Abstract
The significance of hyperketonemia in adults with diabetes presenting to the emergency department with acute illness, not due to a diabetic hyperglycemic emergency, has not been well characterized. Adult patients with diabetes presenting to the emergency department who had venous blood gas and beta-hydroxybutyrate levels measured whilst in the emergency department were retrospectively evaluated for the relationship between BHB and clinical outcomes. Over 6 months, 404 patients with diabetes had at least one beta-hydroxybutyrate level measured in the emergency department. There were 23 admissions for diabetic ketoacidosis (DKA) or hyperosmolar state. Of the remainder, 58 patients had a beta-hydroxybutyrate ≥ 1 mmol/L; this group had a higher glucose at presentation (19.0 (8.8) versus 10.4 (9.9) mmol/L), higher HbA1c (8.8 (5.4) versus 8.0 (3.3)%), lower bicarbonate (22.6 (6.2) versus 24.8 (4.7) mmol/L), and higher anion gap (14.8 (6.1) versus 12.6 (4.2)) than had those with BHB < 1 mmol/L. There was no association between the presence of ketosis and the length of stay (4.2 (7.3) versus (3.0) (7.2) days). Acute illness in those with diabetes associated with ketosis in the absence of DKA is associated with worse glycaemic control than in those without ketosis. Ketosis may represent an intermediate state of metabolic dysregulation rather than being associated with a more severe acute illness, as suggested by no relationship between BHB and length of stay.
Highlights
Ketone bodies—beta-hydroxybutyrate (BHB), acetoacetate, and acetone—are an important energy source during energy restriction
Over a 6-month period in 2018, 404 patients with diabetes presenting to the ED had at least one venous blood gas (VBG) level and one BHB level measured whilst in the ED
There were 23 diabetes emergencies in total, including diabetic ketoacidosis (DKA) in 12 patients with T1DM, DKA due to a sodium glucose cotransporter type 2 inhibitors (SGLT2i) in a patient with T2DM, DKA in 2 patients with T2DM, and DKA in 2 patients with diabetes due to exocrine pancreatic disease; HHS was present in 6 cases
Summary
Ketone bodies—beta-hydroxybutyrate (BHB), acetoacetate, and acetone—are an important energy source during energy restriction. They are predominately produced from fatty acids by the liver [1]. A study performed in a paediatric population presenting to the ED found an association between ketone levels and fever, and ketone levels were higher in children who were admitted [4]. This suggests that ketosis occurs as part of a stress response to illness. Defining the expected degree of ketosis with acute illness has become more important given the ability to undertake point-of-care BHB testing [5] and that sodium glucose cotransporter type 2 inhibitors (SGLT2i) may precipitate euglycaemic DKA with intercurrent illness [6]
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