Non-diabetic ketoacidosis: a case series and literature review

Bashir, Bilal; Fahmy, Ahmed A; Raza, Farheen; Banerjee, Moulinath

doi:10.1136/postgradmedj-2020-138513

Cited by 13 publications

(9 citation statements)

References 35 publications

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“…Plasma BOH was systematically increased after exercise in five studies, while plasma AA increase after exercise was more equivocal [25]. Yet, in our muscle disease patients, the adjusted BOH and AA levels were in line with the increased raw levels reported in several pathological conditions (such as diabetes, intoxication or inherited metabolism diseases [53]). In addition, BOH and AA are in equilibrium with a low NAD/NADH ratio (high NADH) in the mitochondria.…”

Section: Discriminative Value Of Exercise-induced Increase In β-Hydro...supporting

confidence: 81%

Biomarkers of Redox Balance Adjusted to Exercise Intensity as a Useful Tool to Identify Patients at Risk of Muscle Disease through Exercise Test

et al. 2022

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The screening of skeletal muscle diseases constitutes an unresolved challenge. Currently, exercise tests or plasmatic tests alone have shown limited performance in the screening of subjects with an increased risk of muscle oxidative metabolism impairment. Intensity-adjusted energy substrate levels of lactate (La), pyruvate (Pyr), β-hydroxybutyrate (BOH) and acetoacetate (AA) during a cardiopulmonary exercise test (CPET) could constitute alternative valid biomarkers to select “at-risk” patients, requiring the gold-standard diagnosis procedure through muscle biopsy. Thus, we aimed to test: 1) the validity of the V’O2-adjusted La, Pyr, BOH and AA during a CPET for the assessment of the muscle oxidative metabolism (exercise and mitochondrial respiration parameters); and 2) the discriminative value of the V’O2-adjusted energy and redox markers, as well as five other V’O2-adjusted TCA cycle-related metabolites, between healthy subjects, subjects with muscle complaints and muscle disease patients. Two hundred and thirty subjects with muscle complaints without diagnosis, nine patients with a diagnosed muscle disease and ten healthy subjects performed a CPET with blood assessments at rest, at the estimated 1st ventilatory threshold and at the maximal intensity. Twelve subjects with muscle complaints presenting a severe alteration of their profile underwent a muscle biopsy. The V’O2-adjusted plasma levels of La, Pyr, BOH and AA, and their respective ratios showed significant correlations with functional and muscle fiber mitochondrial respiration parameters. Differences in exercise V’O2-adjusted La/Pyr, BOH, AA and BOH/AA were observed between healthy subjects, subjects with muscle complaints without diagnosis and muscle disease patients. The energy substrate and redox blood profile of complaining subjects with severe exercise intolerance matched the blood profile of muscle disease patients. Adding five tricarboxylic acid cycle intermediates did not improve the discriminative value of the intensity-adjusted energy and redox markers. The V’O2-adjusted La, Pyr, BOH, AA and their respective ratios constitute valid muscle biomarkers that reveal similar blunted adaptations in muscle disease patients and in subjects with muscle complaints and severe exercise intolerance. A targeted metabolomic approach to improve the screening of “at-risk” patients is discussed.

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Section: Discriminative Value Of Exercise-induced Increase In β-Hydro...supporting

confidence: 81%

Biomarkers of Redox Balance Adjusted to Exercise Intensity as a Useful Tool to Identify Patients at Risk of Muscle Disease through Exercise Test

et al. 2022

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“…SKA management generally responds well to providing the substrate glucose, which stimulates endogenous production of insulin, restoring the insulin to glucagon ratio and reverses ketogenesis. 14 DKA/EKA, on the other hand, benefits from expeditious correction of dehydration and insulin infusion with dextrose containing drip, to reverse insulin insufficiency and suppress ketogenesis. 13 In our patient, the concurrent occurrence of lactic acidosis and ketoacidosis was reflected in an augmented anion gap, but his ketone levels far exceeded that of SKA, suggesting a possible metformin-related and starvation-independent ketogenesis.…”

Section: Discussionmentioning

confidence: 99%

“…13 In our patient, the concurrent occurrence of lactic acidosis and ketoacidosis was reflected in an augmented anion gap, but his ketone levels far exceeded that of SKA, suggesting a possible metformin-related and starvation-independent ketogenesis. 8,14,15…”

Section: Discussionmentioning

confidence: 99%

Unusual case of concurrent metformin-associated lactic acidosis and euglycaemic ketoacidosis

