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Background: Our bodies have adaptive mechanisms to fasting, in which glycogen stored in the liver and muscle protein are broken down, but also lipid mobilisation is triggered. As a result, glycerol and fatty acids are released into the bloodstream, increasing the production of ketone bodies in liver. However, there are limited studies on the incidence of perioperative urinary ketosis, the intraoperative blood glucose changes and metabolic acidosis after fasting for surgery in non‐diabetic adult patients. Methods: We conducted a retrospective cohort study involving 1831 patients undergoing gynecologic surgery under general anesthesia from January to December 2022. Ketosis was assessed using a postoperative urine test, while blood glucose levels and acid–base status were collected from intraoperative arterial blood gas analyses. Results: Of 1535 patients who underwent postoperative urinalysis, 912 (59.4%) patients had ketonuria. Patients with ketonuria were younger, had lower body mass index, and had fewer comorbidities than those without ketonuria. After adjustments, younger age, higher body mass index and surgery starting late afternoon were significant risk factors for postoperative ketonuria. Of the 929 patients assessed with intraoperative arterial blood gas analyses, 29.0% showed metabolic acidosis. Multivariable logistic regression revealed that perioperative ketonuria and prolonged surgery significantly increased the risk for moderate‐to‐severe metabolic acidosis. Conclusion: Perioperative urinary ketosis and intraoperative metabolic acidosis are common in patients undergoing gynecologic surgery, even with short‐term preoperative fasting. The risks are notably higher in younger patients with lower body mass index. Optimization of preoperative fasting strategies including implementation of oral carbohydrate loading should be considered for reducing perioperative metabolic derangement due to ketosis. [ABSTRACT FROM AUTHOR]

Simple Summary: This study investigates the impact of subclinical ketosis (SCK) and subclinical acidosis (SCA) on dairy cow rumination, eating, drinking and locomotion behavior. It focuses on cows in their second or subsequent lactation, producing an average of 12,000 kg/year milk in their previous lactation. The cows were categorized into three groups, SCK, SCA, and healthy cows, based on the milk fat–protein ratio, blood beta-hydroxybutyrate and clinical examinations by a veterinarian. The results show significant differences between the cows affected by SCK and the healthy cows. SCK leads to a reduction in the milk yield (11.78%), rumination time (17.47%), and various eating and chewing behaviors. SCA is associated with a substantial decrease in Eating Time 2 (ET2) by 36.84% and Eating Chews 2 (EC2) by 38.10% compared to the healthy cows. These findings highlight the influence of SCA on feeding behaviors and chewing activity, with implications for nutrient intake and cow health. Additionally, SCK affects locomotion parameters, leading to a 27.36% reduction in the overall activity levels, as well as reductions in the Walking Time (WT), Other Activity Time (OAT), and Activity Change (AC). Early detection and effective management of SCK are crucial for maintaining dairy cow health and productivity. In conclusion, this research underscores the need for advanced strategies to prevent and manage subclinical metabolic disorders in the dairy industry. Effective management and early detection methods are essential to mitigate the impact of SCK and SCA on dairy cow health and benefit the dairy farming sector. This study delves into the effects of subclinical ketosis (SCK) and subclinical acidosis (SCA) on various parameters related to dairy cow rumination, eating, drinking and locomotion behavior. The research hypothesized that these subclinical metabolic disorders could affect behaviors such as rumination, feeding, and locomotion. A total of 320 dairy cows, with a focus on those in their second or subsequent lactation, producing an average of 12,000 kg/year milk in their previous lactation, were examined. These cows were classified into three groups: those with SCK, those with SCA, and healthy cows. The health status of the cows was determined based on the milk fat–protein ratio, blood beta-hydroxybutyrate, and the results of clinical examinations performed by a veterinarian. The data collected during the study included parameters from the RumiWatch sensors. The results revealed significant differences between the cows affected by SCK and the healthy cows, with reductions observed in the rumination time (17.47%) and various eating and chewing behaviors. These changes indicated that SCK had a substantial impact on the cows' behavior. In the context of SCA, the study found significant reductions in Eating Time 2 (ET2) of 36.84% when compared to the healthy cows. Additionally, Eating Chews 2 (EC2) exhibited a significant reduction in the SCA group, with an average of 312.06 units (±17.93), compared to the healthy group's average of 504.20 units (±18.87). These findings emphasize that SCA influences feeding behaviors and chewing activity, which can have implications for nutrient intake and overall cow health. The study also highlights the considerable impact of SCK on locomotion parameters, as the cows with SCK exhibited a 27.36% reduction in the walking time levels. These cows also displayed reductions in the Walking Time (WT), Other Activity Time (OAT), and Activity Change (AC). In conclusion, this research underscores the critical need for advanced strategies to prevent and manage subclinical metabolic disorders within the dairy farming industry. The study findings have far-reaching implications for enhancing the well-being and performance of dairy cattle. Effective management practices and detection methods are essential to mitigate the impact of SCK and SCA on dairy cow health and productivity, ultimately benefiting the dairy farming sector. [ABSTRACT FROM AUTHOR]

