Alcoholic ketoacidosis - AKA


  • Mobilisation of free fatty acids in association with ↑ liver capacity to convert these to ketones
  • Two types ketones produced - acetoacetate and ß-hydroxybutyrate
  • With alcohol metabolism there is an overall decrease in available NAD
  • In AKA - NAD dependent hepatic oxidation of free fatty acids is switched to ketone formation
  • Associated fall in Insulin, rise in cortisol, growth hormone, glucagon and epinephrine


Our urinary dip sticks only measure acetoacetate (in reaction with nitroprusside on stick)

Dip stick may be negative for ketones in:

  • Alcoholic ketoacidosis
  • Severely shocked DKA (no peripheral conversion of ß-hydroxybutyrate to acetoacetate)



  • Binge drinking & ↓ food for days
  • Nausea & vomiting
  • Abdominal pain


  • Most patients alert (rarely coma)
  • Tachypnoeic
  • Possible concurrent sepsis etc
  • Blood alcohol undetectable
  • VBGs show a high anion gap acidosis (DDx)
  • Glucosuria absent

Differential Dx

  • High anion gap acidosis (link)
  • DKA


  • Thiamine ( ? Wernicke Korsakoff)
  • Saline
  • Glucose - ↑ insulin release, ↓ lipolysis - so ↓ ketone production

Content by Dr Íomhar O' Sullivan. Last review Dr ÍOS 16/04/22.