An unusual cause for ketoacidosis

Metabolic fingerprint of patients showing responsiveness to treatment of septic shock in intensive care unit

OBJECTIVE

An early metabolic signature associated with the responsiveness to treatment can be useful in the better management of septic shock patients. This would help clinicians in designing personalized treatment protocols for patients showing non-responsiveness to treatment.

METHODS

We analyzed the serum on Day 1 (n = 60), Day 3 (n = 47), and Day 5 (n = 26) of patients with septic shock under treatment using NMR-based metabolomics. Partial least square discriminant analysis (PLS-DA) was performed to generate the list of metabolites that can be identified as potential disease biomarkers having statistical significance (that is, metabolites that had a VIP score > 1, and p value < 0.05, False discovery rate (FDR) < 0.05).

RESULTS

Common significant metabolites amongst the three time points were obtained that distinguished the patients being responsive (R) and non-responsive (NR) to treatments, namely 3 hydroxybutyrate, lactate, and phenylalanine which were lower, whereas glutamate and choline higher in patients showing responsiveness.

DISCUSSION

The study gave these metabolic signatures identifying patients' responsiveness to treatment. The results of the study will aid in the development of targeted therapy for ICU patients.

Ketosis in patients undergoing medically supervised therapeutic fasting-results from an observational trial

BACKGROUND/AIM

Medically supervised fasting has long tradition and broad acceptance in some European countries. The exact amount to which ketone bodies are produced as well as their possible contribution to beneficial effects in this procedure are open.

METHODS

Open-label observational trial with in-patients undergoing medically supervised fasting with supplementation of approximately 40 g/d carbohydrates as part of an established routine care. Daily finger-stick blood samples for measurement of glucose and ß-hydroxybutyrate. Descriptive analysis for all data.

RESULTS

Complete sets of data of 17 patients (5 m, mean age 63.1) could be evaluated. Mean concentrations of ß-hydroxybutyrate rose continuously to a mean maximum of 3.6 mmol/L with an individual maximum of 5.1 mmol/L, while glucose decreased within normal range. Two patients with type 2 diabetes produced significantly less ß-hydroxybutyrate. Courses for ß-hydroxybutyrate and glucose showed a weak inverse correlation, while no serious adverse effects could be observed.

CONCLUSION

Medically supervised fasting with definite small amounts of carbohydrates by fluid intake may lead to limited increases of ketone bodies in their biopositive range, as known e.g. from epileptology or sports medicine. Clinical consequences deserve further research.

Effect of chrysin on changes in intestinal environment and microbiome induced by fructose-feeding in rats

Intake of fructose-containing sugars is epidemiological and experimentally linked to metabolic syndrome (MS). We recently verified that the dietary polyphenol chrysin was able to abolish some of the metabolic changes induced by fructose-feeding in the rat. Because the role of the intestine upon fructose-induced MS is poorly understood, we decided to investigate the influence of fructose, in vivo, on the intestinal environment and the ability of chrysin to interfere with the putative observed changes. For this, adult male Sprague-Dawley rats were treated for 18 weeks as follows: (A) tap water (CONT), (B) tap water and chrysin (100 mg kg^-1 day^-1) (CHRY), (C) 10% fructose in tap water (FRUCT), and (D) 10% fructose in tap water and chrysin (100 mg kg^-1 day^-1) (FRUCT + CHRY). Our findings show that the relative expression of SGLT1 and GLUT2 mRNA were not affected by fructose-feeding and/or chrysin. In contrast, GLUT5 mRNA expression was markedly increased in fructose-fed animals, and this effect was reduced by chrysin. However, the apparent permeability to ¹⁴C-FRUCT was markedly and similarly decreased in FRUCT, CHRY and FRUCT + CHRY rats. Jejunal villus width and crypt depth were significantly higher in FRUCT and FRUCT + CHRYS rats, respectively. Finally, chrysin did not alter gut microbiota composition, but fructose significantly increased Lactobacillus and E. coli. Moreover, FRUCT + CHRY rats had an increase on the Firmicutes to Bacteroidetes ratio. This is the first report showing that chrysin is able to interfere with the effects of fructose at the intestinal level, which may contribute to the fructose-induced MS features.