Very low-calorie diets (VLCDs) are used preoperatively in bariatric-metabolic surgery; however, this can lead to physiological ketosis. Euglycemic ketoacidosis is an increasingly recognized complication in diabetic patients on sodium-glucose-cotransporter-2 inhibitors (SGLT2i) undergoing surgery and requires assessment of ketones for diagnosis and monitoring. VLCD induced ketosis may confound monitoring in this group. We aimed to evaluate the influence of VLCD, compared to standard fasting, on perioperative ketone levels and acid-base balance. Twenty-seven patients were prospectively recruited to the intervention group and 26 to the control group from two tertiary referral centres in Melbourne, Australia. Intervention group patients were severely obese (body mass index) (BMI) (≥35), undergoing bariatric-metabolic surgery, and prescribed 2 wk of VLCD preoperatively. Control group patients underwent general surgical procedures and prescribed standard procedural fasting only. Patients were excluded if diabetic or prescribed SGLT2i. Ketone and acid-base measurements were taken at regular intervals. Univariate and multivariate regression was utilised with significance defined as P < 0.005. ClinicalTrials.gov ID: NCT05442918. Patients on VLCD, compared to standard fasting, had an increased median preoperative (0.60 versus 0.21 mmol/L), immediate postoperative (0.99 versus 0.34 mmol/L) and day 1 postoperative (0.69 versus 0.21 mmol/L) ketone level (P < 0.001). Preoperative acid-base balance was normal in both groups, however VLCD patients were found to have a metabolic acidosis immediately postoperatively (pH 7.29 versus pH 7.35) (P = 0.019). Acid-base balance had normalized in VLCD patients on postoperative day 1. Preoperative VLCD resulted in increased pre- and postoperative ketone levels with immediate postoperative values consistent with metabolic ketoacidosis. This should be considered particularly when monitoring diabetic patients prescribed SGLT2i. [ABSTRACT FROM AUTHOR]

Starvation ketosis and pancreatitis are uncommon and underrecognized etiologies of euglycemic diabetic ketoacidosis (DKA). Euglycemic DKA is associated commonly with pregnancy, use of insulin en route to the hospital, and use of sodium-glucose cotransporter-2 (SGLT-2) inhibitors. A 58-year-old male with past medical history of type II diabetes mellitus and alcoholism presented with chief complaint of nausea, vomiting, and poor oral intake for several weeks. Despite extensive history of diabetes and no recent SGLT-2 inhibitor use, his labs were consistent with euglycemic DKA. His imaging and clinical history also confirmed alcoholic pancreatitis. The patient was admitted for euglycemic DKA secondary to starvation ketosis and alcoholic pancreatitis. His anion gap and beta-hydroxybutyrate rapidly cleared with initiation of the DKA protocol. This case teaches us that clinicians should consider early initiation of the DKA protocol even in the setting of euglycemia, when a patient presents with high-anion-gap metabolic acidosis, a high beta-hydroxybutyrate level, and a clinical picture of pancreatitis and starvation [ABSTRACT FROM AUTHOR]

