Controversies around the measurement of blood ketones to diagnose and manage diabetic ketoacidosis
Open accessAbstract
The measurement of blood ketones in preference to urine ketones has become a well-established tool in the diagnosis and management of diabetic ketoacidosis (DKA). However, there remains considerable disparity between diabetes guidelines regarding if, how, and when this test should be used. While recent guidelines now mainly emphasize blood measurement, several issues nonetheless remain. Many laboratories still measure blood ketones using a semiquantitative test that does not measure the predominant ketone, β-hydroxybutyrate (BOHB), which may hinder patient management. Even when BOHB is measured, the evidence for cutoffs used in DKA diagnosis or exclusion is limited, while its use in gauging severity, treatment progress, and resolution is not fully clear. Lastly, although employing point-of-care meters instead of a laboratory for BOHB measurement brings undoubted benefits, this approach has its own challenges. This article provides a perspective on these topics to complement current recommendations and to suggest how future research may improve its use in the DKA context.
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Assay methods for ketones that do not include measurement of βOHB may provide misleading clinical information by underestimating total ketone body concentration.
“Thus, assay methods for ketones that do not include measurement of bOHB may provide misleading clinical information by underestimating total ketone body concentration (295,299).”
From Guidelines and Recommendations for Laboratory Analysis in the Diagnosis and Management of Diabetes Mellitus (2023) · cites this paper as [299]
Blood ketone determinations that measure beta-hydroxybutyrate specifically are useful for both diagnosis and ongoing monitoring of diabetic ketoacidosis.
“Blood ketone determinations that measure bOHB specifically are useful for both diagnosis (299,301) and ongoing monitoring of DKA (298,299).”
From Guidelines and Recommendations for Laboratory Analysis in the Diagnosis and Management of Diabetes Mellitus (2023) · cites this paper as [299]
Individuals with well-documented diabetic ketoacidosis generally have beta-hydroxybutyrate concentrations greater than 2 mmol/L.
“Individuals with well-documented diabetic ketoacidosis (serum bicarbonate <15 mmol/L, arterial pH <7.3, plasma glucose >14.9 mmol/L [250 mg/dL]) generally have bOHB concentrations >2 mmol/L (299).”
From Guidelines and Recommendations for Laboratory Analysis in the Diagnosis and Management of Diabetes Mellitus (2023) · cites this paper as [299]
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- Authors
- Kilpatrick, E. S., Butler, A. E., Ostlundh, L., Atkin, S. L., & Sacks, D. B.
- Affiliations
- Manchester Royal Infirmary (GB)
- Royal College of Surgeons in Ireland - Bahrain (BH)
- College of Medicine and Health Sciences, United Arab Emirates University, Al Ain
- National Institutes of Health (US)
- Venue
- Diabetes Care
- Publisher
- American Diabetes Association
- Published
- 2022-01-17
- Volume
- 45
- Issue
- 2
- Pages
- 267-272
- ISSN
- 0149-5992 (ISSN-L)
- PMC
- PMC8897555
- OpenAlex
- W4206613598
- Semantic Scholar
- 01a47fd506ad9246bb4f39a904c087d4a3bbe820
- Cited by
- 41
- References
- 29
- Citations by year
- 2026: 12 · 2025: 8 · 2024: 10 · 2023: 8 · 2022: 3
- FWCI
- 1.03
- Type
- journal article
- Language
- en
- Update notices
- correction (2022-03-03)
- Open access
- bronze
- doi.org
- Locations
- Diabetes Care (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Figshare (submittedVersion, cc-by-nd)
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
- Health Sciences › Medicine › Physiology › Clinical Laboratory Practices and Quality Control
- Health Sciences › Medicine › Physiology › Diet and metabolism studies
- Keywords
- diabetic ketoacidosis, beta-hydroxybutyrate, urinary ketones, diabetes guidelines, ketone testing
- MeSH terms
- Diabetes Mellitus, Humans, Ketones, Diabetic Ketoacidosis, Point-of-Care Systems, 3-Hydroxybutyric Acid
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