Starvation Ketoacidosis

Aka: Starvation Ketoacidosis, Starvation Ketosis, Fasting Ketoacidosis, Fasting Ketosis

1. See Also
   1. Ketoacidosis
   2. Alcoholic Ketoacidosis
   3. Euglycemic Ketoacidosis
2. Pathophysiology
   1. See Ketoacidosis
   2. Fasting or starvation results in an inadequate Glucose supply for metabolic need
      1. Similar to Alcoholic Ketoacidosis (also related to inadequate Glucose)
   3. Ketone Bodies from Triglyceride metabolism (acetyl-CoA via ketogenic pathway) in the absence of Glucose
      1. Mild Ketosis (1 mmol/L) results from a 12-14 hour fast
      2. Moderate Ketosis (8-10 mmol/L) peaks
         1. Gradually after 20-30 days of inadequate calories (or within 3 days of Fasting)
         2. Serum bicarbonate ultimately falls and levels off at 18 mEq/L
3. Differential Diagnosis
   1. See Ketoacidosis
   2. Alcoholic Ketoacidosis
   3. Euglycemic Ketoacidosis
   4. Low-Carbohydrate Diet (<40-50 g/day)
      1. May results in mild Ketosis
4. Labs: Ketone Detection
   1. See Ketoacidosis
   2. Serum Beta-Hydroxybutyrate
      1. Primary metabolite of Ketone Bodies in most Ketoacidosis (includes Diabetic Ketoacidosis, Alcoholic Ketoacidosis)
   3. Urine Ketones
      1. Nitroprusside reaction detects acetone and Acetoacetate, but not Serum Beta-Hydroxybutyrate
      2. May be near normal despite significant Ketoacidosis (due to Beta-Hydroxybutyrate)
      3. Positive in Isoproteronol Poisoning (primarily due to acetone)
5. Labs: General Labs
   1. Metabolic Acidosis with Anion Gap
      1. Absent only in Isoproteronol Poisoning (since acetone is not a charged partical)
   2. Metabolic panel (chemistry panel)
      1. Serum Sodium
      2. Serum Potassium
      3. Serum Glucose
      4. Serum Creatinine
      5. Serum Calcium
      6. Serum Magnesium
      7. Serum Phosphorus
   3. Venous Blood Gas
   4. Serum Osmolal Gap
      1. Increased in Alcoholic Ketoacidosis and in toxic Alcohol ingestions (e.g. Methanol, ethylene gylcol, propyl Alcohol)
6. Management
   1. Differentiate from Diabetic Ketoacidosis, Euglycemic Ketoacidosis (SGLT2 Inhibitors), Alcoholic Ketoacidosis
      1. Insulin is not typically indicated in Starvation Ketoacidosis and Alcoholic Ketoacidosis
   2. Dextrose in crystalloid (NS, LR)
      1. Dextrose is critical in clearing Ketone Bodies
      2. In Alcoholic Ketoacidosis, Thiamine 100 mg is given prior to dextrose
   3. Electrolytes
      1. Monitor and replace Serum Potassium, Serum Magnesium, Serum Phosphorus
7. References
   1. Mehta and Emmett in Sterns and Traub (2019) UpToDate, Fasting Ketosis and Alcoholic Ketoacidosis, accessed 7/19/2019