Objective: Rare coexistence of disease or pathology Background: Chronic acetaminophen toxicity has been known to cause anion gap metabolic acidosis (AGMA) due to accumulation of 5-oxoproline metabolites. This diagnosis requires a high index of suspicion because acetaminophen use is very common among patients, it is often difficult to gauge the extent of use, and patients often have multiple comorbid conditions complicating diagnoses. Case Report: A 68-year-old man with multiple medical comorbidities presented to the Emergency Department with recurrent generalized weakness. On all occasions, the patient denied focal weakness or infectious symptoms. He also denied ingestions other than prescribed medications, including acetaminophen 325 mg as needed, which he described taking "a couple times" a day. His vital signs were normal other than tachypnea to 28 breaths/min. The physical examination was notable for Kussmaul breathing pattern and slight confusion. The patient's prior 3 presentations were notable for profound AGMA, hypernatremia, acute kidney injury, and ketosis. As the patient's blood urea nitrogen, blood sugar, liver tests, lactic acid, and serum osmolality were normal, the patient was diagnosed with "starvation ketosis" and received supportive care each time with fluids and sodium bicarbonate. Further investigation at his final admission revealed an elevated 5-oxoproline level and a delayed diagnosis of chronic acetaminophen toxicity. Conclusions: This report emphasizes the need for a high index of suspicion related to chronic acetaminophen toxicity and other ingestions contributing to a metabolic acidosis in at-risk populations, even when routine history is unrevealing. Furthermore, severe acidosis should prompt more extensive investigation when out of proportion to obvious routine etiologies. [ABSTRACT FROM AUTHOR]

Background: Alcoholic ketoacidosis (AKA) is defined by metabolic acidosis and ketosis in a patient with alcohol use. This is a common presentation in the emergency department (ED) and requires targeted therapies.Objective: This narrative review evaluates the pathogenesis, diagnosis, and management of AKA for emergency clinicians.Discussion: AKA is frequently evaluated and managed in the ED. The underlying pathophysiology is related to poor glycogen stores and elevated nicotinamide adenine dinucleotide and hydrogen. This results in metabolic acidosis with elevated beta-hydroxybutyrate levels. Patients with AKA most commonly present with a history of alcohol use (acute or chronic), poor oral intake, gastrointestinal symptoms, and ketoacidosis on laboratory assessment. Patients are generally dehydrated, and serum glucose can be low, normal, or mildly elevated. An anion gap metabolic acidosis with ketosis and electrolyte abnormalities are usually present on laboratory evaluation. Management includes fluid resuscitation, glucose and vitamin supplementation, electrolyte repletion, and evaluation for other conditions.Conclusions: Emergency clinician knowledge of the evaluation and management of AKA is essential in caring for these patients. [ABSTRACT FROM AUTHOR]

