Research Article

Alcoholic ketoacidosis: an underdiagnosed condition?

Br Med J (Clin Res Ed) 1986; 292 doi: https://doi.org/10.1136/bmj.292.6518.463 (Published 15 February 1986) Cite this as: Br Med J (Clin Res Ed) 1986;292:463

Under-diagnosis of alcoholic ketoacidosis may be fatal - A major concern. Re: Alcoholic ketoacidosis: an underdiagnosed condition?

We read with interest the research article expressing apprehension that alcoholic patients with alcoholic ketoacidosis are underdiagnosed (1).There is increasing evidence that rather than being benign and self-limiting, alcoholic ketoacidosis may be a significant cause of mortality in patients with alcohol dependence(2).

Background:
Alcoholic ketoacidosis is characterised by metabolic acidosis with an elevated anion gap, elevated serum ketone levels, and a normal or low glucose concentration.(2.3) Alcohol dehydrogenase (ADH), a cytosolic enzyme, metabolizes alcohol to acetaldehyde in hepatocytes. Acetaldehyde is metabolized further to acetic acid by aldehyde dehydrogenase producing significantly higher beta-hydroxybutyric acid with other ketone bodies, which in turn, causes an elevated ratio of the reduced form of nicotinamide adenine dinucleotide (NADH) to nicotinamide adenine dinucleotide (NAD +) leading to altered redox status in hepatic mitochondria.

In contrast to diabetic ketoacidosis, the predominant ketone body in AKA is β-OH butyric acid. Routine clinical assays for ketonemia test are done for AcAc and acetone but not for beta-hydroxy butyric acid and therefore, lab reports misguide clinicians and they underestimate the degree of ketonemia. In AKA, the increased ratio of NADH/NAD+ increases the proportion of beta hydroxybutyrate relative to acetoacetate. (4)

Although well described in international emergency medicine literature, UK emergency physicians rarely make the diagnosis of AKA (2)

Lab-diagnosis with advanced Glucose/Ketone meter:
Blood ketone testing methods that quantify beta-hydroxybutyrate, the predominant ketone body in AKA, are recommended over urine ketone testing for diagnosing and monitoring ketoacidosis. Capillary blood samples are not only preferred over urine samples to detect and monitor AKA, they are also easier to obtain and allow for immediate reflex testing of ketones. (5)

Blood beta-hydroxyburyrate testing indicates the patient’s status at the time of the test, whereas urine may have been in the bladder for several hours. Urine testing can also produce false positive or negative results due to highly colored urine, highly acidic urine, exposure of the urine test strips to air for prolonged periods, drugs such as the ACE inhibitor captopril, or high doses of vitamin C.(5)

Conclusion:
Beta-hydroxybutyric acid being the predominant ketone body in alcoholic ketoacidosis, use of new glucose/ketone meters may be considered to monitor metabolic acidosis in alcoholic patients to avoid complication and reduce hospital stay. (5)

Ananya Pramanik, Lecturer

Victor Brown Jr, Student

Tanu Pramanik, Professor & Principal

Careers Abroad Institute School of Medicine, #32, Hargreaves Avenue, Mandeville, Manchester, Jamaica, WI
www.caisom.org Email: info@caisom.org

References:
1. Thompson C J et al. Research Article: Alcoholic ketoacidosis: an underdiagnosed condition? Br Med J (Clin Res Ed) 1986; 292 doi: https://doi.org/10.1136/bmj.292.6518.463 (Published 15 February 1986)
2. L C McGuire L C, Cruickshank A M, Munro P T. Alcoholic ketoacidosis. Emerg Med J. 2006 Volume 23, Issue 6.
2. Adams SL. Alcoholic ketoacidosis. Emerg Med Clin North Am. 1990 Nov. 8(4):749-60. [Medline].
3. Harper JP. Alcoholic ketoacidosis. N Z Med J. 1997 Jan 24. 110(1036):18. [Medline]
4. Palmer JP. Alcoholic ketoacidosis: clinical and laboratory presentation, pathophysiology and treatment. Clin Endocrinol Metab. 1983 Jul. ID - AM17047/AM/NIADDK(2):381-9. [Medline].
5. Costa, R. F., Vivé, E. G., Badia, A. R., Corsa, L. L., & Santos, D. P. (2009, October). Evaluación del glucómetro de uso hospitalario StatStrip (Nova) y estudio comparativo en pacientes ingresados en la uci [Evaluation of hospital use StatStrip glucometer (Nova) and comparative study in patients admitted to the ICU]. Poster session presented at the meeting of the Congreso Nacional del Laboratorio Clínico, Valencia, Spain. http://www.novabio.us/statstrip-ketone/.

Competing interests: No competing interests

16 April 2018
Tanu Pramanik
Professor & Principal
Ananya Pramanik, Lecturer, Victor Brown Jr,Student
Careers Abroad Institute School of Medicine
#32, Hargreaves Avenue, Mandeville, Manchester, Jamaica, WI