D-3-Hydroxybutyrate & Diabetic Ketoacidosis
D-3-Hydroxybutyrate & Diabetic Ketoacidosis
Diabetic Ketoacidosis is characterised by an accumulation of ketone bodies in response to insulin deficiency, most commonly occurring in T1DM patients, but is becoming increasingly prevalent among sufferers of T2DM.
Diabetic ketoacidosis is associated with symptoms such as polyuria, polydipsia, fever, vomiting, abdominal pain and fatigue with the most severe cases resulting in disastrous consequences such as cerebral oedema and death.
D-3-Hydroxybutyrate is considered to be the predominant ketone bodies associated with diabetic ketoacidosis and novel methods of detection utilise this biomarker to provide robust and accurate quantification of ketone bodies and aid in confident diagnosis of diabetic ketoacidosis.
This guide discusses the physiological and pathological processes associated with diabetic ketoacidosis and the relevant biomarkers, the complications associated with this condition and classic and novel detection methods.
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Featured Reagent – D-3-Hydroxybutyrate (Ranbut)
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Benefits of D-3-Hydroxybutyrate
Superior Methodology – The commercially available nitroprusside method is a semi-quantitative dipstick test which only detects acetone and acetoacetate. As the most abundant ketone produced during ketosis, D-3-hydroxybutyrate is more sensitive and specific.
Excellent precision – The Randox Ranbut assay displayed an excellent precision of <3.5%.
Exceptional correlation – A correlation coefficient of r=0.9954 was displayed when the Randox method was compared against other commercially available methods.
Wide Measuring Range – The Randox Ranbut assay has a measuring range of 0.100 – 5.75mmol/l for the comfortable detection of clinically important results.
Calibrator and controls available – Randox offer a complete testing package.
Applications available – Detail of instrument-specific settings for the convenient use of the Randox Ranbut assay on a variety of clinical chemistry analysers.
Traditional Methods
Ketogenesis is a biochemical process whereby the body produces ketone bodies (acetone, acetoacetate, beta-hydroxybutyrate). As ketone bodies are water soluble, they do not require lipoproteins for transport 1.
In healthy humans, small amounts of ketones are continuously made for the body to use an energy source. Ketone bodies increase in times of fasting and sleeping 1.
Physiological Significance
Urinalysis is an essential part of the diagnostic review for kidney disease and other renal impairments. Whilst the dipstick test allows for rapid and simultaneous chemical analyses of urine, including ketones, the chemical reactions on dipsticks are complicated and can be affected by oxidising, reducing, and discolouring substances in urine. Therefore, false positives and false negative results are common in dipstick testing 4.
Clinical Significance
When the carbohydrate stores are significantly decreased, or the fatty acid concentration is increased, there is an upregulation of the ketogenic pathway and consequently, an increased production of ketone bodies. This is commonly observed in alcoholism, type I diabetes and starvation. Most organs, including the brain, can utilise ketones whereas the heart utilises fatty acids as its source of energy, but can also use ketones. The liver however, cannot utilise ketones, despite producing them as the liver lacks the necessary enzyme ketoacyl-CoA transferase 1.
Ketosis is the presence of ketones. Whilst ketosis is not dangerous, if left untreated, especially in diabetes, ketoacidosis (high levels of ketones) develops 2.
In type 1 diabetes mellitus (T1DM), the body is unable to produce insulin resulting in bodily cells not receiving energy from glucose, causing the body to release hormones to breakdown fat for energy, producing ketones. If left untreated, diabetic ketoacidosis develops, a serious health condition. Diabetic ketoacidosis is commonly triggered by an illness, infection or missing insulin treatments 3.
References
[1] Dhillon KK, Gupta S. Biochemistry, Ketogenesis. Treasure Island: StatPearls Publishing; 2020. https://www.ncbi.nlm.nih.gov/books/NBK493179/ (accessed 28 September 2020).
[2] Hecht M. Ketosis vs. Ketoacidosis: What You Should Know. https://www.healthline.com/health/ketosis-vs-ketoacidosis (accessed 28 September 2020).
[3] Mayo Clinic. Diabetic ketoacidosis. https://www.mayoclinic.org/diseases-conditions/diabetic-ketoacidosis/symptoms-causes/syc-20371551 (accessed 28 September 2020).
[4] Han TH. Urinalysis: The Usefulness and Limitations of Urine Dipstick Testing. Journal of the Korean Society if Pediatric Nephrology 2013; 17(2): 42-48.