Background: The potential of a ketone monoester (β-hydroxybutyrate; KEβHB) supplement to rapidly mimic a state of nutritional ketosis offers a new therapeutic possibility for diabetes prevention and management. While KEβHB supplementation has a glucose-lowering effect in adults with obesity, its impact on glucose control in other insulin-resistant states is unknown.Objectives: The primary objective was to investigate the effect of KEβHB-supplemented drink on plasma glucose in adults with prediabetes. The secondary objective was to determine its impact on plasma glucoregulatory peptides.Methods: This randomized controlled trial [called CETUS (Cross-over randomizEd Trial of β-hydroxybUtyrate in prediabeteS)] included 18 adults [67% men, mean age = 55 y, mean BMI (kg/m2) = 28.4] with prediabetes (glycated hemoglobin between 5.7% and 6.4% and/or fasting plasma glucose between 100 and 125 mg/dL). Participants were randomly assigned to receive KEβHB-supplemented and placebo drinks in a crossover sequence (washout period of 7-10 d between the drinks). Blood samples were collected from 0 to 150 min, at intervals of 30 min. Paired-samples t tests were used to investigate the change in the outcome variables [β-hydroxybutyrate (βHB), glucose, and glucoregulatory peptides] after both drinks. Repeated measures analyses were conducted to determine the change in concentrations of the prespecified outcomes over time.Results: Blood βHB concentrations increased to 3.5 mmol/L within 30 minutes after KEβHB supplementation. Plasma glucose AUC was significantly lower after KEβHB supplementation than after the placebo [mean difference (95% CI): -59 (-85.3, -32.3) mmol/L × min]. Compared with the placebo, KEβHB supplementation led to significantly greater AUCs for plasma insulin [0.237 (0.044, 0.429) nmol/L × min], C-peptide [0.259 (0.114, 0.403) nmol/L × min], and glucose-dependent insulinotropic peptide [0.243 (0.085, 0.401) nmol/L × min], with no significant differences in the AUCs for amylin, glucagon, and glucagon-like peptide 1.Conclusions: Ingestion of the KEβHB-supplemented drink acutely increased the blood βHB concentrations and lowered the plasma glucose concentrations in adults with prediabetes. Further research is needed to investigate the dynamics of repeated ingestions of a KEβHB supplement by individuals with prediabetes, with a view to preventing new-onset diabetes. This trial was registered at www.clinicaltrials.gov as NCT03889210. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to examine whether the degree of ketosis, measured as plasma β-hydroxybutyrate (βHB) in fasting, was associated with changes in appetite feelings and plasma concentration of appetite-related hormones after weight loss.Methods: A total of 87 individuals with obesity (BMI: 36.5 ± 4.0 kg/m2 ; age: 42.4 ± 9.7 years; 39 males) underwent 8 weeks of a very low-energy diet. Body weight/composition, plasma concentration of βHB, and appetite-related hormones (active ghrelin, active glucagon-like peptide 1 [GLP-1], total peptide YY, cholecystokinin [CCK], and insulin) and subjective appetite feelings were measured at baseline and week 9.Results: Participants lost 17.7 ± 4.1 kg and were ketotic (βHB: 1.24 ± 0.82 mmol/L in fasting) at week 9. A negative association was found between βHB in fasting at week 9 and changes in basal (r = -0.315, P = 0.003) and postprandial ghrelin concentration (r = -0.286, P = 0.008), and a positive association was found with the change in postprandial GLP-1 (r = 0.244, P = 0.025) and CCK (r = 0.228, P = 0.035). No association was seen between βHB in fasting and changes in peptide YY or subjective feelings of appetite.Conclusions: βHB plasma concentration in fasting is associated with lower concentrations of the hunger hormone ghrelin and increased concentrations of the satiety hormones GLP-1 and CCK. Future studies should explore the molecular mechanisms by which βHB modulates the secretion of gut hormones. [ABSTRACT FROM AUTHOR]

Obesity is an epidemic with high burden of disease. It is directly proportional to increased risk of morbidity and mortality. Ketogenic diet and herbal supplements have recently gained popularity amongst patients struggling with weight loss. There are limited data available for most of these supplements contrary to the claims laid by the mainstream media. Due to lack of awareness, this patient population is at high risk of adverse effects. We present a case of severe acidosis secondary to ketogenic diet and acetic acid (vinegar) ingestion. The use of dietary acetic acid is usually well tolerated; however, in this case, the large quantities and presence of acute renal injury and metformin use may have worsened the acidosis. Severe ketosis in setting of ketogenic diets is a serious complication, which is infrequently reported in literature. Many of these diets and supplements may seem harmless, but as our case illustrates, when combined with other risk factors, patients can face serious adverse effects and even require hospitalization. It is imperative that such dietary practices are physician supervised to avoid complications. With the recent surge of over-the-counter weight loss supplements and ketogenic diets, physicians also need to engage in dietary discussion with patients when attempting to lose weight. [ABSTRACT FROM AUTHOR]

