Thread by @agrawalkris

😇Acidosis in DKA: Why the Gap⁉️
Hello, #nephtwitter, hope you enjoyed the latest blog post renalfellow.org/2020/08/13/the…
Let’s talk all about
⚡Diabetic Ketoacidosis⚡………
⚡Are you ready⁉️
💥#Tweetorial #DKA #Acidosis #Aniongap @theskeletonKG #NSMC @podkopiluwak💥

2a/💢 Let’s consider a 44 yo M presents with altered mentation🧠. ✨He has a fruity odor on his breath. Glucose was 1000 with serum bicarb of 10.
✨Urine dipstick was negative for ketones. Is this patient in DKA❓

2b/ What is responsible for his fruity fetor?

2c/Let’s read on to deduce the answer:
💢DKA is a metabolic state associated with pathologically ⏫ serum and urine concentrations of ketone bodies, namely
🔥Acetone
🔥Acetoacetate, and
🔥beta-hydroxybutyrate.
ncbi.nlm.nih.gov/books/NBK53484…

3/ Before proceeding let’s check🤔 our basics🧐
Which of the following is a cause of non anion gap metabolic acidosis❓

4/ Yes ☑️, it's Diarrhea
💥 Very simple mnemonics to remember the causes👇👇

5a/ So why is there ketoacidosis in DKA❓
🌠Insulin regulates ketogenesis
🌠Low insulin state leads to the following👇👇

5b/ (1) ⏫Lipolysis
-means increased fatty acids in circulation for delivery to the liver
🌟Insulin usually inhibits lipase🚫
🌟In its absence, hormones like Epi, NE, Cortisol, GH result in FFA generation

5b/ (2) ⚡⚡Alteration of hepatic metabolism, so that formation of ketones occurs.

💦FFA in liver is degraded to
✨TG synthesis
✨B oxidation in mitochondria

5b/ (3)⚡⚡Insulin also stimulates acetylCoA carboxylase.
In its absence, acetylCoA activity is ⤵️ so substrates cannot enter the Kreb’s cycle⇏
glucagon allows FFA to enter ⏩into mitochondria via carnitine shuttle
pubmed.ncbi.nlm.nih.gov/24286946/

6/ 🔥Acetoacetate is the initial ketone body.

💦It is converted to β-hydroxybutyrate and acetone.

💦Acetoacetate and β-hydroxybutyrate are strong acids and their accumulation will lead to acidosis.

7/ Which of the ketone bodies is true keto acid chemically❓

8a/ Yup 🎯 it's Acetoacetic acid..

💡Knowing that, which ketone body is detected on urinary dipstick?

8b/ #/ 🌟Urine dipstick 🧪 only detects acetoacetate.

⚡⚡A low or negative ketone test on urine dipstick does not rule out DKA⚡⚡
📝Remember to check serum beta hydroxybutyrate.
zora.uzh.ch/id/eprint/1274…

9/ 💦Acetone is responsible for the distinctive smell on the breath of patients with DKA.

✨Normally, Acetoacetate and β-hydroxybutyrate are present in 1:1 concentration.

✨In DKA,the ratio is shifted towards β-hydroxybutyrate upto 10:1.
onlinelibrary.wiley.com/doi/full/10.10…

10/ 💥Insulin deficiency also leads to other clinical signs of DKA
✨⤵️ glucose utilization
✨⬆️glycogenolysis
✨leading to hyperglycemia
✨Leading to osmotic diuresis (aggravated by ketonuria), loss of water and electrolytes and dehydration.

zora.uzh.ch/id/eprint/1274…

11/ Finally to summarize🎯
💥DKA is metabolic acidosis due to accumulated ketone bodies.
🔥A low or negative ketone test on urine dipstick does not rule out DKA.