Glucose is essential as the human body runs on it. Without adequate glucose, the body starts to break down fats for energy. The byproduct of fat breakdown is ketone (ketone bodies).
It is a normal process but some people are at risk of having a high ketone level in the blood such as those suffering from diabetes.
People with type 1 diabetes mellitus are prone to developing diabetic ketoacidosis. In a very rare circumstance, people with type 2 diabetes mellitus may experience the same condition too.
Image 1: A urine test strip can be used to check for the level of ketones in urine at home.
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Symptoms of ketone buildup in the blood
- Excessive dry mouth
- A glucose reading greater than 240 mg/dL
- Excessive thirst
- Frequent urination
- Flushed skin
- Nausea with/without vomiting
- Confusion
- Extreme fatigue
- Fruity breath
- Trouble breathing
Image 2: Measuring the level of ketones in urine.
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What happens in the body if the ketone level gets out of control?
An excessive level of ketones in the body makes your blood acidic, which could lead to diabetic ketoacidosis if not managed right away. It is an emergency situation as it could make your brain swell, loss your consciousness, be in a diabetic coma, or worst, death. (1, 2, and 3)
What is the clinical implication of having ketones in urine?
The urine should be free from any ketone bodies. If there are ketones in the urine, it is an indicator that your body turn to fats for energy rather than using carbohydrates. It is usually common in people following a low-carb diet. A high level of ketone in urine is common in people with uncontrolled diabetes because of the body’s inability to metabolize carbohydrates.
Checking the level of ketones in the urine is helpful in managing and monitoring the condition of people with diabetes mellitus. If there is too much ketones in urine, it indicates that the insulin dose has to be adjusted.
There is also a high possibility of electrolyte imbalance and dehydration. If not handled properly could lead to diabetic ketoacidosis and diabetic coma. (2, 3, and 4)
Image 3: Pregnant women are at risk for developing excessive ketones in the urine.
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Image 4: Excessive exercise and dieting can contribute to the build up of ketones in the blood.
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What could be the reasons for the high levels of ketones in urine?
There are many reasons why people with diabetes have a high level of ketone in urine. It could be due to:
- Current illness
- Ineffective insulin pump
- Missing an insulin shot
- Not receiving enough insulin
- Missed a meal/not eaten enough
- Received spoiled insulin (4, 5)
For people without diabetes, a high level of ketones in the urine is probably due to the following:
- Eating-related disorders
- Pregnancy
- Strenuous exercise
- Excessive diarrhea/vomiting
- Low carbohydrate intake
- Underlying infection
- Excessive alcohol intake
- Pneumonia
- Fasting
- High fever
- Burns
- Hyperthyroidism
- Heart attack
- Sepsis
- Stroke (6)
Testing for the presence of ketones in the urine
The level of ketones in urine can be checked in the laboratory or even right in the comfort of home. Ideally, the person should not drink or eat anything a few hours before the test.
To come up with an accurate result, the patient should first thoroughly wash the hands and clean the genitalia using a sterile cleansing pad. Urine should be collected and put in a clean container (at least two ounces) and the urine sample should be immediately given to the healthcare provider.
When checking the level of ketones in urine at home, a spot test is performed using a urine test strip. Capture the urine and place in a clean container. Dip the test strip into the container that has a urine. You have to wait for a few minutes before reading the color of the strip. You can easily compare he color of the strip with the color chart. (5, 6, and 7)
Also see: Urinalysis (Urine testing) – Types, Process, Results Interpretation, Reference charts
What to keep in mind?
The result of the ketone urine test varies according to age, medical history, gender, dietary habit, and exercise.
When is the best time to have a ketone urine test?
It is better to test your ketone levels at the beginning or end of the day and one study suggests that they are better detected in the first urine sample of the day and in the evening few hours after the dinner.
But if you are suffering from diabetes and/or other health conditions that might trigger the increase level of ketones in the blood, then the doctor might order a ketone urine test to check the level of ketones. The test is performed every four to six hours, especially if you exhibit the following symptoms:
- A blood sugar level higher than 240 mg/dl
- Nausea with or without vomiting
- Stomachache
- A feeling of fatigue
- Cold/flu
- Dry mouth followed by excessive thirst
- Flushed skin
- Confusion
- Fruity-smelling breath
Abnormalities in ketone urine test – what does it mean?
