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Starvation Ketosis and The Kidney: In-Depth Topic Review
Starvation Ketosis and The Kidney: In-Depth Topic Review
Starvation Ketosis and The Kidney: In-Depth Topic Review
aDivision
of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, El Paso, TX, USA;
bTexas
Tech Health Sciences Center, El Paso, TX, USA
Abstract
Background: The remarkable ability of the body to adapt to Introduction
long-term starvation has been critical for survival of primi-
tive man. An appreciation of these processes can provide the Ketoacidosis develops when caloric intake is insuffi-
clinician better insight into many clinical conditions charac- cient to meet normal metabolic demands. Imbalances in
terized by ketoacidosis. Summary: The body adapts to long- fuel utilization can lead to ketosis in chronic illness where
term fasting by conserving nitrogen, as the brain increasing- anorexia coexists with increased catabolism. Other causes
ly utilizes keto acids, sparing the need for glucose. This shift of ketoacidosis include diabetic ketoacidosis, alcoholic ke-
in fuel utilization decreases the need for mobilization of ami- toacidosis, salicylate intoxication, SGLT2 inhibitor thera-
no acids from the muscle for purposes of gluconeogenesis. py, and calorie sufficient but carbohydrate-restricted diets
Loss of urinary nitrogen is initially in the form of urea when [1–6]. Familiarity with the pathophysiology and metabol-
hepatic gluconeogenesis is dominant and later as ammonia ic consequences of ketogenesis is critical, given the poten-
reflecting increased glutamine uptake by the kidney. The tial for the clinician to encounter one of these conditions.
carbon skeleton of glutamine is utilized for glucose produc- This review describes the metabolic changes that occur
tion and regeneration of consumed HCO3−. The replacement when an otherwise normal individual undergoes fasting
of urea with NH4+ provides the osmoles needed for urine over an extended period of time. These changes can be
flow and waste product excretion. Over time, the urinary loss sequentially categorized into the postabsorptive, gluco-
of nitrogen is minimized as kidney uptake of filtered ketone neogenic, and conservation of protein phase.
bodies becomes more complete. Adjustments in urine Na+
serve to minimize kidney K+ wasting and, along with chang-
es in urine pH, minimize the likelihood of uric acid precipita- Postabsorptive Phase
tion. There is a sexual dimorphism in response to starvation.
Key Message: Ketoacidosis is a major feature of common In the first 24 h of fasting, completion of dietary glu-
clinical conditions to include diabetic ketoacidosis, alcoholic cose absorption leads to a fall in blood glucose levels, sig-
ketoacidosis, salicylate intoxication, SGLT2 inhibitor thera- naling a decrease in circulating insulin and an increase in
py, and calorie sufficient but carbohydrate-restricted diets. glucagon levels. Glucagon stimulates the release of glu-
Dietary glucose
utilization
Lipolysis/ketogenesis
Rates of process
Glycogenolysis
Gluconeogenesis
0 12 24 5 10 15 20
Hours Days
cose from glycogen stores in the liver, while the fall in in- from nonprotein precursors keeping proteolysis at a mini-
sulin decreases transport of glucose into the skeletal mus- mum during this early phase of food deprivation.
cle and adipose tissues ensuring an adequate amount of Reduced insulin levels activate lipolysis making fatty ac-
blood glucose is available for the brain where it is com- ids available to serve as an alternative fuel for the skeletal
pletely oxidized to carbon dioxide and water [7]. This re- muscle in the later stages of the postabsorptive phase. Ox-
sponse also provides the necessary fuel for tissues that are idation of fatty acids generates acetyl CoA, which exerts an
exclusively glycolytic, such as erythrocytes, the kidney inhibitory effect on pyruvate dehydrogenase [10]. This ef-
medulla, and bone marrow (Fig. 1). fect ensures the small quantity of remaining glucose taken
Glycogenolysis in the liver is derived from its typical up by the skeletal muscle does not undergo complete oxi-
reserve of 70 g and provides about 75% of the glucose re- dation in the citric acid cycle but is preferentially metabo-
quirements in the postabsorptive phase. Glucose-6-phos- lized to pyruvate and lactate, which are then converted
phatase in the liver removes the phosphate group from glu- back to glucose in the liver. Fatty acid mobilization and
cose-6 phosphate generating free glucose, which is released oxidation in the liver provide the energy to fuel glucose
into the bloodstream for uptake by other cells [8]. Glyco- production since there is a net consumption of 4 ATP mol-
gen is also stored in the skeletal muscle, but due to the lack ecules for each molecule of glucose synthesized via the Cori
of glucose-6-phosphatase, muscle glycogen must first be cycle. The early reliance on the Cori cycle activity in the
metabolized to lactate, which is then released into the cir- postabsorptive state conserves protein by sparing the need
culation and resynthesized into glucose by the liver via the for amino acid precursors for gluconeogenesis.