Objective: This study sought to investigate how glycemia and ketonemia variations during two ketogenic diet protocols affect appetite, executive functions, and mood in young women with overweight.Methods: Fifty healthy young females with overweight were randomly assigned to (1) a ketogenic diet without any restriction on energy intake, (2) a commercial energy-restricted ketogenic Mediterranean diet, and (3) an energy-restricted Mediterranean diet for 10 days. A visual analogue scale was used to test appetite, and one mood test and two cognitive tasks (working memory and inhibition control) were performed. Moreover, body composition, fasting blood glucose, and β-hydroxybutyrate (BHB) were measured.Results: A positive correlation was found between glycemia and appetite (P = 0.019), unfullness score (P =  0.001), and desire to eat (P = 0.030) (pre- and postdiet levels). Postdiet BHB levels showed a positive correlation with fullness score (P = 0.002) and a negative correlation with appetite (P = 0.022) and desire to eat (P = 0.009). A positive correlation was found between prediet levels of glycemia and reaction times in the go-trials of the executive function test (P = 0.018). Postdiet BHB level showed a negative correlation with the accuracy of the no-go trials (P = 0.027).Conclusions: Ketogenic diets, compared with a Mediterranean diet, have a greater effect in terms of appetite reduction but might affect inhibition functions. [ABSTRACT FROM AUTHOR]

Despite existing therapy, patients with heart failure (HF) experience substantial morbidity and mortality, highlighting the urgent need to identify novel pathophysiological mechanisms and therapies, as well. Traditional models for pharmacological intervention have targeted neurohormonal axes and hemodynamic disturbances in HF. However, several studies have now highlighted the potential for ketone metabolic modulation as a promising treatment paradigm. During the pathophysiological progression of HF, the failing heart reduces fatty acid and glucose oxidation, with associated increases in ketone metabolism. Recent studies indicate that enhanced myocardial ketone use is adaptive in HF, and limited data demonstrate beneficial effects of exogenous ketone therapy in studies of animal models and humans with HF. This review will summarize current evidence supporting a salutary role for ketones in HF including (1) normal myocardial ketone use, (2) alterations in ketone metabolism in the failing heart, (3) effects of therapeutic ketosis in animals and humans with HF, and (4) the potential significance of ketosis associated with sodium-glucose cotransporter 2 inhibitors. Although a number of important questions remain regarding the use of therapeutic ketosis and mechanism of action in HF, current evidence suggests potential benefit, in particular, in HF with reduced ejection fraction, with theoretical rationale for its use in HF with preserved ejection fraction. Although it is early in its study and development, therapeutic ketosis across the spectrum of HF holds significant promise. [ABSTRACT FROM AUTHOR]

Background. Multiple acyl-coA dehydrogenase deficiency (MADD) is a rare, inherited, autosomal-recessive disorder leading to the accumulation of acylcarnitine of all chain lengths. Acute decompensation with cardiac, respiratory or hepatic failure and metabolic abnormalities may be life-threatening. Case Presentation. A 29-year-old woman presented with severe lactic acidosis associated with intense myalgia and muscle weakness. The clinical examination revealed symmetric upper and lower limb motor impairment (rated at 2 or 3 out of 5 on the Medical Research Council scale) and clear amyotrophy. Laboratory tests had revealed severe rhabdomyolysis, with a serum creatine phosphokinase level of 8,700 IU/L and asymptomatic hypoglycemia in the absence of ketosis. Electromyography revealed myotonic bursts in all four limbs. The absence of myositis-specific autoantibodies ruled out a diagnosis of autoimmune myositis. Finally, Acylcarnitine profile and gas chromatography–mass spectrometry analysis of organic acids led to the diagnosis of MADD. A treatment based on the intravenous infusion of glucose solutes, administration of riboflavin, and supplementation with coenzyme Q10 and carnitine was effective. Lipid consumption was strictly prohibited in the early stages of treatment. The clinical and biochemical parameters rapidly improved and we noticed a complete disappearance of the motor deficit, without sequelae. Conclusion. A diagnosis of MADD must be considered whenever acute or chronic muscle involvement is associated with metabolic disorders. Acute heart, respiratory or hepatic failure and metabolic abnormalities caused by MADD may be life-threatening, and will require intensive care. [ABSTRACT FROM AUTHOR]