Small ketones in urine – 20 mg/dl
It is just normal to have a small number of ketones in urine, especially in people who are trying to lose weight and exerting efforts to keep the blood sugar level in a healthy level.
Moderate ketones in urine – 30 to 40 mg/dl
Excessive number of ketone sin urine – greater than 80 mg/dl
If there is a moderate to excessive amount of ketones in urine, it could put you in a life-threatening condition. It is a must to consult a healthcare provider the soonest time possible. One thing you should not do – do not exercise when the ketone level is high as doing so can worsen the condition. The doctor will order the following test:
- Blood glucose test
- Protein test
- Urine pH level
Is ketone in urine a sign of ketoacidosis?
It is a must to check the level of ketones in urine as too much ketones in urine can be a potential indicator of diabetic ketoacidosis – which is a complication of diabetes. Hence, people with diabetes should strictly monitor their sugar level along with the ketone level.
In fact, people with diabetes mellitus are first diagnosed upon checking the level of ketone sin urine. Diabetic ketoacidosis is the first sign of diabetes. (7, 8)
Clinical manifestations of diabetic ketoacidosis
- nausea with/without vomiting
- troubled breathing
- excessive thirst
- flushed skin
- fruity-smelling breath
- confusion
- sleepiness
- abdominal pain
Note: people in a state of diabetic ketoacidosis should seek help the soonest time possible as it could lead to diabetic coma or even death. (7, 8)
Ketones in urine test
A ketone urine test measures the amount of ketones in urine. In a normal circumstance, the body turns to glucose as a source of energy. If the cells don’t get enough glucose, the body would turn to fat for energy. The burning of fats leads to the release of ketones, which can be detected in the blood and urine.
A significant amount of ketones in urine could indicate diabetic ketoacidosis; which is a complication of diabetes. If not managed right away could lead to coma or even death. A ketone urine test is helpful as it can prompt the person to get the right treatment at the right time. (9, 10)
Urine ketone strip test
A urine ketone test is a non-invasive way of checking the level of ketones in the body. It can be done at home using a urine ketone strip, which can be easily purchased at the leading online and traditional brick and mortar stores.
There are many brands of urine ketone strip test to choose from. It is best to ask for a doctor’s recommendation before buying a urine ketone strip.
Before performing a urine ketone strip test make it a habit to read the product insert thoroughly. Some urine ketone strip products have detailed instructions that need to be followed to come up with the most accurate result. Below are the recommended ways to perform a urine ketone strip test:
- Using a clean-catch urine, saturate the end of the strip/dip stick.
- Shake off the excess urine in the strip.
- Wait for at least 15 seconds before reading.
- The side of the bottle has a color array which you are going to use to compare the color on the strip.
Image 6: The result of ketone urine test is compared with the chart attached to the kit.
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Interpreting results
If the color of the strip changes, then it is an indicator that there are ketones in urine. To determine if the number of ketones in your urine is small, moderate, or excessive, you have to compare the color with the chart.
If there’s a small trace of ketones, it is an indicator that ketones start to buildup. If the reading of ketones in urine is in moderate to excessive level, it is a warning sign and you have to immediately call your doctor for help.
Result interpretation varies depending on the kind of urine test strip you use. There are different brands and some give the results in numbers while others indicate if there is trace, small, or large number of ketones.
You will be able to know the exact number of ketones if the test strip gives you a number. That you have to compare with the normal range of ketone sin urine. If you are not aware of the normal range of ketones for your conditions, then you have to consult your doctor.
Ensuring the accuracy of urine ketone test
- Before using the testing kit, make sure you check the expiration date. An expired test kit could lead to false results.
- Keep the test strip away from direct heat of the sun, light, and air.
- Do the test early in the morning or after dinner as these times have the most reliable result.
Aside from the ketone test, your doctor might also request other urine test to check for the level of protein, sugar, pH to check the acidity, and blood ketones. These tests are usually required in patients with diabetes.
The significance of ketone urine test
Checking the level of ketones in urine is helpful in monitoring people who are at high risk of developing ketones such as people with diabetes mellitus, both type 1 and type 2.
If you are diabetic and your urine has an abnormal number of ketones, it means that you are not getting enough insulin. If you don’t have diabetes, you could still develop a significant number of ketones in urine if you are:
- excessively vomiting
- chronic diarrhea
- digestive-related problems
- perform strenuous exercise
- very low carbohydrate diet
- suffering from eating-related disorders
- pregnant
How is a ketone urine test performed?
