Lactation Ketoacidosis: A Systematic Review of Case Reports

Starvation Ketoacidosis on the Acute Medical Take: An Easily Missed Complication of the Keto Diet

Starvation ketoacidosis represents one of the three forms of metabolic acidosis caused by the accumulation of ketone bodies within the blood stream. It can be easily missed in patients who present acutely and are found to have an unexplained or profound metabolic acidosis. Here, we present a life-threatening case of severe ketoacidosis in a breast-feeding mother without diabetes who was on a strict ketogenic diet. Although a ketogenic diet has been previously considered to be safe in non-pregnant individuals, its safety in breast-feeding mothers in the post-partum period is less known and may be associated with greater harm. Health professionals and mothers should be aware of the potential risks associated with a strict ketogenic diet when combined with breast-feeding, especially in the earlier stages of the post-partum period. Prompt investigation, diagnosis and immediate management is vital to avoid life-threatening complications. We report a case admitted on the acute medical take with starvation ketoacidosis associated with ketogenic diet and adequate calorie consumption who was breast-feeding at the time of admission.

LEARNING POINTS

Always check ketones in patients with an unexplained metabolic acidosis; there can be overlap between starvation, alcohol-related and lactic acidosis.Management of starvation ketoacidosis is often empirical, involving close monitoring of fluid status and electrolytes.Clinicians should discuss the risk of ketoacidosis associated with the ketogenic diet in women who plan to breast-feed and lose weight following pregnancy.

Pathology of Ketoacidosis in Emergency of Diabetic Ketoacidosis and Alcoholic Ketoacidosis: A Retrospective Study

This study is aimed at examining which factors are useful for the diagnosis and distinction of ketoacidosis. We recruited 21 diabetic ketoacidosis (DKA) and alcoholic ketoacidosis (AKA) patients hospitalized in Kawasaki Medical School General Medical Center from April 2015 to March 2021. Almost all patients in this study were brought to the emergency room in a coma and hospitalized. All patients underwent blood gas aspiration and laboratory tests. We evaluated the difference in diagnosis markers in emergencies between DKA and alcoholic ketoacidosis AKA. Compared to AKA patients, DKA patients had statistically higher values of serum acetoacetic acid and lower values of serum lactate, arterial blood pH, and base excess. In contrast, total ketone bodies, β-hydroxybutyric acid, and β-hydroxybutyric acid/acetoacetic acid ratio in serum did not differ between the two patient groups. It was shown that evaluation of each pathology such as low body weight, diabetes, liver dysfunction, and dehydration was important. It is important to perform differential diagnosis for taking medical histories such as insulin deficiency, alcohol abuse, or starvation as the etiology in Japanese subjects with DKA or AKA. Moreover, it is important to precisely comprehend the pathology of dehydration and alcoholic metabolism which would lead to appropriate treatment for DKA and AKA.

A Case of Severe Lactation Ketoacidosis in a Nondiabetic Mother on a Ketogenic Diet

Lactation ketoacidosis is a rare yet severe metabolic emergency that has been reported in breastfeeding mothers. Reduced carbohydrate intake during breastfeeding has been reported as a common trigger for ketoacidosis. We report the case of a 31-year-old mother without diabetes who presented with life-threatening lactation ketoacidosis after following a ketogenic diet while exclusively breastfeeding her newborn baby. She was managed in the intensive care unit with dextrose and insulin infusion to reverse ketoacidosis. With prompt treatment, the patient's ketoacidosis resolved within 24 hours, and she was discharged well 3 days later. We further discuss the underlying increased metabolic demand in lactating women that puts them at risk of ketoacidosis, underlining the importance of early recognition of lactation ketoacidosis and nutritional education for lactating women.

Late-onset multiple acyl-CoA dehydrogenase deficiency: an insidious presentation

Multiple acyl-CoA dehydrogenase deficiency (MADD) is a rare inborn error of metabolism that results in impairment of mitochondrial β-oxidation of fatty acids. It is inherited in an autosomal recessive manner and impairs electron transfer in the electron transport chain. The clinical manifestations of MADD are highly variable and include exercise intolerance, myopathy, cardiomyopathy, encephalopathy, coma and death. Early-onset MADD is often associated with a high mortality with significant number of patients presenting with severe metabolic acidosis, non-ketotic hypoglycaemia and/or hyperammonaemic presentations. While late-onset MADD is suggested to have a lower mortality, the severe encephalopathic presentations may well be under-reported as a diagnosis of MADD may not be considered.MADD is treatable with riboflavin and appropriate nutrition with a focus on prevention and early management of metabolic decompensation. The neonatal phenotype differs significantly from late-onset MADD, where diagnosis may be delayed due to heterogeneity in clinical features, atypical presentation and confounding comorbidities, together with lower awareness among physicians.This report describes a woman in her 30s who presented with acute-onset ataxia, confusion and hyperammonaemic encephalopathy requiring intubation. Subsequent biochemical investigation revealed a diagnosis of MADD. At present, there are no national guidelines in Australia for the management of MADD. This case highlights the investigation and treatment of late-onset MADD.

Severe lactation ketoacidosis presenting as a respiratory complaint

Ketoacidosis, a type of high anion gap metabolic acidosis, results from 1 of 3 etiologies: diabetic ketoacidosis, alcoholic ketoacidosis, or starvation ketoacidosis (SKA). In rare instances, young and otherwise healthy lactating women have been found to develop lactation ketoacidosis, a form of SKA, when the high energy requirements of breastfeeding are not met with adequate carbohydrate intake. We present the case of a 29-year-old woman who presented to our emergency department with respiratory distress and headache and was found to have severe lactation ketoacidosis. The patient was treated with infusions of dextrose and bicarbonate in the emergency department and medical intensive care unit. She was discharged without complication 3 days later, after nutrition and lactation consultation. This case highlights both the importance of maintaining a broad differential diagnosis that includes lactation ketoacidosis and performing a careful interview to identify patient populations at risk for this pathology.

The Role of Short-Chain Fatty Acids in Mediating Very Low-Calorie Ketogenic Diet-Infant Gut Microbiota Relationships and Its Therapeutic Potential in Obesity

As the very low-calorie ketogenic diet (VLCKD) gains increased interest as a therapeutic approach for many diseases, little is known about its therapeutic use in childhood obesity. Indeed, the role of VLCKD during pregnancy and lactation in influencing short chain fatty acid (SCFA)-producing bacteria and the potential mechanisms involved in the protective effects on obesity are still unclear. Infants are characterized by a diverse gut microbiota composition with higher abundance of SCFA-producing bacteria. Maternal VLCKD during pregnancy and lactation stimulates the growth of diverse species of SCFA-producing bacteria, which may induce epigenetic changes in infant obese gene expression and modulate adipose tissue inflammation in obesity. Therefore, this review aims to determine the mechanistic role of SCFAs in mediating VLCKD-infant gut microbiota relationships and its protective effects on obesity.