Lactation ketoacidosis is an extremely rare type of high anion gap metabolic acidosis. We report two lactating women who were diagnosed with lactation ketoacidosis. The first patient presented to the Emergency Department at Royal Darwin Hospital, Darwin, Australia, in 2018 with lethargy, nausea and abdominal pain after she commenced a new diet regimen based on three meals of protein per day and free of glucose, gluten and dairy products. The second patient presented to the Emergency Department at Sultan Qaboos University Hospital, Muscat, Oman, in 2018 with headache, severe malaise, epigastric pain and worsening of gastroesophageal symptoms. Blood investigation results showed that both patients had high anion gap metabolic acidosis, ketosis and hypoglycaemia. The patients responded well to intravenous dextrose and resumption of a balanced diet. Both patients were able to continue breastfeeding and remained well on follow-up. [ABSTRACT FROM AUTHOR]

Population growth and urbanization lead to an increasing demand for milk in sub-Saharan Africa, but the production potential of the 65.9 million dairy cows in the region is far from being fully exploited to meet this demand. With the aim to support decision-making for breeding and management of dairy cattle in commercial farms, we performed a comparative study of daily milk offtake, chemical composition of milk, prevalence of metabolic disorders, and body weight development of local and crossbred cattle genotypes in peri-urban commercial farms in Ouagadougou, Burkina Faso. We used data that were collected during regular visits of 7 farms in peri-urban areas of the city over a 16-mo period. Animals belonged to 3 breed groups (123 local zebu, 49 Sahelian crossbred, and 42 European crossbred cows). We applied a mixed model approach to evaluate the genetic and seasonal effects on daily milk offtake, milk composition, and body weight. Nonlinear growth models were fitted to model the body weight development according to genotype, season, and reproductive status of cows. The milk fat-to-milk protein ratio was used to determine the prevalence of ketosis and acidosis. Daily milk offtake from crossbred cows was 3.1- to 4.3-fold higher than from local zebu cows; furthermore, crossbred cows had a higher body weight and maturity rate than local zebu cows. In contrast, no genotype differences were found in milk fat and milk protein percentage and prevalence of ketosis and acidosis. Additionally, seasonal effects suggested that higher production performances could be realized through improved management of dairy cows, particularly in the late dry and rainy season. Improved feeding management could also reduce the risk of metabolic disorders. In summary, production performances of crossbred dairy cows in peri-urban production systems in Burkina Faso are higher as compared with local zebu cows. However, environmental effects suggest that further studies are needed to systematically assess genotype by environment interactions to guide the development of sustainable breeding and management programs for dairy cattle in Burkina Faso. [ABSTRACT FROM AUTHOR]

Ketosis is still an important problem which must be solved in dairy herds. Early precise diagnosis and proper evaluation of the cause of the disease is essential for good management of ketosis on dairy farms. The aim of our work was to analyse the occurrence of rumen dysfunction in connection with subclinical ketosis in dairy herds and to evaluate the relationships between beta-hydroxybutyrate (BHB) concentration in blood and metabolic parameters in blood, urine and rumen fluid. We analysed the results of metabolic profile tests performed in dairy cattle herds from 1,338 cows. The concentration of BHB significantly correlated with glucose, NEFA (nonesterified fatty acids), bilirubin, AST (aspartate aminotransferase), GGT (γ-glutamyl transferase), urea, magnesium and calcium in blood serum and with following parameters of rumen fluid – acetate, propionate, butyrate, acetate/propionate and infusoria. Significant but weak correlations were found between BHB and urine parameters (pH, specific gravity, potassium, magnesium, chloride). Subclinical ruminal acidosis was found in 23.1% and 16.7% of dairy cows with light (BHB 1.2–2 mmol/L) and more severe subclinical ketosis (BHB >2 mmol/L) and simple ruminal indigestion in 16.7% and 30%, respectively. On the basis of performed analysis we can conclude that rumen dysfunction is an important factor for the development of ketosis. Veterinary practitioners should suggest checking the feeding management in their diagnostic work with the aim to distinguish primary and secondary ketosis. Only complex and precise diagnostic work allows applying correct and successful therapy not only for individual animals but also for herd health management. [ABSTRACT FROM AUTHOR]

