Many hospitals are still using Acetest or Ketostix (nitroprusside test) for monitoring ketoacidosis (either DKA or AKA).
· This test detects acetoacetate and acetone only, which comprise less than 25% of the ketone bodies.
· Visual, semi-quantitative only.
· Subject to false positive results from drug interference.
· Subject to false negative risk. “It is important to bear in mind, therefore that a negative nitroprusside test result does not rule out ketoacidosis.” (Tietz Textbook of Clinical Chemistry)
Why should the laboratory switch to KetoSite® from Stanbio Laboratory?
· American Diabetes Association recommends using ß-hydroxybutyrate.
· BOHB dominant ketone> 3:1
· Quantitative results.
· KetoSite® eliminates false negative from insensitivity (Tietz).
· KetoSite® eliminates false positive from drug interference (NIH).
· KetoSite® can reduce overall patient costs (Henry Ford Hospital).
Using ß-hydroxybutyrate to monitor ketones is an opportunity to improve quality of care for diabetics, improve hospital efficiency and save significant money.
Testing instrument - STAT-Site® Analyzer #100100
Keto-Site® Test cards - 50 test kit #301050
Why will the hospital appreciate this system?
· Improved turn around times for ketone testing.
· Reduced laboratory testing in patients with ketoacidosis.
· Reduced blood-drawing events.
· Significant reductions of time patients spend in the Clinical Decision Unit, saving sizeable sums of money.
· When you compare the overall savings to the hospital, the minor increase in the test cost over the nitroprusside types becomes a non-issue.
· Significantly higher reimbursement with ß-hydroxybutyrate.
· The bottom line is improved utilization of hospital emergency room facilities and staff as well as improved outcomes for patient care.
Average hospital is presented with 50 DKA episodes per year,
representing the following savings:
$ 100,000 Savings for CDU
$ 4,500 Savings for laboratory
$ 2,400 Increased reimbursement
(CPT 82010 — acetone or other ketone bodies, serum; quantitative vs.
CPT 82009 — acetone or other ketone bodies, serum; qualitative)
Source: Henry Ford Hospital Study 1998
Other Uses
Other applications for this product include monitoring ketogenic diets, which are used as an alternative medical treatment for controlling epilepsy. For more information, go to www.epilepsyfoundation.org.
Understanding the Ketone Testing
What are ketones?
Stored triglycerides are broken down into fatty acids and transported to the liver for oxidation. Ketones are a byproduct of this process. There are three ketone bodies: acetone, acetoacetate and ß-hydroxybutyrate.
Why test for ketones?
One of the most important conditions of Type I Diabetes is a tendency towards development of ketosis. Ketones are an important marker for measuring diabetic control in addition to glucose testing. Pregnant women with Gestational Diabetes Mellitus are prone to the development of elevated ketone levels. It has been reported that this can have a profound influence on the developing fetus.(1) Maternal ketonemia in the poorly controlled pregnant patient with diabetes has been reported to be associated with an increased stillbirth rate and increased evidence of congenital anomalies and impaired neurophysiological development in the infant.(1) Malnutrition, as well as alcoholic ketoacidosis, can be detected by testing for ketones.(2)
When to test for ketones?
For monitoring diabetic control, the American Diabetes Association Clinical Practice Recommendations state that under the following conditions one should test for the presence of ketones:
· During acute illness or stress.
· When blood glucose levels consistently exceed 240 mg/dL.
· During pregnancy.
· When any symptoms of ketoacidosis are present.
Why blood ketones?
As in glucose testing, variations in fluid intake and urine concentration can significantly affect urine ketone test results. Blood is a better indicator of current patient condition.
Why test for ß-hydroxybutyrate?
· ß-hydroxybutyrate can account for greater than 75% of the total ketone bodies and demonstrates excellent stability, making it the most reliable indicator of both sub-clinical and clinical ketosis and ketoacidosis. (3,4)
· ß-hydroxybutyrate measurements also provide a useful tool for the differentiation of metabolic acidosis.
Measure ß-hydroxybutyrate to accurately monitor ketosis and developing ketoacidosis in a variety of clinical conditions because it:
· Is the most direct measurement indicating metabolic well-being of patient in diabetic ketoacidosis (DKA), alcoholic ketoacidosis (AKA), and starvation.
· Clearly indicates trend and direction of metabolic disorder.
· Clearly demonstrates end of catabolism, i.e., normal metabolism.
· Shows no interference from common sulfhydryl compounds, i.e., captopril, mesna, and n-acetylcystein.
· Is not influenced by other acid or base parameters that sometimes appear with DKA, i.e., lactate (cardiac), ascorbate (vitamin C) therapy, salicylate (analgesic).
How can I test for ß-hydroxybutyrate?
Today a direct quantitative enzymatic method of determining ß-hydroxybutyrate levels in blood samples (i.e., whole blood, serum or plasma) is available.
How does this test differ from current dipstick or tablet tests?
The traditional nitroprusside reaction used in dipstick or tablet tests measures only acetoacetate and acetone which account for only 25% (or less) of total ketone bodies. Also, these methods do not measure ß-hydroxybutyrate, and thus do not accurately reflect the degree of ketosis or ketoacidosis. In addition, the nitroprusside tests have an unacceptably high risk of false positive results due to drug interference and false negative results due to reagent deterioration. (5,6)
What commercial ß-hydroxybutyrate tests are available?
Stanbio Laboratory, manufactures tests for ß-hydroxybutyrate in two formats. A liquid enzymatic reagent kit and a convenient dry chemistry kit, KetoSite®, that is used on the STAT-Site® analyzer. To obtain more information, call 866-782-6246.
References
1. New England Journal of Medicine, Correlations Between Antepartum Maternal Metabolism and Intelligence of Offspring, by T. Rizzo, B. E. Metzger, W. J. Burns and K. K. Burns, copyright September 1991, vol. 325, pgs. 911-916, no. 13.
2. TIETZ TEXTBOOK OF CLINICAL CHEMISTRY, SECOND EDITION edited by Carl A. Burtis and Edward R. Ashwood, copyright W. B. Saunders Company, Division of Harcourt Brace and Company, pgs. 971-975, Ketone Bodies.
3. DIABETES REVIEWS, KETOACIDOSIS AND LACTIC ACIDOSIS, Volume 2,
Number 2, Spring 1994, by The American Diabetes Association, pgs. 209-238,
Diabetic Ketoacidosis, a combined Metobolic-Nephrologic Approach to Therapy by DeFronzo, et al.
4. NEW ENGLAND JOLRNAL OF MEDICINE, ALTERED REDOX STATE OBSCURING KETOACIDOSIS IN DIABETIC PATIENTS WITH LACTIC ACTIDOSIS, by Earl B. Marliss, M.D., John L. Ohman, Jr., Thomas I. Asoki, M.D., and George P. Kozak, M.D., October 29, 1970.
5. JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, UNRECOGNIZED FALSE-POSITIVE KETONES FROM DRUGS CONTAINING FREE-SULPHYDRYL GROUPS, April 7, 1993, vol. 269, no. 13, pg. 1634, by Gyorgy Csako, M.D., et al.
6. DIABETES CARE, vol. 18. no. 1, January 1995, pgs. 137-38, CLINICAL UTILITY OF ß-HYDROXYBUTYRATE DETERMINED BY REFLECTANCE METER IN THE MANAGEMENT OF DIABETIC KETOACIDOSIS, by Guillermo E. Umpierrez, M.D., Nelson B. Watts, M.D., and Lawrence S. Phillips, M.D. from the Department of Medicine.
