Ketones in Urine

Ketones in urine, or ketonuria, as the name suggests, is characterized by the presence of ketones or ketone bodies in the urine. Ketones build up in the body when fat cells are burned to produce energy.

This can be a dangerous condition if the amount of ketone is very high, particularly in people with diabetes who have high glucose levels.

Carbohydrates, fats, and proteins are metabolized by the body for the generation of energy, which is used for various metabolic and enzymatic processes within the cells. On a priority basis, carbohydrates are always metabolized for the production of energy. This is then followed by the metabolization of fats and proteins. However, in some instances when the body starts generating high proportions of energy by metabolizing fats or fatty acids, a waste product of this activity accumulates in the body, which is called ketone bodies. This is usually associated with a lack of sugar or carbohydrates in the diet. These ketones are known to be eliminated through the kidneys. Hence, doctors usually perform urine tests to identify the presence of excessive ketones in the body.

The concentration of ketone bodies in the urine under normal conditions is less than 20mg/dl. However, if this value rises to abnormal levels, it could be indicative of a condition known as ketoacidosis.

Some of the common symptoms of ketonuria are:

• Thirst: The body loses excess fluid during the increased excretion of ketones. This leads to increased thirst.
• Frequent urination: The body tries to excrete accumulated ketones, which are associated with an increased urge to urinate.
• Nausea or vomiting: As the body tries to get rid of excess amounts of ketones through urine, it increases the excretion of salts like sodium and potassium. Low levels of sodium and potassium may lead to symptoms like nausea and vomiting.
• Dehydration: Loss of excess fluids from the body through urination and vomiting may lead to dehydration.
• Heavy breathing: Labored breathing is a symptom associated with high levels of ketones in the blood.
• Dilation of pupils
• Confusion: This is a rare symptom and is a harmful effect of ketones in the blood and brain.

Symptoms are produced by the accumulation of ketone bodies. Another characteristic symptom of ketonuria is fruity-smelling breath. The fruity smell is caused by the presence of acetone. In serious conditions, ketonuria may result in coma or death.

As glucose is not converted into energy, the body depends on fats and muscles for the production of energy. Ketones are produced as a byproduct of this process. The ketones produced enter the blood, making it acidic.

These ketone bodies are excreted in the urine. If left untreated, ketone bodies may accumulate in the blood, resulting in hyperglycemia, ketoacidosis, and ketonuria. When ketone is excreted in urine, sodium is expelled along with it. Moreover, ketones may interfere with the excretion of uric acid, leading to depression and acidosis.

Ketonuria is associated with many conditions like starvation, dietary imbalance, digestive disturbances, eclampsia, prolonged vomiting and diarrhea, glycogen storage diseases, severe and strenuous exercise, fever, pregnancy, lactation, hyperthyroidism, and long-term exposure to cold temperatures.

Tests for ketones are performed with the help of test strips. The strips are dipped in a urine sample and are usually expressed as positive or negative. Testing for ketones is important if blood sugar levels are over 300 mg/dl and if you have fruity-smelling breath.

Breathlessness, frequent urination, dilated pupils, dry mouth, excessive thirst, nausea, vomiting, abdominal pain, and dry skin are some of the associated symptoms that warrant a ketone test. While preparing for the test, certain medications and supplements should be avoided. Change in the color of the dipstick indicates the presence of ketones in the urine.

Controlling blood sugar levels is the best way to avoid ketonuria. A healthy diet often helps control sugar levels in the blood. Those who are diabetic should control the disease to manage ketone levels in the blood. Lifestyle changes are also essential to manage ketone levels in the blood and urine. Avoiding a ketogenic diet is the best way to control the accumulation of ketones.

During digestion, components of food, including carbohydrates, fats, and proteins, are converted into products that can be used by tissues. Glucose is the most important fuel for performing different activities in the cells.

Glucose is delivered to different cells and tissues by the hormone insulin. In the absence of insulin, cells lack glucose to provide energy for tissues, including muscles. Diabetes mellitus is a disease in which the pancreas fails to produce enough insulin.

Due to this, an adequate amount of glucose is not delivered to the cells. Thus, the body tries to produce energy by breaking down muscle and fat. Ketones are byproducts of this breakdown process. Ketone bodies are made up of three components: beta-hydroxybutyric acid, acetoacetic acid, and acetone.

