Alcoholic Ketosis

Abstract

Twenty-four chronic alcohol abusers hospitalized during a twenty-seven-month period were suspected of having "alcoholic ketoacidosis" because they had ketonuria or ketonemia with little or no glucosuria. Twenty-one had moderate or severe ketosis, with plasma 3-hydroxybutyrate of 5.2 to 22.5 mmol/L. Fifteen of this group were not diabetic, while six were later found to have mild postprandial hyperglycemia without glycosuria. Three patients who had continued to drink until shortly before admission, though at first suspected of having alcoholic ketosis, were found to have predominant lactic acidosis, with minor elevations of plasma 3-hydroxybutyrate. In contrast to previously reported patients with "alcoholic ketoacidosis", severe acidemia was uncommon in this series. Indeed, seven patients were alkalemic, because of coexisting respiratory or metabolic alkalosis. Most patients had eaten poorly for several days (and usually longer) and had allegedly decreased their alcohol intake during that period. That history, and the usual rapid clearing of ketosis simply by treatment with solutions of glucose and NaCl, suggested that acute starvation was an important factor in the pathogenesis of this disorder. Four patients were treated with insulin and four with NaHCO3 solutions. In retrospect, the need for either of these treatments was not clear. Two of the twenty-four patients died, one from circulatory failure secondary to hemorrhage and the other from pulmonary edema, but no patient died because of ketoacidosis per se.

Major ketogenesis and the absence of an osmolar gap in an atypical case of alcoholic ketoacidosis

“…However, in the series presented by Fulop et al 1 and Halperin et al 2 and in the present case, the lowest pH values (57¢28) were associated with the highest concentrations of b-hydroxybutyrate and lactate (415 mmol/ L). Moderately raised ketone concentrations (510 mmol/ L) were associated with normal or slightly below normal pH values.…”

Management of Hyperglycemic Crises in Patients With Diabetes

“…Patients with chronic ethanol abuse with a recent binge culminating in nausea, vomiting, and acute starvation may present with alcoholic ketoacidosis (AKA). In virtually all reported series of AKA, the elevation of total ketone body concentration DIABETES CARE, VOLUME 24, NUMBER 1, JANUARY 2001 139 (7-10 mmol/l) is comparable to that reported in patients with DKA (161,162). However, in in vitro studies, the altered redox cellular state in AKA caused by an increased ratio of NADH to NAD levels leads to a reduction of pyruvate and oxaloacetate, which results in impaired gluconeogenesis (163).…”

Acid-Base Aspects of Ketoacidosis

“…Ball et al [71] reported a patient with combined ketoacidosis and lactic acidosis whose ratio was 22.4 (9.9/0.4 mmol/1). Fulop and Hoberman [72] described a patient with alco holic ketoacidosis who had a negative serum Acetest reaction despite a plasma P-OHB level of 12.9 mmol/1. Likewise, 2 of the 5 patients of Levy et al [74] with alco holic ketoacidosis had negative tests for urinary and se rum ketones, and in the series of 30 cases of alcoholic ke toacidosis recently reported by Soffer and Hamburger [73], most patients had negative reactions.…”

“…Rather, the intracellular ratios of both lactate/pyruvate and P-OHB/AcAc are influenced coterminously by the redox state. Nevertheless, because the latter ratio is directed pri marily by intramitochondrial events, and the former by changes in the extramitochondrial compartment, the ab sence of a close correlation between the serum concentra tions of P-OHB and lactate is not surprising [42], The p-OHB/AcAc ratio in DKA is typically about 3 to 1, but several clinical reports documenting the finding of negative or weakly positive tests for blood and/or urinary ketones, despite pronounced acidosis [36,37,67,[72][73][74], suggest that P-OHB/AcAc ratios sometimes exceed 10 to 1. Alberti and Ilockaday [24], in a study of 50 patients with diabetic coma and precoma, emphasized that al though the mean P-OHB/AcAc ratio was 5.2, the individ ual values ranged from 1.9 to as high as 31.7.…”