Role of measurement of blood ketone bodies in the management of diabetic ketoacidosis

Abstract

Objective:The present study was designed to investigate whether early detection of blood ketone bodies help in diagnosing Diabetic ketoacidosis (DKA) and also to explore whether early changes in blood β-hydroxybutyrate is associated with serum electrolytes and acid-base abnormalities. Research Design and Methods: A total of 122 consecutive type 2 diabetic patients (age 39 ± 15 yrs and body mass index 20.3 ± 2.4 kg/m 2 , mean ± SD) were included in the study. Plasma glucose was measured by glucose oxidase method, glycosylated haemoglobin (HbA 1C ) by high-performance liquid chromatography method, blood β-hydroxybutyrate by biosensor method; urinary acetone was measured by strip based on nitroprusside reaction. Serum urea and creatinine were measured by enzymatic method. Serum electrolytes were measured by ion sensitive electrode technique. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for urinary ketone method were calculated against the blood ketone. Results: The relative frequencies of DKA, using urinary ketone and blood ketone criteria, were 15.6% (19 out of 122) and 13.9% (17 out of 122), respectively. In contrast, 50% (61 out of 122) patients showed hyperketonemia. Using blood ketone as the reference method, the sensitivity of urinary ketone measurement was found to be 32.6% and specificity was 93.7%. PPV and NPV of urinary ketone against blood ketone were 73.68% and 71.84%, respectively. The DKA subjects, diagnosed by blood ketone criteria, showed significant biochemical derangements as compared to Non-DKA subjects [serum urea (P < 0.001), creatinine (P = 0.02), sodium (P < 0.001), potassium (P < 0.001), total carbon dioxide (P = 0.02), and osmolality (P = 0.02)]. Correlation analysis shows that electrolytes, blood gas, and acid-base status have highly significant correlation with blood ketone levels (Na + -r = −0.303, P < 0.001; K + -r = 0.449, P < 0.001; Mg 2+ -r = −0.174, P < 0.05; TCO 2 -r = −0.573, P < 0.001; venous blood pH-r = −0.659, P < 0.001, and osmolality-r = −0.273, P < 0.002). No such correlation was found with plasma glucose except that for serum sodium (r = −0.301, P < 0.001). Conclusions: Measurement of ketonuria by nitroprusside reaction has considerable limitations with an error of about 25-30% in detecting the ketonemic status of type 2 diabetic patients. The present data also demonstrated that severity of hyperketonemia, but not that of hyperglycemia, reflects the underlying biochemical derangements in type 2 diabetic patients better.

Comparison of urinary and plasma ketone using urinary nitroprusside strip in patients with diabetic ketoacidosis

“…The results of this study was in line with our study results. 12 Hirobata et al in another study showed that Serum ketone body levels were negatively correlated with the levels of blood HCO3 -and pH which was in line with our study results because in this study we found that this correlation was negative and significant. 13…”

Evaluation of the Accuracy of Capillary Hydroxybutyrate Measurement Compared with Other Measurements in the Diagnosis of Diabetic Ketoacidosis: A Systematic Review

“…The search identified nine studies that met the inclusion criteria of which: one compared capillary β-OHB with blood glucose levels ≥10.0 mmols/L [ 4 ]; two compared capillary β-OHB with standard measures (arterial blood gases, anion gap and carbon dioxide) of DKA [ 23 , 24 ], although one did not include urine ketones [ 23 ]; one compared capillary β-OHB with the manual enzymatic method [ 25 ]; five compared capillary β-OHB with urine ketones in detecting DKA [ 6 , 14 , 25 , 26 , 27 ] (refer to Table 2 ).…”

“…The studies included a total of 2019 participants, with a range of 19–529. Studies were completed in Australia [ 9 ], Banglaesh [ 27 ], France [ 14 ], Greece [ 25 ], Singapore [ 24 ], South Africa [ 28 ], Thailand [ 6 ], and USA [ 23 , 26 ].…”

“…In a sample of 50 participants capillary β-OHB had a higher sensitivity, specificity and positive predictive value than urine ketones (99.87% versus 89.89%, 92.89% versus 52.78%, and 92.89% versus 41.87%) in detecting DKA in ED [ 25 ]. However, in a sample of 121 participants capillary β-OHB at the level of >3.0 mmols/L as the reference method, sensitivity of urine ketones was reported at 32.6% and specificity at 93.7%, with a positive predictive value of 73.68% and negative predictive value of 71.84% [ 27 ]. The relative risk of DKA of capillary β-OHB ≥ 3.0 mmols/L was higher than the measurement of +++ urine ketones 74 (95% CI: 48–88) versus 31 (95% CI: 18–45), low values of capillary β-OHB and urine ketones demonstrated a good correlation, but a poor correlation between high values was found [ 14 ].…”