These ketone bodies enter the bloodstream and are eventually excreted through urine. Acetone is excreted through lungs, and this process provides a fruity smell to the breath. As the ketone bodies mix with blood, it becomes acidic.

When left untreated, glucose and ketone bodies accumulate in the blood. As the levels increase, they may develop into a serious condition. As ketones are excreted in urine, it may also cause the excretion of sodium and potassium along with it.

Ketonuria is also associated with other conditions like:

• Starvation: This is one of the less common causes of ketonuria. During periods of food deprivation, insulin levels decrease. Over several days of starvation, the brain changes glucose as the primary fueling agent. Thus, the body desperately tries to produce enough energy by depending on fats and muscles, creating ketone bodies as byproducts.
• Digestive disturbances: When carbohydrate intake and absorption are adequate, ketone synthesis is inhibited in the body. However, when digestive disturbances affect the intake or absorption of carbohydrates, fats and muscle tissues are used as the primary fuel in the body. The process of converting these components into energy releases ketone bodies as byproducts, which accumulate in the blood. The accumulated product is then excreted through urine.
• Dietary imbalance: A high-fat or low-carbohydrate diet affects carbohydrate availability for the production of energy in the body. Fats are then burned to produce enough energy, leading to the accumulation of ketones in the blood. The accumulated ketone bodies are then excreted through urine.
• Eclampsia: Eclampsia is a convulsive form of gestational hypertension and is known to be associated with ketonuria.
• Excessive vomiting and diarrhea: Excessive vomiting and diarrhea causes the body to go into starvation mode, and it tries to break down fat as fuel for energy. This leads to the production of excess ketones in the body, which then accumulate in the blood. The excess ketones are then excreted through urine.
• Glycogen storage disease: This is a group of inherited disorders in which the production of normal glycogen is reduced, while abnormal glycogen builds up in tissues. Thus, the body lacks an adequate amount of carbohydrate fuel for energy, forcing it to depend on fatty tissues to meet the demand. This leads to the accumulation of ketone bodies.
• Severe, strenuous exercise: Exercising muscles increases the demand for energy. In the absence or depletion of storage of glucose, the body looks for alternative sources of fats. The use of these alternative fuels leads to the production of ketone byproducts. Accumulated ketones are then released through urine.

Other possible causes of ketonuria include prolonged exposure to cold temperature and fever.

One should not wait for an emergency situation to occur before learning when to identify the level of ketones in the urine. First and foremost, check with the doctor, as they will guide you to diagnosis and treatment. Below are a few instances of when one should go in to check the level of ketone bodies in the urine:

• When one is not well, such as with flu, cold, sore throat, cases of food poisoning, or any other medical condition.
• When one has unexplained high levels of blood glucose over 250 mg/dl two times in a row.
• When one is planning to exercise, but has blood glucose levels over 250 mg/dl.
• A pregnant woman should anyways regularly check for ketones every morning before having breakfast. It should also be done at any time when blood glucose levels are over 250 mg/dl. If a pregnant woman is diagnosed with ketones in the urine she is advised to increase the intake of carbohydrates in her diet during late evening or at night.
• If an individual is diagnosed with symptoms pertaining to DKA. These symptoms include increased urination, pain in the abdomen, and dry mouth.
• If one’s insulin pump has malfunctioned, which then causes an interruption in the delivery of insulin.
• If an individual is undergoing or has experienced traumatic cases of stress.
• Certain changes in lifestyle which have caused excessive stress.

Once the doctor determines the presence of ketones, the first general treatment would include increasing intake of fluids such as water or any other calorie-free fluids to flush out the excess ketones from the body. One should also regularly take insulin to bring the blood glucose levels down and keep an eye on them as well as ketone body levels every two to three hours each day. If ketones are present, the doctor may also advise additional insulin to lower blood glucose levels. If the ketone levels still do not go down, the patient will need to be admitted to the hospital. 

A ketone blood test is an accurate diagnostic test for ketonuria. But, in most cases, urine tests for ketones are the recommended investigation method. A urine test is based on spot tests on a dip stick.

The dip sticks contain chemicals that indicate the presence of ketones in the form of a color change. The dipstick is placed in a urine sample to check for color change. The change is then compared to a color chart.