Cori cycle. Approximately 10–15% of the remaining glu-
cose requirement in this phase is derived from gluconeo-
genesis utilizing lactate and pyruvate as substrates. Glyc- Gluconeogenic Phase
erol, a by-product of hydrolysis of triglycerides, also serves
as a gluconeogenic precursor [9]. While the Cori cycle does As glycogen stores become exhausted after 24 h of
not result in net production of glucose, early reliance on fasting, patients enter a gluconeogenic phase where
this pathway allows glucose to be synthesized primarily substantial amounts of gluconeogenic precursors de-
Glutamine Urea
2. ↑ Production of urea is
Small intestine exported to kidney
Urea cycle
Glutamine
α-ketoglutarate Glutamate
7. Accumulation of acetyl-CoA
ALT directed to ketone body formation
α-ketoglutarate Alanine Alanine
for utilization by brain
1. Proteolysis generates
ALT
glucogenic amino acids Pyruvate Ketone bodies
Glutamate Pyruvate PD (-)
5. ↓ Insulin leads to
PC Acetyl-CoA lipolysis
Branch chain ↑CPT1
amino acids Glucose Glucose Oxaloacetate Citrate
(+) Fatty acids
↓ TCA cycle
activity
8. Export of glucose ↓ACC
Acetyl-CoA ↓ Malonyl-CoA
for brain and tissues exclusively 3. TCA cycle
Skeletal Muscle glycolytic (red blood cells) intermediates directed to
↑ MCoAD
6. ↓ Malonyl-CoA directs
gluconeogenesis fatty acids to β-oxidation
AMPK
↑ Glucagon
Fig. 2. Elucidation of the primary metabolic pathways during the kidney for gluconeogenesis and production of NH4+ to serve as the
gluconeogenic and transition to conservation of protein phases of counterion for excretion of ketoacid anions. Decreased urine urea
starvation. Following the depletion of glycogen, skeletal muscle, and increased urine ammonium excretion reflect this shift in glu-
alanine, and glutamine become the major source for glucose ho- coneogenesis from the liver to kidney. Reduced insulin levels pro-
meostasis. In skeletal muscle, alanine transaminase converts L- mote lipolysis and delivery of fatty acids to the liver, while in-
glutamate and pyruvate into α-ketoglutarate and L-alanine. The creased glucagon through activation of AMPK causes diminished
resulting L-alanine is shuttled to the liver where the amino group levels of malonyl-CoA. These changes direct fatty acids to undergo
is used for urea synthesis, and the residual pyruvate is used for glu- β-oxidation and formation of ketone bodies. Increasing utilization
coneogenesis via conversion to oxaloacetate. Initially, the principal of ketone bodies by the brain spares glucose for exclusively glyco-
site of glutamine metabolism is the small intestine where active lytic tissues, such as red blood cells, bone marrow, and the kidney
shedding of intestinal cells activates purine synthesis creating a medulla. ALT, alanine aminotransferase; PC, pyruvate carboxyl-
high demand for glutamine uptake. A by-product of intestinal glu- ase; PD, pyruvate decarboxylase; TCA, tricarboxylic acid cycle;
tamine metabolism is additional alanine that is delivered to the ACC, Acetyl CoA carboxylase; MCoAD, malonyl-CoA decarbox-
liver. Beginning in the gluconeogenic phase and increasing into the ylase; AMPK, 5′ adenosine monophosphate-activated protein.
