude: Body Condition Quantity of Ketones Being Produced After a meal: 0.1 mmol/L Overnight Fast: 0.3 mmol/L Ketogenic Diet (Nutritional ketosis): 1-8 mmol/L >20 Days Fasting: 10 mmol/L Uncontrolled Diabetes (Ketoacidosis): >20 mmol/L Here's a more detailed explanation: Fact 1: Every human body maintains the blood and cellular fluids within a very narrow range between being too acidic (low pH) and too basic (high pH). If the blood pH gets out of the normal range, either too low or too high, big problems happen. Fact 2: The Continue reading >>
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 >>
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 >>
Starvation Ketoacidosis: Treatment Pitfalls
Dear Editor, Yeow et al.1 describe a case of non-diabetic euglycaemic acidosis resulting from post op dysphagia and poor intake of approximately six weeks duration. We have seen a similar case of ‘starvation ketoacidosis’ in a patient undergoing percutaneous endoscopic gastrostomy feeding tube replacement. We think that intravenous (IV) glucose should be the initial treatment, with the addition of insulin only if required. The correspondence from Frise and Mackillop2 states this strategy is effective for treating ketoacidosis in pregnancy; however, there are also some other pitfalls in treatment of starvation ketoacidosis which must be considered, and some overlap with alcoholic ketoacidosis. Unlike patients with diabetic ketoacidosis, patients with starvation ketosis release insulin when carbohydrate is administered. They are also producing high levels of glucose elevating hormones such as glucagon and have depleted glycogen stores. These hormones cause the lipolysis which helps generate ketones for fuel. The addition of exogenous insulin in this state risks hypoglycaemia. Once provided with adequate carbohydrate the insulin levels will rise and counter-regulatory hormone levels will fall, resolving the ketosis. Alcoholics are another group prone to ketosis (alcoholic ketoacidosis (AKA)) and are particularly prone to hypoglycaemia; administration of insulin to those patients would have to be with caution and literature3 on AKA reports resolution without insulin administration, although there is little evidence outside of case reports. Starved patients and alcoholics are also both at risk of thiamine deficiency. Depletion of body thiamine stores can occur within four weeks. It is important to consider this, as administration of IV glucose in thiamine deficiency can Continue reading >>
What Is Starvation Ketosis?
Starvation ketosis is a metabolic state in humans and many animals in which the body breaks down fat and produces acids known as ketones, then uses these as a primary energy source. The “starvation” part of the name owes to the fact that, in most cases, people only use ketones for energy when they aren’t getting adequate glucose from food. The body typically converts carbohydrates to glucose as a main source of energy, but once the liver has used all of its stored glucose it begins to metabolize fatty acids, forming ketone bodies. Malnutrition and fasting are two of the most common causes, but it can also be the result of conditions like diabetes, alcoholism, and a low carbohydrate diet. People sometimes intentionally trigger this state as a means of burning fat to lose weight, but whether this practice is safe or even advisable is widely disputed in the medical community. Ketones are capable of supplying energy to the body, but an abnormally high level can cause a number of problems, including organ damage, coma, and even death. Understanding Ketones The liver typically makes ketones in response to some sort of energy crisis in the body. People generally get the majority of their energy by synthesizing glucose, which is a sugar molecule found in carbohydrates like bread and grain products. When people aren’t getting enough glucose, the liver begins creating ketones that the body uses in combination with any fat stores it has on hand. Ketones in many ways prevent the body from robbing muscles of their core proteins. Starvation ketosis happens when these become the body’s primary source of energy. The condition can usually be identified by looking for excesses. The body gets rid of unneeded supplies by spilling them out through exhalations, urine, and sweat. Wh Continue reading >>
Starvation Ketoacidosis – A Rare But Significant Metabolic Condition
Diabetic ketoacidosis and pregnancy related ketoacidosis are the most common forms of ketoacidosis seen in acute medical units. We describe here two rare cases of starvation ketoacidosis. Case 1: 63 years old gentleman with no history of diabetes, presented with persistent vomiting for 48 hours. His admission bloods revealed Serum Bicarbonate of 8, pH 7.19, pCO2 2.7, base excess of -17.8, plasma glucose 5.2 mmol/l and serum alcohol <100. Serum ketones were 3.4 mmol/l. He was managed with iv fluids mainly with dextrose infusions. His symptoms, serum ketones and pH levels normalised while his blood glucose remained stable over 3 days and was discharged home. Case 2: 67 years lady with past history of COPD, excess alcohol intake and osteoporosis, presented with feeling unwell, since she stopped eating after she had an argument with her son 5 days ago. Her bloods revealed Serum Bicarbonate of 14, pH 7.43, pCO2 3.5, base excess of -4.7, plasma glucose 6.7 mmol/l and serum alcohol <100. Serum ketones were 3.4 mmol/l. She was managed with iv fluids mainly with dextrose infusions with iv Vitamin B complex. Her symptoms, serum ketones and pH levels normalised while her blood glucose remained stable over next day and was discharged home. These two cases highlight the condition of starvation ketoacidosis, being a significant cause of metabolic acidosis, presented with symptoms of vomiting and being unwell respectively. Prompt diagnosis and treatment targeted to correct volume and calorie (mainly from carbohydrates) deficit helped to move these patients from a metabolic state based on fatty acid catabolism to eumetabolic state. Distinction from diabetic keto-acidosis is extremely important. If misdiagnosed as euglycaemic diabetic ketoacidosis, consequent inappropriate insulin thera Continue reading >>
