Starvation ketoacidosis

Background

• Eating disorders, prolonged fasting, severely calorie-restricted diets, restricted access to food (low socioeconomic and elderly patients) may be causes of starvation ketoacidosis.
• When insulin levels are low and glucagon levels are high (such as in a fasting state), long chain fatty acids and glycerol from triglycerides are released from peripheral fat stores and are transported to the liver. The fatty acids undergo beta-oxidation and generate acetyl-CoA. However, with excessive amounts of acetyl-CoA, the Krebs cycle may become oversaturated, and instead the acetyl-CoA enter the ketogenic pathway resulting in production of ketone bodies.
• Mild ketosis (1mmol/L) results after fasting for approximately 12 to 14 hours. However, the ketoacid concentration rises with continued fasting and will peak after 20 to 30 days (8-10mmol/L).

Clinical Features

• Nausea and vomiting
• Abdominal pain
• Dehydration
• Altered mental status
• Fatigue
• Kussmaul breathing

Differential Diagnosis

• Diabetic ketoacidosis
• Alcoholic ketoacidosis
• Lactic acidosis
• Toxic alcohol (methanol or ethylene glycol) ingestion
• Uremia
• Salicylate toxicity
• Sepsis

Evaluation

• Serum chemistry (elevated anion gap)
• Glucose (usually euglycemic or hypoglycemic)
• Urinalysis (ketonuria)
• Serum beta-hydroxybutyrate
• Lactate
• Salicylate level (if overdose suspected)
• Serum osmolality (if toxic alcohol ingestion suspected)

Management

Dextrose and saline solutions

• Dextrose
  • Will cause increase in insulin and decrease in glucagon secretion, which will reduce ketone production and increase ketone metabolism
  • Beta-hydroxybutyrate and acetoacetate will regenerate bicarbonate, causing partial correction of metabolic acidosis
• Saline or lactated ringer
  • Will provide volume resuscitation and will in turn reduce secretion of glucagon (which promotes ketogenesis)

Considerations

• Rate of infusion dependent on volume status
• If hypokalemic, need to correct before administering glucose (as glucose stimulates insulin production which will drive K into cells and worsen hypokalemia)

Disposition

• If mild, can be discharged after correction of acidosis, electrolytes, and hypovolemia
• If severe, admit for close monitoring

See Also

• Alcoholic ketoacidosis
• Diabetic ketoacidosis