conservation of protein phase, glutamine metabolism shifts to the
rived from amino acids are added to lactate, pyruvate, amino acids are preferentially catabolized in the skeletal
and glycerol, to meet cerebral glucose requirements muscle to their α-keto acids by transamination of pyru-
(Fig. 1). A persistent decrease in insulin levels promotes vate and serve as the primary precursor for generation
proteolysis in the muscle, providing the needed supply of alanine. Alanine is released by skeletal muscle and
of substrate for increasing hepatic gluconeogenesis. Al- after uptake in the liver; the carbon skeleton is convert-
anine and glutamine are the most abundant amino ac- ed to glucose while the amino group is converted to
ids released by the skeletal muscle. Despite alanine con- urea and excreted in the urine. This alanine-glucose cy-
stituting only about 7–10% of amino acid residues in cle transfers the amino groups of branched-chain ami-
the skeletal muscle, it accounts for 30–40% of amino no acids to the liver without increasing blood ammonia
acids released from the muscle during this phase [11– levels and provides control points for feedback inhibi-
13]. The plasma concentration of branch chain amino tion of gluconeogenesis. For example, increased con-
acids (leucine, isoleucine, and valine) increases early in centrations of keto acids exert an inhibitory effect on
fasting and peaks at approximately day 5 [12]. These gluconeogenesis by decreasing the degradation of
Skeletal muscle
Ketone bodies
proteolysis
Inhibitory effect on
lipolysis
Adipose tissue
↑ Insulin (+)
Fig. 3. Control points for feedback inhibition of ketone bodies on gluconeogenesis, proteolysis, and ketogenesis.
In addition to exerting negative feedback signals, ketone bodies stimulate insulin release from the pancreatic beta
cells, which in turn exerts an inhibitory effect on alanine uptake by the liver, providing an additional moderating
effect on gluconeogenesis. Ketone bodies also participate in the reduction in blood pressure and metabolic rate
that typically occurs with prolonged fasting by decreasing sympathetic tone through receptors in sympathetic
ganglia.
branch chain amino acids thereby removing a source of to activation of 5′ adenosine monophosphate-activated
nitrogen for alanine synthesis [14–17]. In addition, in- protein which inhibits the activity of acetyl-CoA carbox-
sulin exerts an inhibitory effect on alanine uptake by the ylase and simultaneously activates malonyl-CoA decar-
liver, providing an additional moderating effect on glu- boxylase [22, 23] (Fig. 2). The fall in malonyl-CoA acti-
coneogenesis [18]. vates carnitine palmitoyltransferase-I, facilitating the en-
The carbon skeleton for glutamine synthesis comes try of fatty acyl groups into the mitochondria. Normally,
from amino acids such as glutamate, aspartate, valine, acetyl CoA generated from hepatic β-oxidation of fatty
and isoleucine. Glutamine serves as a major energy-yield- acids undergoes complete oxidation in the citric acid cy-
ing fuel for rapid turnover of cells in the mucosa of the cle, followed by the electron transport chain to produce
intestine and cells of the immune system. Some of the ATP. Since the liver can only produce ATP in an amount
glutamine taken up by the intestine is only partially oxi- equal to what can be utilized, production of keto acids
dized in order to provide additional alanine for hepatic serves as an overflow pathway for the large quantity of
gluconeogenesis [19, 20]. Glutamine is also the primary acetyl CoA produced [24]. Depletion of oxaloacetate due
substrate for gluconeogenesis in the kidney where pro- to increased gluconeogenesis also favors ketogenesis,
duction of ammonia as a by-product serves a major role since this substrate is essential for acetyl CoA to enter the
in maintenance of acid-base balance [21]. citric acid cycle. In addition, accumulation of acetyl CoA
The flux of fatty acids to the liver continues to increase ensures pyruvate is utilized as a substrate for gluconeo-
during the gluconeogenic phase and is primarily directed genesis by exerting an inhibitory effect on pyruvate dehy-
to generation of ketone bodies. Increased glucagon leads drogenase [10].
Glutamine 2Na+
B◦AT1 SNAT3 Glutamine
Na+ Glutamine H+
NH4+ α-ketoglutarate
HCO3-
Malate
3HCO3-
NH4+ TCA HCO3- NBC1
NHE3 Na+
cycle
Na+
Oxidative phosphorylation
and ↑ ATP production
NH4+
Fig. 4. Kidney proximal tubular catabolism of glutamine. The de- transported across the basolateral membrane into the systemic cir-
velopment of acidosis during starvation leads to increased extrac- culation. NBC1, Na+/3HCO3− cotransporter; SNAT3, basolateral
tion and catabolism of glutamine by the proximal tubule. Acidosis glutamine transporter; BoAT1, Na+-dependent neutral amino acid
upregulates the apical and basolateral uptake of glutamine and the cotransporter; NHE3, apical Na+/H+ exchanger; TCA, tricarbox-
mitochondrial enzymes that facilitate metabolism of glutamine. ylic acid cycle; GLUT, glucose transporter; PEPCK, phosphoenol-
The net effect is increased ammoniagenesis, gluconeogenesis, ATP pyruvate carboxykinase.