As a preparation for the test, the doctor may ask the patient to avoid some supplements and medications that will interfere with the test result. These include glucocorticoids, levodopa, metformin, methionine, captopril, and vitamin C.

The normal range of ketone is less than 0.6 mmol/L and may be shown as a negative result. A ketone range of 0.6 – 1.5 mmol/L may indicate the presence of trace amounts of ketones in the blood.

High ketone levels are indicated by a range of 1.6 to 3.0 mmol/L. The dangerous level is expressed as a ketone value above 3.0 mmol/L. It is important to keep track of ketone levels in the blood and to inform the doctor accordingly. High or increasing values of ketones may be found through poorly-controlled diabetes, starvation, diet, poisoning, alkalosis, and some metabolic disorders.

As ketonuria is associated with uncontrolled diabetes, taking extra insulin to bring down blood glucose may help control levels of ketones in the blood. Treatment of ketonuria depends on the underlying cause of the condition.

A healthy, balanced diet will help control the condition caused by diet and starvation. Closely monitoring the levels of ketone in the blood, particularly in diabetic patients, may help prevent the occurrence of ketonuria.

Avoiding prolonged exposure to cold and severe exercise also helps prevent ketonuria, particularly in those who have a high risk of developing this condition.

Lifestyle changes are equally important in managing ketonuria. Avoiding a ketogenic diet, a diet high in fats and low in carbohydrates, is an ideal step towards controlling the production of ketones in the body.

A ketogenic diet mimics starvation, so the body tries to find alternative processes for the production of energy. Fresh fruits and vegetables should be included in the diet. Consumption of low glycemic index (GI) foods may help in controlling the condition.

Some common low GI foods include cucumber, kale, eggplant, peaches, cauliflower, peppers, and okra. One should not exercise or be on a diet if ketone levels are high. Treatment with insulin and intravenous fluids are used to bring blood sugar levels back to normal. This helps reduce ketones.

Other treatments may include:

• Intravenous fluid replacement (IV): One of the symptoms of DKA is frequent urination, which ultimately results in the loss of fluids from the body. Thus, keeping the body hydrated is a must. The doctor may suggest rehydrating with IV fluids to help dilute the extra glucose in the blood.
• Insulin: In some emergency situations, people are given insulin via the IV method. This is done to improve the body’s ability to use excess glucose in the blood for energy production. In such cases, glucose levels are tested on an hourly basis. IV insulin is no longer required when the ketones and the blood acidic levels are brought back to a normal range, after which one can resume the normal insulin regimen.
• Replacement of electrolytes: At times, electrolyte levels may become very low. Some examples of electrolytes include sodium, chloride, and potassium. If the loss of these electrolytes is too great, the heart and muscles cannot function properly.

Complications of High Ketone Bodies

Studies reveal that ketones can cause blood acidity, which is known to cause DKA. This in turn leads to various side effects which can be life-threatening, such as:

• Diabetic coma
• Swelling in the brain
• Loss of consciousness
• Death

So, it is very important to plan immediate treatment when ketone levels rise above the normal range.

Prevention

Carefully managing diabetes is one of the keys to prevent the ketone bodies from rising. The following measures will ensure the blood sugar is kept at a healthy level and the production of ketone is minimized.

Regularly check blood sugar levels:  The doctor will provide suggestions on how frequently one should check blood sugar levels. Usually, this is done four to six times each day. However, one should monitor blood sugar levels more often in cases such as:

• When one is sick
• If there are any symptoms of high or low blood sugar
• If blood sugar levels grow higher than the normal range

Dietary changes: Keep a tab on what you consume on a daily basis. Controlling the intake of carbs and insulin dosage is very important for the management of diabetes. Speak to a dietitian for a better diet.

Pregnant women and nursing mothers are also recommended to follow a well-balanced diet with proper quantities of fats, proteins, and carbs. Inadequate carbs can cause ketones in the urine. Include fresh fruits, veggies, dairy products, and cereals in balanced proportions.

Cinnamon is popularly known to improve the absorption of sugar in the body’s cells, even when there is an absence of insulin. One should consume at least two to three grams of cinnamon after meals. This is very beneficial among patients suffering from diabetes. However, a faulty diet can also cause hypoglycemic attacks.