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D-3-Hydroxybutyrate (Ranbut)
Reagent | D-3-Hydroxybutyrate (Ketone)
Powered by BiozD-3-Hydroxybutyrate: A Superior Marker of Ketoacidosis
Benefits of the Randox D-3-Hydroxybutyrate (Ketone) Assay
Superior methodology
The commercially available nitroprusside method is a semi-quantitative dipstick test which only detects acetone and acetoacetate. As the most abundant ketone produced during ketosis, D-3-hydroxybutyrate is more sensitive and specific.
Exceptional correlation
A correlation coefficient of r=0.9954 was displayed when the Randox method was compared against other commercially available methods.
Excellent precision
The Randox Ranbut assay displayed an excellent precision of <3.5%.
Calibrator and controls available
Calibrator and controls are available offering a complete testing package.
Applications available
Applications available detailing instrument-specific settings for the convenient use of the Randox Ranbut assay on a variety of clinical chemistry analysers.
Ordering Information
| Cat No | Size | ||||
|---|---|---|---|---|---|
| RB1007 | 10 x 10ml (S) | Enquire | Kit Insert Request | MSDS | Buy Online |
| RB1008 | 10 x 50ml (S) | Enquire | Kit Insert Request | MSDS | Buy Online |
| (L) Indicates liquid option (S) Indicates standard included in kit | |||||
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Diagnostic Uses
Ketosis is a metabolic process that occurs when the body switches from glucose to predominantly fat metabolism for energy production, this happens when carbohydrate availability reaches low levels. The metabolism of fatty acids in the liver results in the production of chemical by-products known as ketone bodies or ketones. Ketosis occurs when the body produces more ketones than the liver can process.
DKA is a serious complication of both Type I Diabetes Mellitus (T1DM), however can also affect individuals with T2DM. The condition is linked to insulin deficiency and occurs when glucose levels are consistently high and insulin levels are severely low. Due to this imbalance glucose builds up in the blood and the body responds by metabolising fat rather than glucose. DKA is usually one of the first indicators of T1DM.
Ketosis is not normally dangerous and is typical of ketogenic diets which are low in carbohydrates. Ketones however are poisonous when present in high levels leading to ketoacidosis, DKA for example if left untreated can cause damage to vital organs and in some instances may lead to a coma or death. DKA is commonly triggered by an illness, infection or missing insulin treatments.
The American Diabetes Association recommends testing for ketosis in diabetics when symptoms of ketoacidosis are present, when
glucose levels are consistently elevated, during pregnancy and if experiencing any illness. NICE also recommend monitoring ketones in patients with T1DM especially during periods of illness.
Semi-quantitative, nitroprusside-based methods remain common for the detection of ketones in the blood and urine of diabetic patients. The nitroprusside method is available in both tablet and reagent test strip form where urine or blood is applied, and a colour change observed. There are several limitations associated with Nitroprusside methods;
- Capable of detecting only acetone and acetoacetate, as such they lack sensitivity especially in early stages of DKA.
- The intensity of the colour change observed is subjective compared to quantitative methods like D-3-Hydroxybutyrate which can be used to monitor recovery and improvements to treatment.
- Several medications including Valproic Acid and Vitamin C can interfere with nitroprusside methods leading to false positive
results. - False negative results are common as the method does not detect the main ketone body – D-3-Hydroxybutyrate. As ketoacidosis improves and D-3-Hydroxybutyrate is converted to acetoacetate the result with urine dipsticks can appear positive despite the patient’s status improving by this stage.
- D-3-Hydroxybutyrate is a more reliable indicator of ketosis and DKA due to its superior stability when compared to acetone and
acetoacetate.
When the carbohydrate stores are significantly decreased, or the fatty acid concentration is increased, there is an upregulation of the ketogenic pathway and consequently, an increased production of ketone bodies. This is commonly observed in alcoholism, type I diabetes and starvation. Most organs, including the brain, can utilise ketones as its source of energy. The liver however, cannot utilise ketones, despite producing them, as the liver lacks the necessary enzyme ketoacyl-CoA transferase 1.
Ketosis is the presence of ketones. Whilst ketosis is not dangerous, if left untreated, especially in diabetes, ketoacidosis (high levels of ketones) develops 2.
In type 1 diabetes mellitus (T1DM), the body is unable to produce insulin resulting in bodily cells not receiving energy from glucose, causing the body to release hormones to breakdown fat for energy, producing ketones. If left untreated, diabetic ketoacidosis develops, a serious health condition. Diabetic ketoacidosis is commonly triggered by an illness, infection or missing insulin treatments 3.
There are three main ketones produced as a result of ketosis; D – 3 – Hydroxybutyrate, acetoacetate and acetone.