production, and net synthesis of HCO3−. Glucose and HCO3− are
Diabetic Increased anion gap metabolic acidosis, increased plasma Deficiency of insulin is primary defect, increased glucagon, and
ketoacidosis [1] glucose (typically 350–800 mg/dL) causes osmotic diuresis absent stimulatory effect of ketone bodies on insulin release
leading to marked volume depletion and depletion of resulting in unrestrained lipolysis and delivery of fatty acids to liver
electrolytes, such as K+ and PO4− primed to generate ketone bodies and unregulated gluconeogenesis
SGLT2i-induced Increased anion gap metabolic acidosis, plasma glucose Lowering of plasma glucose with SGLT2i leads to decreased insulin
euglycemic normal or increased (often <250 mg/dL), cell shift in water, levels and increased lipolysis, increased glucagon/insulin ratio
ketoacidosis [2] and K+ are minimal making disturbances in plasma Na+ and causes ketogenesis in liver, glycosuric effect of drug minimizes
K+ less severe when compared to typical diabetic ketoacidosis, degree of hyperglycemia
symptoms are nonspecific such as malaise and nausea
Alcoholic Increased anion gap metabolic acidosis dominant disturbance, Ethanol metabolism increases liver NADH/NAD+ ratio, decreased
ketoacidosis [3] respiratory alkalosis (alcohol withdrawal), and metabolic food intake (reduction in insulin) combined with increased
alkalosis (vomiting) also common, decreased plasma levels of adrenergic state (alcohol withdrawal) leads to marked lipolysis and
Mg2+, K+, PO4−, and Na+ are also common delivery of fatty acids to ketogenic liver
Pregnancy [4] Anion gap metabolic acidosis, normal or low plasma glucose, Normal pregnancy is characterized by insulin resistance (human
risk is increased with skipped meals, β-agonists, tocolytics, placental lactogen and progesterone) and increased reliance on fat
and glucocorticoids oxidation causing exaggerated ketogenesis after short periods of
starvation or conditions of stress (adaptations ensure maximal
availability of glucose for developing fetus)
Salicylate Respiratory alkalosis typically dominant, often with increased Alkalemia contributes to ketogenesis through stimulatory effects on
intoxication [5] anion gap metabolic acidosis due to increased ketogenesis and hormone-sensitive lipase, leading to increased lipolysis and
lactic acid facilitating the entry of fatty acids into the mitochondria by
decreasing the inhibitory effect of malonyl-CoA on carnitine
palmitoyltransferase, salicylates uncouple oxidative phosphorylation
causing increased lactate production
Ketogenic diets Degree of acidosis tends to be mild when insulin reserve is Degree of ketosis is related to degree of carbohydrate restriction,
[6] normal, long-term use may increase the risk of nephrolithiasis initial weight lost due to reduced volume from ketonuria, keto acids
and osteoporosis, such diets should be avoided with SGLT2i exert an inhibitory effect on appetite
The transition from liver to kidney as the predomi- load sufficiency to require only 100–200 mL/day urine
nant site of gluconeogenesis is reflected by changes in output, permitting survival with the 200–300 mL/day of
urine nitrogen excretion products. High urine urea ex- water produced by metabolism with minimal additional
cretion is present early on and then progressively de- water intake [33].