Prolonged fasting leads to a shift from carbohydrate to fat as the primary energy source, resulting in the production of ketones such as beta-hydroxybutyrate. Hyperketonaemia and ketoacidosis have been observed in young children fasting for surgery. The aim of this study was to investigate ketonaemia in adults fasted for surgery. One hundred non-diabetic adults presenting for elective or emergency surgery were assessed for the presence of hyperketonaemia (beta-hydroxybutyrate levels more than 1 mmol/l), and the relationship between beta-hydroxybutyrate, blood glucose and fasting duration was investigated. Three of 100 patients demonstrated hyperketonaemia, one of whom had ingested a ketogenic supplement the evening prior to surgery. No patient demonstrated beta-hydroxybutyrate levels suggestive of ketoacidosis (above 3 mmol/l). No relationship between fasting duration and ketone or glucose levels was observed. We found no evidence that prolonged preoperative fasting led to beta-hydroxybutyrate levels consistent with ketoacidosis. [ABSTRACT FROM AUTHOR]

Objective: The effect of Ramadan fasting and continuing sodium-glucose co-transporter-2 (SGLT2) inhibitor use on ketonemia, blood pressure and renal function in Muslim patients with type 2 diabetes.Methods: This is a single-centre prospective observational controlled cohort study. Muslim patients aged 21-75 years with type 2 diabetes and estimated glomerular filtration rate (eGFR) ≥ 45 ml/min/1.73 m2 were eligible if they had no contraindication to observe Ramadan fasting. Patients in study group were on stable dose of SGLT2 inhibitor for at least 3 months before enrolment and continued during study period, while patients in control group were not on SGLT2 inhibitor before and during study period. All participants attended baseline visit before Ramadan and follow-up visit during Ramadan.Results: A total of 68 patients of similar baseline characteristics were included in the study: 35 in study group and 33 in control group. During Ramadan fasting, patients from study and control group had similar change in weight (LS mean change of -1.8 versus -1.1 kg, p = 0.205), eGFR (LS mean change of -6.0 versus -4.2 ml/min/1.73 m2, p = 0.399), sitting systolic BP (LS mean change of -8.1 versus -10.4 mmHg, p = 0.569), sitting diastolic BP (LS mean change of -3.7 versus -3.5 mmHg, p = 0.934) and plasma β-hydroxybutyrate level (LS mean change of -0.01 versus -0.02 mmol/L, p = 0.649).Conclusions: Ramadan fasting was associated with significant changes in weight, BP and eGFR regardless whether patients were on SGLT2 inhibitor treatment. Continued use of SGLT2 Inhibitors during Ramadan did not increase ketonemia, nor increase risk of eGFR deterioration and hypoglycaemia. [ABSTRACT FROM AUTHOR]

Diabetic ketoacidosis (DKA) is a form of a hyperglycemic emergency mainly characterized by the triad of hyperglycemia, ketosis, and anion gap metabolic acidosis. DKA may be the initial presentation in approximately 25-40 % of patients with type 1 diabetes. It may also occur in at least 34% of patients with type 2 diabetes. DKA has economic as well as medical implications. This review aims to explore and discuss diabetic ketoacidosis, its pathophysiology, clinical presentation, diagnosis, and management, including nuances in special populations such as pediatrics, obstetrics, and patients with chronic kidney disease. [ABSTRACT FROM AUTHOR]