Ketonuria and Acetonuria: Causes, Symptoms, Treatment, Ayurveda Understanding

Article by Dr Manasa S, B.A.M.S

What are Ketonuria and Acetonuria?

Ketonuria is a medical condition associated with high levels of ketones in the urine. This condition is also called ketoaciduria and acetonuria. It is commonly observed in people with diabetes, and it can also be seen during pregnancy or breastfeeding.

Ketone and acetone

Ketone bodies are produced in the liver, mainly from the oxidation of fatty acids. The ketones thus formed are transported to peripheral tissues to be used up as energy sources. The two main ketone bodies are acetoacetate (AcAc) and 3-beta hydroxybutyrate (3HB) and the third one is acetone which is least abundant.

Brain uses ketone bodies as the primary source of energy supply as it does not have any other substantial non-glucose derived energy resource.

Three major abnormalities of ketone body are as under:

–         Ketosis
–         Hypoketotic hypoglycemia
–         Abnormalities of 3HB / AcAc

In normal conditions, ketosis implies that lipid metabolism has been initiated and the entire process of lipid degradation is intact.

Ketosis is normal during fasting, after prolonged exercise, neonatal period, infancy and pregnancy, times at which the lipid metabolism is particularly active and during consumption of a high-fat diet.

In rare circumstances ketosis indicates an inability to utilize ketone bodies.

Important pathologic reasons / causes for ketosis are

–         diabetes,
–         deficiency of corticosteroids or growth hormone,
–         ketotic hypoglycemia of childhood,
–         intoxication with alcohol or salicylates and
–         inborn errors of metabolism

Common causes of ketonuria

Ketogenic diet – When someone is on a low carbohydrate diet or during starvation or fasting, the body uses fats and proteins to derive their energy. During these circumstances there occurs ketonuria which does not pose any health risk if this ketogenic diet is done in a balanced way.

Low levels of Insulin – Insulin is an important hormone secreted by pancreas. Insulin converts carbohydrates into simple sugars or glucose, which are then transported to each and every cell including muscles, heart and brain to be used up for their energy. Individuals who are diagnosed with diabetes have either less insulin or the cells of the body cannot utilize the insulin properly. In these kinds of situations where the body has less insulin to convert the sugar into fuel, the body uses proteins and fats stored in the body to generate fuel. While doing so, the ketone bodies are secreted as a waste product. When the body is in the state of low insulin levels for a longer period of time, the ketone bodies get accumulated in the blood stream leading to a condition known as ketoacidosis or diabetic ketoacidosis. When there is increased accumulation of the ketone bodies in the bloodstream, the kidneys try to eliminate them through urine. When someone is diagnosed with diabetes and they have ketonuria, then it is likely to have high blood sugar levels.

Other causes of ketonuria

Other causes of ketonuria include

–         Pregnancy
–         Breastfeeding
–         Starvation
–         Excessive alcohol consumption
–         Excessive vomiting
–         Infection or certain health issues
–         Heart attack
–         Certain medications like corticosteroids and diuretics
–         Emotional or physical trauma

Symptoms of ketonuria

Most often ketonuria follows or causes ketoacidosis. Common symptoms of ketonuria are –

–         Breath smells fruity
–         Thirst, dry mouth and dehydration
–         Feeling tired and confused
–         Difficulty in focusing
–         Severe fatigue
–         Nausea and or Vomiting
–         Stomach pain
–         Breathing difficulty
–         Frequent urination

Healthcare professionals might also find signs of –

–         Increased blood sugar levels
–         Significant dehydration
–         Signs of electrolyte imbalance

Other signs which may be associated with ketonuria are –

–         Signs of sepsis

–         Signs of pneumonia

–         Signs of urinary tract infections

Diagnosis

Most cases of ketonuria are diagnosed with the help of presenting signs and symptoms and through blood and urine tests.

Few commonly used tests are mentioned below –

–         Finger-stick ketone blood test
–         Urine strip test
–         Blood tests to check the levels of sugar in the blood
–         Breathe tests to check for fruity smell of acetone
–         Complete blood count
–         Blood culture tests to check for the presence of infections
–         Drug screen
–         Tests to measure the enzymes, to measure the levels of ketones

Other tests

–         Chest X-ray
–         CT scan
–         Electrocardiogram

Preventive measures

Detection of diabetes and prompt treatment of existing diabetes is the most important and first line of preventive measure. Few important measures include –

Regular monitoring of the blood sugar levels

–         In an uncontrolled diabetic phase, the blood sugar ideally should be checked 4 to 6 times a day

–         When the blood sugar levels are increasing in spite of regular medications  

–         Blood sugar levels should be checked if an individual experiences the signs of high blood sugar levels

–         Feeling sick with extreme tiredness and increased thirst and urination

Adopting a balanced diet

Consuming a well-balanced diet with enough proteins, good fats, vegetables and fruits and keeping the carbohydrate portion less helps in control of diabetes in the long term. Regular monitoring of the insulin dose helps in control of hyperglycaemic conditions.