creases, while ammonia becomes the predominant ni- Within the protein conservation phase, hepatic pro-
trogenous product [27]. While these changes reflect re- duction of ketone bodies will eventually lead to equal
ductions in muscle protein breakdown, they also provide utilization in brain, muscle, and kidney, minus a small
the means to prevent oliguira. Given that each molecule amount excreted in the urine. In this steady state, star-
of urea is synthesized from 2 NH4+ and 2 HCO3− ions, vation ketosis is characterized by a plasma bicarbonate
urinary excretion of NH4+ coupled to β-hydroxybutyrate concentration of approximately 18 mEq/L, a
provides 4 times the number of osmoles compared to β-hydroxybutyrate concentration of 8–10 mmol/L, and
urea [32]. According to one calculation, 75% less protein a normal-to-low plasma glucose concentration. While
catabolism is required to provide the needed osmoles plasma insulin levels are reduced, there remains a suf-
(NH4-β-hydroxybutyrate as compared to urea) to main- ficient amount of insulin to prevent excessive mobiliza-
tain a daily urine output of 500 mL at a urine concentra- tion of fatty acids. Ketone bodies play a major role in
tion of 600 mOsm/kg H2O [32]. In the absence of a hot establishing this new equilibrium by exerting a direct
or dry environment, the nitrogen-sparing effect of pro- stimulatory effect on insulin release combined with di-
longed starvation could reduce the osmotic excretory rect inhibitory effects on lipolysis in adipocytes [16, 28,
Fig. 5. Ketone body uptake and oxidation in the proximal tubule erates an amount of HCO3− equal to what was consumed in their
provides a protein-sparing effect by way of ATP turnover. Metab- production. In addition, the suppressive effect on ammoniagenesis
olism of glutamine to NH4+ and HCO3− results in production of and requirement for glutamine uptake results in less proteolysis
ATP (see Fig. 4). Since ATP is not stored and kidney production and provides a protein-sparing effect as one transitions into the
must equal utilization, the additional ATP produced from increas- conservation of protein phase. SMCT, sodium-coupled monocar-
ing uptake and subsequent oxidation of ketone bodies exert a sup- boxylate transporter; TCA, tricarboxylic acid cycle; SNAT3, baso-
pressive effect on ammoniagenesis and glutamine uptake. Acid- lateral glutamine transporter; NAD+, nicotinamide adenine dinu-
base balance is maintained since oxidation of ketone bodies regen- cleotide; NADH, reduced nicotinamide adenine dinucleotide.
34] (Fig. 3). Keto acids and fatty acids progressively Kidney’s Role in Starvation
substitute for glucose as the preferred fuel for both skel-
etal and cardiac muscle as starvation progresses into the The kidney plays a critical role in the steady state
protein conservation phase. Eventually, free fatty acid achieved during the protein conservation phase. At low
utilization becomes dominant, sparing keto acids for plasma concentrations, filtered ketone bodies are com-
the brain, as uptake of acetoacetate by muscle is re- pletely reabsorbed by the saturable Na+-coupled mono-
turned back to the blood as β-hydroxybutyrate, signify- carboxylate transporters SMCT1 (SLC5A8) and SMCT2
ing a more reduced redox potential in muscle mito- (SLC5A12) in the proximal tubule [36, 37] (Fig. 5). Keto-
chondria secondary to fatty acids oxidation [33]. This nuria develops as plasma levels rise and the filtered load
reduced state has also been linked to a reduction in of ketoacid salt increases. The loss of Na+ coupled aceto-
muscle proteolysis adding to the nitrogen-sparing ef- acetate and β-hydroxybutyrate in the first of several days
fect of keto acids in skeletal muscle [35]. Cahill hypoth- of fasting results in negative Na+ balance and is the mech-
esized the preference for ketoacid utilization by the anism responsible for the rapid initial weight loss which
brain is directly correlated to the brain/carcass ratio occurs in the first days of total fasting [38, 39]. The urine
across species since the brain preferentially utilizes keto Cl− concentration is low during this time and reflects the
acids, as opposed to preferential use of fatty acids by the contraction of extracellular fluid volume. As ammonia-
carcass [33]. Table 1 summarizes other clinical condi- genesis increases, NH4+ replaces Na+ as the obligate cat-
tions characterized by ketoacidosis. ion accompanying organic acid salt excretion. At this
point, urinary Na+ and Cl− are both low reflective of in-
Na+-β-hydroxybutyrate ↑↑ ↓ ↓
Cl− ↓ ↓ ↓
K+ ↑↑ ↓ ↓
Urea ↑↑ ↑ ↓
NH4+β-hydroxybutyrate ↓ ↑↑ ↓
Comment ↑ Hepatic gluconeogenesis causes ↑ urea Gluconeogenesis ↓ in liver and ↑ in kidney, ↑ Kidney reabsorption of keto
production, keto acids excreted as Na+ salt, urine urea ↓, NH4+ replaces Na+ as ketoacid acids leads to ↓
↑ K+ loss due to coupling of ↑ aldosterone salt, ↓ K+ loss due to ↓ distal Na+ delivery ammoniagenesis, glutamine
and ↑ Na+ in distal nephron uptake ↓
creased proximal reabsorption in response to volume [38]. Last, reabsorption and subsequent oxidation of ke-
contraction (Table 2). Decreased distal Na+ delivery lim- tone bodies in the kidney regenerates consumed HCO3−
its K+ loss from the body even though circulating levels of thereby lessening the degree of acidosis that otherwise oc-
mineralocorticoid are increased. Decreased Na+ delivery curs if lost in the urine as a Na+ or K+ salt.
also decreases distal H+ secretion, which along with in-
creased urine NH4+ causes urine pH to be more alkaline,
thereby lessening the risk of uric acid precipitation [32, Natriuresis
40].
