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-   -   Diabetes, Ketones, & DKA (https://www.diabetesforum.com/diabetes-symptoms/98623-diabetes-ketones-dka.html)

Hearts Jounrey 08-20-2018 06:26

Diabetes, Ketones, & DKA
 
Here is my understanding of the dynamics of ketones. I will list a series of cases below to show different profiles of non diabetes, diabetes, hyperglycemia, ketones and DKA. Does this sound right?

A glucose 100 - ketones negative DKA = no Dx - non diabetic Not on keto diet
B glucose 125 - ketones positive 2.0 mmol DKA = no Dx - non diabetic On keto diet
C glucose 500 - ketones positive 5.0 mmol DKA = yes Dx - Type 1 Not on keto diet
D glucose 300 - ketones positive 3.5 mmol DKA = yes Dx - Type 1.5 Not on Keto diet
E glucose 600, - ketones negative DKA = no Dx - Type 2 Not on keto diet

According to Volek and Phinney in their best-selling book "The Art and Science of Low-Carbohydrate Living", nutritional ketosis is defined by serum ketones ranging from 0.5 to 3.0 mM. ... The level of ketones in ketoacidosis are 3-5 times higher than in ketosis resulting from a ketogenic diet.


Hearts Jounrey 08-20-2018 17:11

This is an updated version of the post above on Diabetes, Ketones, & DKA

Here is my understanding of the dynamics of ketones. I will list a series of 7 scenarios below to show different profiles of individuals. Of interest, case #6 below can have very high levels of glucose as a type 2 but no ketones in blood (no DKA)

1 glucose 100 - ketones negative - DKA = no - non diabetic No keto diet
2 glucose 125 - ketones pos 2.0 mmol - DKA = no non diabetic Ketosis state
3 glucose 500 - ketones positive 5.0 mmol DKA = yes - Type 1 No keto diet
4 glucose 150 - ketones negative 0.2 mmol DKA = no - Type 1 No keto diet
5 glucose 300 - ketones positive 3.5 mmol DKA = yes - Type 1.5 No Keto diet
6 glucose 600 - ketones negative 0.0 mmol DKA = no - Type 2 No keto diet
7 glucose 250 - ketones pos 1.5 mmol DKA = no - Type 2 Ketosis stat

According to Volek and Phinney’s book, "The Art and Science of Low-Carbohydrate Living", nutritional ketosis is defined by serum ketones ranging from 0.5 to 3.0 mM. The level of ketones in ketoacidosis are 3-5 times higher than in ketosis resulting from a ketogenic diet.

DKA = glucose over 250 + ketones + no keto diet no ketosis state

*Highly unusual for type 2 diabetics to have ketones in bloodstream if not on keto diet / in ketosis state

One question. Can someone who is not diabetic with normal glucose level and not in ketosis state still have elevated ketones? Can an infection alone or dehydration cause build up of ketones?

Cricket 08-20-2018 17:36

My ketones are higher when I am dehydrated, so I kind of wonder if non-diabetics might experiences that as well.

Squawkx 08-20-2018 23:26

I am out of my league, I don't know what most of this means. But, keep up the good work!

Hearts Jounrey 08-21-2018 00:32

i found out the answer to my own question. Glad i have a non stop motor

There is such a condition as non diabetic DKA where:

a person is non diabetic, normal glucose numbers, hi ketones, and DKA

They can enter this phase by:

1. Get severe infection that creates ketones in blood stream which leads to DKA
2. Starvation
3. alcoholism

Ronnie 06-17-2019 03:10

HEARTS JOURNEY, Thank you for posting this. My husband must stay in theraputic ketosis to prevent seizures. He is T1 Diabetic. I use the GKI index as posted by Keto Mojo to determine what Ronnie's state of Ketosis is. It uses the ketones and the BG to determine the GKI. https-//keto-mojo.com/pages/glucose-ketone-index-gki
I haven't been able to figure out how to keep him in therapeutic Ketosis, overnight.......Most of the time he is still in ketosis but not therapeutic level.I think I did prevent DKA by vigilance when he had the flu very recently. I checked his ketones and BG every 90 minutes. When his Ketones were at the top of the therapeutic level, I gave him a glucose tab and insulin to account for that many carbs. OH, did I mention that his BG was in range so I didn't dare bring it any lower with just insulin. I also caused him to force as much fluids as he could tolerate. I had read that euglycemic DKA is too little insulin with normal bg. Can anyone comment with good knowledge of normal blood sugar but euglycemic DKA.