D-3-Hydroxybutyrate is the most abundant of the three accounting for 75% of total ketones in the body, it is later catabolised into acetoacetate and then into acetone. Due to the higher levels of D-3-Hydroxybutyrate, it is the more sensitive marker for the diagnosis of ketosis, in particular DKA.
Ketogenesis is a biochemical process whereby the body produces ketone bodies (acetone, acetoacetate, beta-hydroxybutyrate. As ketone bodies are water soluble, they do not require lipoproteins for transport 1.
In healthy humans, small amounts of ketones are continuously made for the body to use an energy. Ketone bodies increase in times of fasting and sleeping 1.
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References
[1] Dhillon KK, Gupta S. Biochemistry, Ketogenesis. Treasure Island: StatPearls Publishing; 2020. https://www.ncbi.nlm.nih.gov/books/NBK493179/ (accessed 28 September 2020).
[2] Hecht M. Ketosis vs. Ketoacidosis: What You Should Know. https://www.healthline.com/health/ketosis-vs-ketoacidosis (accessed 28 September 2020).
[3] Mayo Clinic. Diabetic ketoacidosis. https://www.mayoclinic.org/diseases-conditions/diabetic-ketoacidosis/symptoms-causes/syc-20371551 (accessed 28 September 2020).
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We can help create cost-savings for your laboratory through excellent stability, eliminating the requirement for costly test re-runs. Our quality reagents also come in a range of different kit sizes to reduce waste and for your convenience.
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Our traceability of material and extremely tight manufacturing tolerances ensure uniformity across our reagent batches. All of our assays are validated against gold-standard methods.
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Applications are available detailing instrument-specific settings for the convenient use of the Randox superior performance & unique assays on a wide variety of clinical chemistry analysers.
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Randox offer an extensive range of 115 assays across routine and niche tests, and cover over 100 disease makers. Our high performance assays deliver superior methodologies, more accurate and specific results compared to traditional methods.
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Our range of unique assays means that Randox are one of the only manufacturers to offer these tests in an automated biochemistry format.
The in vitro diagnostics market is continuously adapting to the changes in laboratory testing. Consequently, Randox have continued to reinvest in R&D to produce superior performance & unique tests offering laboratories choice, quality and innovation.
The Randox Lp(a) assay is calibrated in nmol/l and traceable to the WHO/IFCC reference material (IFCC SRM 2B) and provides an acceptable bias compared with the Northwest Lipid Metabolism Diabetes Research Laboratory (NLMDRKL) gold standard. A five-point calibrator with accuracy-based assigned target values (in nmol/l) is available, accurately reflecting the heterogeneity of the apo(a) isoforms.
The Randox bile acids test utilises an advanced enzyme cycling method which displays outstanding sensitivity and precision when compared to traditional enzymatic based tests. The Randox 5th Generation Bile Acids test is particularly useful in paediatrics where traditional bile acids tests are affected by haemolytic and lipaemic samples.
A superior assay from Randox, the vanadate oxidation method offers several advantages over the diazo method, including less interference by haemolysis and lipaemia, which is particularly evident for infant and neonatal populations.
The Randox Fructosamine assay utilises the enzymatic method which offers improved specificity and reliability compared to conventional NBT-based methods. The Randox enzymatic method does not suffer from non-specific interferences unlike other commercially available fructosamine assays.
Soluble transferrin receptor (sTfR) is a marker of iron status. In iron deficiency anaemia, sTfR levels are significantly increased, however remain normal in the anaemia of inflammation. Consequently, sTfR measurement is useful in the differential diagnosis of microcytic anaemia.
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World Diabetes Day: The Biggest Burden on the NHS
Diabetes
Approximately 400,000 people in the UK are living with type 1 diabetes, with over 29,000 being children and young people [1]. Type 1 diabetes affects 96% of all children with diabetes in England and Wales, with incidences increasing by approximately 4% each year.
Globally, the UK has the fifth highest rate of type 1 diabetes diagnosis in children (aged up to 14) with 85% of these children having no family history of the condition. Whilst the condition isn’t fatal and can be managed, it cannot be cured. Type 1 diabetes increases the risk of developing other health problems such as heart disease, stroke, foot and circulation problems, sight problems including blindness, nerve damage and kidney problems. However, many of these related conditions are preventable and it is recommended to stabilise blood sugar levels, attend diabetes appointments regularly and complete a diabetes course to educate patients and family members and prevent the risk of further help complications[2].