Awareness about balanced diet, enough exercise and regularly keeping in touch with the health care professional helps in knowing about the current health status. It will also help in making essential changes in treatment or diet required, if the underlying illness is not resolving properly.

Treatment

If Ketonuria is temporary because of change in diet habits or due to starvation or fasting, it requires no treatment. However, in cases of serious medical conditions ketonuria demands a proper treatment.

These treatment protocols include –

–         Fast acting insulin to treat increased blood sugar levels

–         IV fluids to correct the signs and symptoms of dehydration

–         Infusion of sodium, potassium and chloride to correct the electrolyte imbalance

If ketonuria is associated with illness, then additional treatments are included like:

–         Antivirals

–         Antibiotics

–         Heart procedures if the ketonuria is because of heart ailments

Why does ketonuria need immediate treatment?

If the ketonuria is temporary due to fasting or due to exercises or change in the diet, it is more likely that it does not require treatment as it resolves by itself. In more severe cases of ketonuria where there is underlying health concern, it needs a detailed evaluation and prompt treatment. Untreated ketonuria may seriously impact the health and it might result in coma or death.

Few common complications are as below –

Ketoacidosis – When there is an increase in ketones in the blood, it raises the acidic levels of the blood. Increased levels of acid states are dangerous to organs, muscles and nerves and interfere with the normal functioning of the body. Ketoacidosis is a medical emergency if untreated might lead to diabetic coma and even death. Ketoacidosis is most common to people with Diabetes Mellitus Type 1 but this can happen to anyone with diabetes.

Dehydration – When the blood sugar levels increase in an already diabetic patient, it tends to increase ketone levels. Increased ketone levels significantly increase urination leading to dehydration. Dehydration may be associated with nausea, vomiting and diarrhoea adding to already existing dehydration conditions.

In pregnancy – Ketonuria is common in a healthy pregnancy. ‘Mothers to be’ who are diagnosed with diabetes or gestational diabetes are at higher risk of developing ketonemia and ketonuria can lead to ketoacidosis which might harm the developing baby.

Ketonuria / Acetonuria – Ayurveda Understanding

There is a condition called ‘Sura Meha’ explained in the context of Prameha disease. It is one among the ten types of Kaphaja Prameha – kapha type of urinary disorders.

Sura = wine, alcohol

Meha = urinary disorder marked by increased and turbid urination

This condition has been popularly compared to acetonuria. It can also be compared to ketonuria because acetonuria is a variant of ketonuria.

So, both conditions explained in modern medicine i.e. ketonuria and acetonuria can be compared with Sura Meha.

Symptoms of Sura Meha

सुरामेही सुरातुल्यमुपर्यच्छमधो घनम्॥वा.नि.१०॥

Sura tulyam – the urine of the patient suffering from sura meha resembles sura – i.e. wine or alcohol

Upari achcham – clear at the top

Adho ghanam – thick or dense at the bottom

Here we need to observe that the resemblance of urine with wine or alcohol can be compared to the smell of acetone in acetonuria. When the urine is stored in a container and left for a while, the upper portion will be clear. The solid portions of the urine will settle down to the bottom of the container and that is the reason the settled solid part of the urine at the bottom looks dense and solid.

Master Charaka has not explained Sura Meha. In fact he has explained Sandra Prasada Meha in its place. Experts opine that Sura Meha explained by Vagbhata and Sushruta is the same as Sandra Prasada Meha explained by Charaka.

Symptoms of Sandra Prasada Meha

यस्य संहन्यते मूत्रं किञ्चित् किञ्चित् प्रसीदति।

सान्द्रप्रसाद मेहीति तमाहुः श्लेष्मकोपतः॥च.नि.४/१६॥

In sandraprasada meha the urine of the patient becomes partly viscous and partly clear when kept overnight.

Treatment Principles

General line of treatment of prameha and specific line of treatment of kaphaja pramehas may be implied in the treatment of Sura Meha or Sandra Meha as the case may be.

The same principles shall be used in treating ketonuria or acetonuria with Ayurveda interventions.