Hearts Jounrey 06-17-2019 04:21

My reply
 
as you know, diabetic ketoacidosis (DKA) is one of the most serious complications of diabetes (type 1). It is characterised by the combo of hyperglycemia >250 mg/dl), metabolic acidosis which is arterial pH <7.3 and serum bicarbonate <18 mEq/L) and ketosis. But once in a great while, these patients can present with blood glucose levels of less than 200 mg/dl, which is defined as euglycemic DKA.

The possible set of causes of euglycemic DKA includes recent use of insulin, decreased caloric intake, heavy alcohol consumption, chronic liver disease and glycogen storage disorders.

The recent use of sodium glucose cotransporter 2 (SGLT2) inhibitors (often used for type 2 but off label can be used for Type 1 to improve glucose levels) has shed light on another possible contributor of euglycemic DKA

Question. does your husband use SGLT2 inhibitors? i know he is on insulin. If he is running glucose levels say from 80 to 180 (below 200) but his ketone therapeutic levels are what 1.5 mmol to 3 mmol or are they higher like 5 ?

Has he received intravenous fluids and electrolyte replacement?

euDKA could be completely missed if just looking at the serum blood glucose alone. and yes admin of insulin if he has normal or Pre D could be risky as you dont want him having hypos (under 60)

Quote:

Originally Posted by Ronnie (Post 1320207)
HEARTS JOURNEY, Thank you for posting this. My husband must stay in theraputic ketosis to prevent seizures. He is T1 Diabetic. I use the GKI index as posted by Keto Mojo to determine what Ronnie's state of Ketosis is. It uses the ketones and the BG to determine the GKI. https-//keto-mojo.com/pages/glucose-ketone-index-gki
I haven't been able to figure out how to keep him in therapeutic Ketosis, overnight.......Most of the time he is still in ketosis but not therapeutic level.I think I did prevent DKA by vigilance when he had the flu very recently. I checked his ketones and BG every 90 minutes. When his Ketones were at the top of the therapeutic level, I gave him a glucose tab and insulin to account for that many carbs. OH, did I mention that his BG was in range so I didn't dare bring it any lower with just insulin. I also caused him to force as much fluids as he could tolerate. I had read that euglycemic DKA is too little insulin with normal bg. Can anyone comment with good knowledge of normal blood sugar but euglycemic DKA.


Ronnie 06-17-2019 20:46

I spoke with Ronnie's endocrinologist and he said that my approach was correct and keeping Ronnie out of the er if possible was a reasonable thing to do. He knows me and my background. I would not be careless with my husbands life. Dealing with in range blood sugar and out of range ketones required some forthought , loss of sleep and I will be better armed and prepared if it happens again. The DOC felt I had done exactly what the hospital would have done only by the oral route instead of the IV route. The DOC is 61 years T1 Diabetic himself.

Quote:

Originally Posted by Hearts Jounrey (Post 1320209)
as you know, diabetic ketoacidosis (DKA) is one of the most serious complications of diabetes (type 1). It is characterised by the combo of hyperglycemia >250 mg/dl), metabolic acidosis which is arterial pH <7.3 and serum bicarbonate <18 mEq/L) and ketosis. But once in a great while, these patients can present with blood glucose levels of less than 200 mg/dl, which is defined as euglycemic DKA.

The possible set of causes of euglycemic DKA includes recent use of insulin, decreased caloric intake, heavy alcohol consumption, chronic liver disease and glycogen storage disorders.

The recent use of sodium glucose cotransporter 2 (SGLT2) inhibitors (often used for type 2 but off label can be used for Type 1 to improve glucose levels) has shed light on another possible contributor of euglycemic DKA

Question. does your husband use SGLT2 inhibitors? i know he is on insulin. If he is running glucose levels say from 80 to 180 (below 200) but his ketone therapeutic levels are what 1.5 mmol to 3 mmol or are they higher like 5 ?

Has he received intravenous fluids and electrolyte replacement?

euDKA could be completely missed if just looking at the serum blood glucose alone. and yes admin of insulin if he has normal or Pre D could be risky as you dont want him having hypos (under 60)


Ronnie 06-17-2019 20:49

Ronnie only takes novolog, armour thyroid, lactulose, a multi vitamin, calcium and magnesium with potassium. No SGLt inhibitors.
The source of his i problem was a flu virus including fever, cough, congestion, diarrhea.


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