Diabetes in children
Children under five are at the highest risk of developing diabetic ketoacidosis due to a late diagnosis and it is also thought to be due to of lack of public knowledge of the signs and symptoms attributed to type 1 diabetes. Such symptoms include:
- Frequent urination as the kidneys are trying to expel excess sugar in the blood, resulting in dehydration which leads to extreme thirst.
- Increased hunger or unexpected weight loss because the body is unable to attain enough energy from food
- Slow healing cuts as high blood sugar levels can affect blood flow which can cause nerve damage.
- Fatigue as the body is unable to convert sugar into energy
- Irritable behaviour combined with other symptoms can be a means of concern
Diabetes and the NHS
Diabetes costs the NHS approximately £9.8 billion per year, an estimate of 10% of total expenditures. Hospital admissions of children and young people with diabetes presents a considerable burden on themselves, their families and the NHS. It is estimated that approximately 80% of these cases are potentially avoidable.
A report produced by the National Paediatric Diabetes Audit found that although the numbers of admissions didn’t significantly differ year to year, it highlighted differences in terms of socio-economic risk factors:
- Living in a deprived area increases the risk of hospital admissions which can be attributed to lack of education in the community about diabetic symptoms and the management of diabetes.
- Children below 5 years of age have a 35% increased risk of hospitalisation compared to those aged 5-9
- Females have a 33% increased risk of developing type 1 diabetes compared to males.
- Children with poor diabetes control have a twelve-fold increased risk of hospital admission
- Insulin pump users have a 27% increased risk of hospital admission compared to those who use insulin injections.
Figure A. Number of preventable paediatric diabetes admissions [3]
Prevention
There are campaigns in place to aid in the early diagnosis of type 1 diabetes which mainly focus on raising awareness of the signs and symptoms of diabetes. On this World Diabetes Day, it is important to know that it is not just simply the responsibility of the diabetic patient to prevent admission but the main responsibility lies with the diabetic teams that inform the families with children who are diagnosed with type 1 diabetes.
Paediatric diabetes teams should ensure that the families and the children receive structured education for self-management when diagnosed and throughout the illness. In doing so, the diabetic teams should implement blood ketone testing from diagnosis and utilise the nationally agreed hypoglycaemia management guidelines. It is also important that diabetic teams are fully aware of the patient characteristics associated with a greater risk of admission and that they use this knowledge to develop anti-admission strategies specifically tailored to the needs of each individual group.
Primary care practitioners should seek access to a specialist diabetic team who they can refer to when deciding if a patient requires admission to hospital. Furthermore, they should access blood glucose and ketone testing to identify patients at risk of diabetic ketoacidosis that require hospital admission.
How Randox can Help
Randox offer a range of assays to diagnosis and monitor diabetes and to monitor associated complications. Some of these tests are unique to Randox, including:
Fructosamine
The Randox fructosamine assay employs the enzymatic method which offers improved specificity and reliability compared to conventional NBT-based methods. The Randox enzymatic method does not suffer from non-specific interferences unlike other commercially available fructosamine assays.
D-3-Hydroxybutyrate (Ranbut)
The Randox D-3-Hydroxybutyrate (Ranbut) assay detects the most abundant and sensitive ketone in the body, D-3-Hydroxybutyrate. The Randox Ranbut assay is used for the diagnosis of ketosis, more specifically diabetic ketoacidosis. Other commercially available tests, such as the nitroprusside method, are less sensitive as they only detect acetone and acetoacetate, not D-3-Hydroxybutyrate.
Adiponectin
The Randox adiponectin assay is a biomarker in diabetes testing as adiponectin is a protein hormone responsible for regulating the metabolism of lipids and glucose and influences the body’s response to insulin. Adiponectin levels inversely correlates with abdominal visceral fat levels.
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References
[1] National Paediatric Diabetes Audit and Royal College of Paediatrics and Child Health, National Paediatric Diabetes Audit Report 2012-15: Part 2, 2017
[2] NHS, “Avoiding Complications” – Type 1 Diabetes, Available at: https://www.nhs.uk/conditions/type-1-diabetes/avoiding-complications/ [Accessed on 24th October 2018].
[3] “Potentially Preventable Pediatric Hospital Inpatient Stays for Asthma and Diabetes, 2003-2012”, www.hcup-us.ahrq.gov, 2015. [Online] Available: https://www.hcup-us.ahrq.gov/reports/statbriefs/sb192-Pediatric-Preventable-Hospitalizations-Asthma-Diabetes.jsp [Accessed 08-Nov-18]
The Keto Diet: Are the risks worth the benefits?