Yi Koo,

Dutta,

Zhang

2023

Proceedings of Singapore Healthcare

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Metformin-associated lactic acidosis (MALA) and euglycaemic diabetic ketoacidosis (EKA) are both life-threatening endocrine emergencies. MALA is a well-documented complication of anti-glycaemic therapy in diabetics while EKA is an increasingly recognized disease entity with the advent of use of sodium-glucose co-transporter-2 (SGLT-2) inhibitors. However, the occurrence of concurrent metformin-associated lactic acidosis and euglycaemic ketoacidosis (MALKA) is uncommon and rarely reported in the literature. We report an unusual case of MALKA, in a 74-year-old gentleman with no previous history of chronic kidney disease and SGLT-2 inhibitor use, who presented with altered mental status, acute renal failure and profound high anion-gap metabolic acidosis (HAGMA) with lactaemia, ketonaemia and normoglycaemia (pH 6.965, bicarbonate 3.1, creatinine 522, glucose 6.6, lactate 17.5, ketones >8). The patient was initiated on intravenous insulin infusion with dextrose-containing drip and continuous renal replacement therapy (CRRT) in the intensive care unit (ICU). The patient had a prolonged hospital stay but was eventually discharged with a normalised renal function without need for long-term dialysis. The parallel occurrence of MALA and EKA suggest a metformin-associated inhibition of gluconeogenesis. This case highlights the importance of early recognition and investigation of concurrent diabetic ketoacidosis in the presence of MALA and vice versa as MALKA benefits from both prompt institution of parenteral glucose therapy and insulin infusion and consideration of initiation of haemodialysis.

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“…In this study, patients with normal blood glucose levels and without diabetes were considered a true negative for urine ketone. This result might have affected the accuracy of the study results, as an individual can test positive for urine KET after fasting or drinking ( 10 , 11 ). Thus, positivity should not be ruled out simply based on urine and blood glucose results that fall within the normal ranges before a blood KET test.…”

Section: Discussionmentioning

confidence: 99%

Oral rifampicin interferes with urine dipstick tests for patients with pulmonary tuberculosis

Wang¹,

Zhao²,

Du³

et al. 2023

J Thorac Dis

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Background Rifampicin (RMP) and its major metabolite, desacetyl rifampicin (dRMP), can interfere with urine dipstick tests (UDTs) in patients with tuberculosis (TB) who receive oral RMP. This study sought to examine the effects of RMP and dRMP on UDTs using 2 different urine dipsticks (i.e., Arkray’s Aution Sticks 10EA and GIMA’s Combi-Screen 11SYS Plus sticks). Methods Urine colorimetry was applied to measure RMP concentrations and determine the range of total RMP concentration in the urine within 2–6 and 12–24 h of oral administration of RMP. In vitro interference assays and confirmatory tests were performed to evaluate the effects of RMP and dRMP on the analytes. Results The total RMP concentration in the urine of the 40 TB patients analyzed as urine sample was 88–376 µg/mL within 2–6 h and 22–112 µg/mL within 12–24 h of oral administration of RMP. Interference was observed for different analytes at consistent or varied RMP concentrations between the in vitro interference assays and the confirmatory tests, including 75 patients [Aution Sticks 10EA: 250, 250 µg/mL for protein (PRO); 400, 300 µg/mL for leukocyte esterase (LEU); Combi-Screen 11SYS Plus: 125, 150 µg/mL for ketones (KET); 500, 350 µg/mL for nitrite (NIT); 200, 300 µg/mL for PRO; 125, 150 µg/mL for LEU]. Conclusions RMP and dRMP interfered with the analytes of the UDTs using the 2 urine dipsticks in different levels. The in vitro interference assay is not an ideal substitute for the confirmatory test. The collection of urine samples within 12–24 h of administration of RMP can prevent the interference caused by RMP and dRMP.

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Non-diabetic ketoacidosis: a case series and literature review

Cited by 13 publications

References 35 publications

Biomarkers of Redox Balance Adjusted to Exercise Intensity as a Useful Tool to Identify Patients at Risk of Muscle Disease through Exercise Test

Biomarkers of Redox Balance Adjusted to Exercise Intensity as a Useful Tool to Identify Patients at Risk of Muscle Disease through Exercise Test

Unusual case of concurrent metformin-associated lactic acidosis and euglycaemic ketoacidosis

Oral rifampicin interferes with urine dipstick tests for patients with pulmonary tuberculosis

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