Checking for the level of ketones in urine can be done at home or in the laboratory. To come up with the most accurate test, it is important to have a clean catch sample. To be able to observe a clean catch sample, you have to follow these steps:
- make sure you wash your hands.
- Clean the genitalia using a sterile cleansing pad. For men, the tip of the penis should be wiped. Women should clean the genitalia from front to back motion.
- Urinate in the toilet and move the container under the urine stream to catch the sample.
- At least an ounce or two of urine sample should be collected.
- Submit the sample to the lab personnel.
- If you are going to check the presence of ketone in urine at home using a home test kit, make sure you properly follow the instructions that come in the kit. (4, 5, 8, and 10)
Is fasting required before the test?
When checking for ketones in urine, it is a must to not drink or eat for a few hours. If you are uncertain as to what type of preparation to do before the test, you need to consult your doctor, especially if you are suffering from serious medical conditions like diabetes. (3, 5)
Ketonuria and how it is treated?
If you have a high level of ketones in urine, the condition is called ketonuria/ketoaciduria/acetonuria. It is an alarming condition that warrant immediate intervention. However, if the cause of excessive ketones in urine is because of fasting or changes in your diet, do not worry as it will eventually subside on its own. However, if you have a diabetes or other related medical conditions, you would most likely need treatment and management. Life-saving treatments for excessive ketones in urine include the following:
- Intravenous fluids
- Insulin (fast-acting)
- Electrolytes like sodium, chloride, and potassium
- Additional treatments are needed if the excessive ketones in urine is caused by underlying illness. It includes taking antibiotics, antiviral drugs, and even the urgency to perform heart-related procedures. (1, 6, and 9)
What are the complications of excessive ketones in urine?
- Ketoacidosis – it is a health emergency that if not managed could lead to even serious conditions like diabetic coma and death. As the ketone level increases, it makes the blood acidic, which can be extremely toxic to your muscles, nerves, and organs. They could interfere with the normal functions of the body. Ketoacidosis is most likely to occur in people with diabetes mellitus, especially type 1 diabetes.
- Dehydration – If the amount of ketones is high, it could increase the urgency to urinate. If you are not going to drink plenty of fluid, there is a tendency you are going to be dehydrated. Apart from dehydration, a person could also feel nauseated, vomit, or have a diarrhea.
- Gestational diabetes – Pregnant women are at risk for having an excessive level of ketone in the blood. There is a variety of factors leading to increase ketones during pregnancy such as excessive vomiting related to morning sickness, not eating for a long period of time, or have a low carbohydrate diet. If you develop gestational diabetes, your doctor will put you in an insulin medication and proper diet. As the gestational diabetes is addressed, the excessive ketones in urine will resolve too. (1, 4, 8, and 10)
The presence of ketones in urine is caused by a variety of factors. It could be due to food intake, imbalance in diet, or underlying medical condition. It is a must to identify the underlying cause so as to treat, manage, and prevent excessive ketones in urine.
The presence of ketones in urine is a warning sign that something is not right with your body. If the ketones get out of control to the point that it causes headache, nausea, vomiting, and confusion, you have to immediately seek medical attention.
If you are suffering from diabetes mellitus, the presence of ketones in urine is a warning sign that your sugar is out of control. If you check your blood sugar level, make sure that you make it a habit to also check your ketone level. Ask your doctor what you can do to keep your blood sugar level at bay. You also need to talk to your dietitian to help you come up with food choices that are best for your health and overall well-being.
Please see this video – by Dr. Eric strong MD, from Stanford – from (11 :44 to 13 : 55 min) – for ketone bodies and urinalysis – link
References
- https://www.healthline.com/health/ketonuria
- https://medlineplus.gov/lab-tests/ketones-in-urine/
- https://www.webmd.com/diabetes/ketones-and-their-tests#1
- https://www.everydayhealth.com/urine/ketones-urine-test-what-it-measures-what-results-mean/
- https://www.labce.com/spg130944_clinical_significance_of_positive_urine_ketone_res.aspx
- https://www.cardiosmart.org/healthwise/aa11/1279/aa111279
- https://www.drugs.com/cg/blood-and-urine-ketones.html
- https://en.wikipedia.org/wiki/Ketonuria
- https://hvmn.com/blog/ketosis/ketones-in-urine-all-you-need-to-know
- https://beyondtype1.org/ketones/