Basal Vacuolization in Renal Tubular Epithelial Cells at Autopsy and Their Relation to Ketoacidosis

Basal vacuolization of renal tubular epithelial cells is a useful postmortem marker for ketoacidosis. To investigate its incidence and relationship to the severity of ketoacidosis, 158 autopsy cases with elevated β-hydroxybutyrate (>1 mmol/L) over a 7-year-period were retrospectively reviewed. Sixty-eight cases (43%) exhibited basal vacuolizations (vitreous β-hydroxybutyrate: 1.16-29.35 mmol/L, mean 10.28 mmol/L), and 90 cases (57%) did not (vitreous β-hydroxybutyrate: 1.03-13.7 mmol/L, mean 2.84 mmol/L). Quantitative analysis revealed on average a fourfold elevation in β-hydroxybutyrate in cases with basal vacuolizations compared to those without; 10.3% of cases with β-hydroxybutyrate concentrations between 1.01 and 2.00 mmol/L had basal vacuolizations, and this incidence increased to 33.3% with concentrations between 4.01 and 6.00 mmol/L. A marked increase in incidence to >70% was observed with concentrations >6.00 mmol/L, and basal vacuoles were invariably present (100%) with concentrations >14.01 mmol/L. This study demonstrates that basal vacuolizations are a sensitive marker for significant ketoacidosis and reaffirms its use as an indicator for likely cases of fatal ketoacidosis at autopsy.

Life-Threatening Lactation or "Bovine" Ketoacidosis: A Case Report

Lactation or "bovine" ketoacidosis is a rare cause of raised anion gap metabolic acidosis whereby a perfect storm of negative calorie balance (starvation/glucose preferentially used for milk production) and insulin resistance (counter regulatory stress hormone release/infection) leads to a dysregulated ketogenic state. We present a case of life-threatening lactation-related ketoacidosis in a patient 9 weeks postpartum, who presented to the emergency department with an arterial pH of 6.88, HCO3 of 5.8 mmol/L and blood ketone level of 5.8 mmol/L. Treatment consists of aggressive glucose loading, triggering supraphysiologic endogenous insulin release, and subsequent inhibition of ketone body formation.

Septic ketoacidosis

Various unmeasured anions other than lactate appear in the blood of septic patients, including ketones. However, the occurrence of sepsis-induced ketoacidosis without diabetes mellitus has not been reported to date. We herein describe severe ketoacidosis in a patient with septic shock despite the absence of diabetes, alcohol and starvation. A 76-year-old woman presented with septic shock due to acute obstructive cholangitis. She exhibited ketoacidosis and a remarkably strong ion gap, except for ketones. Sepsis alone may lead to ketoacidosis in patients without diabetes under specific conditions. The accumulation of ketones and other strong anions can occur in cases involving a decreased metabolic function. There may be a pathological condition called septic ketoacidosis.

Fructokinase, Fructans, Intestinal Permeability, and Metabolic Syndrome: An Equine Connection?

Fructose is a simple sugar present in honey and fruit, but can also exist as a polymer (fructans) in pasture grasses. Mammals are unable to metabolize fructans, but certain gram positive bacteria contain fructanases and can convert fructans to fructose in the gut. Recent studies suggest that fructose generated from bacteria, or directly obtained from the diet, can induce both increased intestinal permeability and features of metabolic syndrome, especially the development of insulin resistance. The development of insulin resistance is driven in part by the metabolism of fructose by fructokinase C in the liver, which results in oxidative stress in the hepatocyte. Similarly, the metabolism of fructose in the small bowel by intestinal fructokinase may lead to increased intestinal permeability and endotoxemia. While speculative, these observations raise the possibility that the mechanism by which fructans induce laminitis could involve intestinal and hepatic fructokinase. Further studies are indicated to determine the role of fructanases, fructose and fructokinase in equine metabolic syndrome and laminitis.