Concentrations of β-hydroxybutyrate progressively Weight loss in the first 1–5 days of fasting ranges from
increase following sustained fasting. By contrast, urinary 1 to 2 kg per day and gradually slows to an average of 0.3
losses peak after 3–4 days then slightly fall as fasting ex- kg per day over the subsequent 3 weeks. The rapid initial
tends into the protein conservation phase, suggesting the weight loss is primarily due to salt and water diuresis [47–
absence of a tubular max for reabsorption [38, 39, 41]. 49]. Increased skeletal muscle efficiency slows subsequent
The precise mechanism to account for these findings has weight loss by reducing the caloric cost of muscle contrac-
not been defined. A saturable low capacity tubular secre- tion [reviewed in ref.50]. The negative Na+ balance in
tory process mediated by organic anion transporters on subjects who fast for several days is nearly 350 mmol as
the basolateral surface of the tubule has been proposed as compared to a Na+ loss of 150 mmol in subjects eating a
a mechanism for the persistent urinary excretion of diet virtually free of Na+ [47]. An obligatory loss of Na+
β-hydroxybutyrate [42]. due to increased generation and urinary excretion of ke-
The increased capacity for reabsorption of filtered ke- tone bodies is primarily caused by a natriuretic response
tone bodies is an adaptive response during starvation for in early fasting. As discussed earlier, the magnitude of
several reasons. First, minimizing the urinary loss pre- natriuresis begins to decrease as ammoniagenesis in-
vents loss of potential metabolic fuel, since ketone bodies creases, allowing NH4+ to replace Na+ as the major uri-
furnish a significant amount of the caloric requirements nary cation. The development of acidemia contributes to
during fasting. In prolonged starvation kidney reabsorp- the early natriuretic response since metabolic acidosis ex-
tion of ketone bodies spares approximately 225 kcal/day, erts an inhibitory effect on proximal Na+ reabsorption
which would otherwise be lost in the urine [38]. Second, [51]. The rise in glucagon and fall in insulin levels have
kidney reabsorption of ketone bodies exerts an inhibitory been implicated in the natriuresis of early fasting. Infu-
effect on ammoniagenesis (Fig. 5). Infusion of sion of physiological levels glucagon to nonfasting sub-
β-hydroxybutyrate reduces kidney NH4+ production in jects produces a natriuretic response similar to what is
dogs and humans with chronic metabolic acidosis [43– observed in fasting subjects [52]. Decreased insulin levels
45]. This effect is in addition to reductions in the glomer- have been implicated since insulin normally stimulates
ular filtration rate and lower filtered load of Na+ [46]. De- proximal Na+ reabsorption [53]. Refeeding with carbohy-
creased ammoniagenesis reduces the need for glutamine drate, even if the diet is hypocaloric, produces an abrupt
uptake by the kidney minimizing protein breakdown, po- reversal of salt and water loss and leads to an immediate
tentially conserving as much as 7 g of nitrogen per day gain in weight [54]. In some cases, this response is associ-
plasma HCO3− concentration to near normal, in some α-IC cell β-IC cell
References
1 Palmer BF, Clegg DJ. Electrolyte and acid- 3 Palmer BF, Clegg DJ. Electrolyte distur- 5 Palmer BF, Clegg DJ. Salicylate toxicity. N
base disturbances in patients with diabetes bances in patients with chronic alcohol-use Engl J Med. 2020;382(26):2544–55.
mellitus. N Engl J Med. 2015; 373(6): 548– disorder. N Engl J Med. 2017; 377(14):1368– 6 Shah P, Isley WL. Ketoacidosis during a low-car-
59. 77. bohydrate diet. N Engl J Med. 2006;354(1):97–8.
2 Palmer BF, Clegg DJ. Euglycemic ketoacido- 4 Metzger BE, Ravnikar V, Vileisis RA, Freinkel 7 Ramnanan CJ, Edgerton DS, Kraft G, Cher-
sis as a complication of SGLT2 inhibitor ther- N. “Accelerated starvation” and the skipped rington AD. Physiologic action of glucagon
apy. Clin J Am Soc Nephrol. 2021 Feb 9. breakfast in late normal pregnancy. Lancet. on liver glucose metabolism. Diabetes Obes
(Epub before Press). 1982;1:588–92. Metab. 2011;13(Suppl 1):118–25.