Diet trends have continued to evolve throughout the years with a strong influence from celebrities. Beginning in the 1930s the grapefruit diet aka the “Hollywood diet” started which encouraged eating a grapefruit with every meal. More recently an increasing amount of extreme diet trends have emerged. In 2004, Beyoncé started the master cleanse involving a concoction of hot water, lemon juice, maple syrup and cayenne pepper and even crazier was Reese Witherspoon’s “baby food diet”. The newest trend to materialise is the keto diet favoured by celebrities including Halle Berry and the Kardashians. However, the results for long term weight loss and the safety of the diet is still questioned.
What is the ketogenic diet?
The ketogenic diet is a low carb diet which involves drastically reducing carbohydrate intake and replacing it with fat. Initially, the purpose of the ketogenic diet was not to aid weight loss but was prescribed to aid in the treatment of tough-to-control epileptic seizures that were unresponsive to drugs. In the 1920s the diet was found to significantly reduce the frequency of seizures in children. However, the benefits for weight loss have also been realised as the carbohydrate reduction kicks the body into a natural fat burning state called ketosis. By starving the body of carbohydrates and sugars, the first fuel the body burns, the body looks for another source of fuel to retrieve its energy. The body becomes efficient at burning fat for energy whilst also turning fat into ketones in the liver which can supply the brain with energy.
Ketosis
The metabolism of fatty acids in the liver results in the production of ketone bodies. These comprise of three chemicals consisting of acetone (2%), acetoacetate (20%) and D-3-Hydroxybutyrate (78%) and this production is called ketogenesis. The ketone bodies are produced by the chemical acetyl-CoA predominantly in the mitochondrial matrix of liver cells. This process is necessary in small amounts particularly when carbohydrates are scarce, and glucose is not available as a fuel source.
The ketone bodies are water soluble allowing for the transportation across the inner mitochondrial membrane as well as across the blood brain barrier and cell membranes. This allows them to source the brain, heart and muscle with fuel. Interestingly, during starvation they are the major energy source for the brain, providing up to 75%.
The excess production of ketones can accumulate in the body creating a state of ketosis. This stage, although abnormal, is not considered harmful, which is why it is being promoted as a diet craze. However, due to the acidic nature of the ketone bodies, particularly D-3-Hydroxybutyrate, larger amounts of ketone bodies can cause the pH levels in the body to drop to dangerously acidic levels creating a state of ketoacidosis.
Ketoacidosis
The benefits of the keto diet have been well advertised and received a lot of celebrity support. With powerful celebrities such as Halle berry ‘swearing by it’ as it allows her to manage her diabetes, it is easy to see why so many are keen to try it. However, with little to no information about the long-term effects, should we be finding out more before trying it ourselves?
In 2006, a study was conducted reviewing the influence of a low-carbohydrate diet can have on ketoacidosis. In this study the patient who had no history of diabetes was placed on a strict low carbohydrate diet for four years. Although the patient showed a significant decrease in weight on the diet, they also experienced four episodes of ketoacidosis. Each time an episode occurred the patient was administered intravenous fluids and insulin which lead to their recovery, however each time they returned to the diet it wasn’t long before another ketoacidosis episode occurred. When the patient was placed on a diet containing normal amounts of carbohydrates their glucose levels returned to normal, preventing a ketoacidosis episode from occurring again. The more ketones in the blood, the more ill a person with ketoacidosis will become. Left untreated ketoacidosis can cause potentially fatal complications such as severe dehydration, coma and swelling of the brain.
Randox D-3-Hydroxybutyrate (Ranbut) Reagent
Randox Reagents offer a D-3-Hydrobutyrate assay designed to measure the major ketone lvels in the body, D-3-Hydroxybutyrate, allowing for an efficient diagnosis to be implemented. The superior methodology provides more accurate, reliable and specific results compared to the traditional dipstick method of ketone body measurement.
The benefits of the Randox D-3-Hydroxybutyrate (Ranbut) assay include:
- Excellent precision of less than 3.5% CV
- Exceptional correlation coefficient of r=0.9954 when compared against other commercially available methods.
- A wide measuring range of 0.100 – 5.75mmol/l, comfortably detecting levels outside of the healthy range, 0.4 – 0.5mmol/l.
- Enzymatic method for accurate and reliable results
- Reconstituted stability of 7 days when stored between +2 to +8⁰C
References
- Ketoacidosis during a low-carbohydrate diet. Shah, Panjak and Isley, William. s.l. : The new england journal of medicine, 2006, Vol. 354.
Instrument Specific Applications (ISA’s) are available for a wide range of biochemistry analysers. Contact us to enquire about your specific analyser.
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