Efficacy of plasma beta-hydroxybutyrate concentration as a marker for diabetes mellitus in acutely sick cats

Urine ketone measurement is routinely performed in cats with diabetes mellitus to identify impending or established ketoacidosis. Studies using the urinary ketone dipstick test have shown that ketonuria is common in cats with newly diagnosed untreated diabetes mellitus. This test has a low sensitivity as it quantifies the less abundant ketone acetoacetate. The objective of the present study was to determine if ketonaemia is an inherent biochemical finding in untreated feline diabetes mellitus by measuring plasma ss-hydroxybutyrate (ss-OHB) in acutely sick cats. In 122 sick cats (37 diabetic and 85 non-diabetic cats) plasma ss-OHB, glucose, fructosamine, total protein and thyroxine were measured as part of the routine work up. Diabetic cats had significantly elevated ss-OHB values and ss-OHB measurement was a sensitive and specific test to identify diabetes mellitus. The area under the receiver operating characteristic (ROC) curve was 0.93. The cut off value with the highest positive likelihood ratio was 0.58 mmol/l. These results suggest that determination of plasma ss-OHB concentration is a useful method to distinguish between diabetic and non-diabetic sick cats.

Lessons from comparative physiology: could uric acid represent a physiologic alarm signal gone awry in western society?

Uric acid has historically been viewed as a purine metabolic waste product excreted by the kidney and gut that is relatively unimportant other than its penchant to crystallize in joints to cause the disease gout. In recent years, however, there has been the realization that uric acid is not biologically inert but may have a wide range of actions, including being both a pro- and anti-oxidant, a neurostimulant, and an inducer of inflammation and activator of the innate immune response. In this paper, we present the hypothesis that uric acid has a key role in the foraging response associated with starvation and fasting. We further suggest that there is a complex interplay between fructose, uric acid and vitamin C, with fructose and uric acid stimulating the foraging response and vitamin C countering this response. Finally, we suggest that the mutations in ascorbate synthesis and uricase that characterized early primate evolution were likely in response to the need to stimulate the foraging "survival" response and might have inadvertently had a role in accelerating the development of bipedal locomotion and intellectual development. Unfortunately, due to marked changes in the diet, resulting in dramatic increases in fructose- and purine-rich foods, these identical genotypic changes may be largely responsible for the epidemic of obesity, diabetes and cardiovascular disease in today's society.

Defining conditions that lead to the retention of water: The importance of the arterial sodium concentration

BACKGROUND

A water diuresis occurs when a large volume of water is ingested rapidly. Nevertheless, water conservation is required to provide a source of water for evaporative heat dissipation throughout the day. Therefore, the objective was to define conditions that permit the retention of ingested water.

METHODS

Volunteers collected urine q2h plus an overnight specimen; water loading was conducted after overnight food and water restriction; paired arterialized and venous blood samples were analyzed.

RESULTS

When 20 mL water/kg was consumed in <15 minutes, the peak urine flow rate was 11 +/- 0.6 mL/min. The volume of water retained after water intake stopped, and when the urine was hyperosmolar, correlated directly with the daily excretion of sodium plus potassium (r(2)= 0.63). The plasma sodium concentration (P(Na)) was 4.0 +/- 0.5 mmol/L lower in arterialized than paired venous blood 30 to 40 minutes after water ingestion began (P < 0.01). In preliminary studies, the smallest water load consumed in 15 minutes that would reproducibly cause a water diuresis was defined in each subject. This same acute water load was retained, however, if it contained 150-mmol/L fructose, but not glucose, or if it was consumed slowly (sipping). The arterialized P(Na) was not significantly lower than in paired venous samples when water was sipped.

CONCLUSION

A large fall in arterialized and not venous P(Na) best reflected the signal to induce a water diuresis. Although a very large water load can induce a water diuresis, smaller water loads can be retained for future heat dissipation.