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Ketosis: Symptoms, Signs & More
Every cell in your body needs energy to survive. Most of the time, you create energy from the sugar (glucose) in your bloodstream. Insulin helps regulate glucose levels in the blood and stimulate the absorption of glucose by the cells in your body. If you don’t have enough glucose or insufficient insulin to get the job done, your body will break down fat instead for energy. This supply of fat is an alternative energy source that keeps you from starvation. When you break down fat, you produce a compound called a ketone body. This process is called ketosis. Insulin is required by your cells in order to use the glucose in your blood, but ketones do not require insulin. The ketones that don’t get used for energy pass through your kidneys and out through your urine. Ketosis is most likely to occur in people who have diabetes, a condition in which the body produces little or no insulin. Ketosis and Ketoacidosis: What You Need To Know Ketosis simply means that your body is producing ketone bodies. You’re burning fat instead of glucose. Ketosis isn’t necessarily harmful to your health. If you don’t have diabetes and you maintain a healthy diet, it’s unlikely to be a problem. While ketosis itself isn’t particularly dangerous, it’s definitely something to keep an eye on, especially if you have diabetes. Ketosis can be a precursor to ketoacidosis, also known as diabetic ketoacidosis. Ketoacidosis is a condition in which you have both high glucose and high ketone levels. Having ketoacidosis results in your blood becoming too acidic. It’s more common for those with type 1 diabetes rather than type 2. Once symptoms of ketoacidosis begin, they can escalate very quickly. Symptoms include: breath that smells fruity or like nail polish or nail polish remover rapid breat Continue reading >>
Ketosis Vs. Ketoacidosis: What You Should Know
Despite the similarity in name, ketosis and ketoacidosis are two different things. Ketoacidosis refers to diabetic ketoacidosis (DKA) and is a complication of type 1 diabetes mellitus. It’s a life-threatening condition resulting from dangerously high levels of ketones and blood sugar. This combination makes your blood too acidic, which can change the normal functioning of internal organs like your liver and kidneys. It’s critical that you get prompt treatment. DKA can occur very quickly. It may develop in less than 24 hours. It mostly occurs in people with type 1 diabetes whose bodies do not produce any insulin. Several things can lead to DKA, including illness, improper diet, or not taking an adequate dose of insulin. DKA can also occur in individuals with type 2 diabetes who have little or no insulin production. Ketosis is the presence of ketones. It’s not harmful. You can be in ketosis if you’re on a low-carbohydrate diet or fasting, or if you’ve consumed too much alcohol. If you have ketosis, you have a higher than usual level of ketones in your blood or urine, but not high enough to cause acidosis. Ketones are a chemical your body produces when it burns stored fat. Some people choose a low-carb diet to help with weight loss. While there is some controversy over their safety, low-carb diets are generally fine. Talk to your doctor before beginning any extreme diet plan. DKA is the leading cause of death in people under 24 years old who have diabetes. The overall death rate for ketoacidosis is 2 to 5 percent. People under the age of 30 make up 36 percent of DKA cases. Twenty-seven percent of people with DKA are between the ages of 30 and 50, 23 percent are between the ages of 51 and 70, and 14 percent are over the age of 70. Ketosis may cause bad breath. Ket Continue reading >>
Extreme Gestational Starvation Ketoacidosis: Case Report And Review Of Pathophysiology
A case of severe starvation ketoacidosis developing during pregnancy is presented. The insulinopenic/insulinresistant state found during fasting in late gestation predisposes to ketosis. Superimposition of stress hormones, which further augment lipolysis, exacerbates the degree of ketoacidosis. In our patient, gestational diabetes, twin pregnancies, preterm labor, and occult infection were factors that contributed to severe starvation ketoacidosis. Diagnosis was delayed because starvation ketosis is not generally considered to be a cause of severe acidosis, and because the anion gap was not elevated. Improved understanding of the complex fuel metabolism during pregnancy should aid in prevention, early recognition, and appropriate therapy of this condition. Continue reading >>
