Non-diabetic ketoacidosis: A case of alcoholic ketoacidosis accompanied by hyperglycemia.

Alcoholic ketoacidosis (AKA) lacks specific clinical presentation. The results of blood testing commonly show hemoconcentration, elevated ß-hydroxybutyrate levels, and acidosis in patients with AKA. Herein, we report a case of AKA accompanied by hyperglycemia and review the related literature. Case report: AKA associated with hyperglycemia is rare, and its pathogenesis is similar to that of diabetic ketoacidosis, thereby making differentiation challenging. Accordingly, AKA is easily misdiagnosed by endocrinologists. The main symptoms of a 37-year-old female included hyperglycemia, elevated ß-hydroxybutyrate levels, and metabolic acidosis. Primary clinical presentations were severe nausea and vomiting. The patient initially diagnosed with DKA were eventually confirmed as AKA, who recovered after active therapy with rehydration and correction of hyperglycemia, electrolyte imbalance, and ketosis. This study provides a reference for clinicians to reduce missed diagnosis and the misdiagnosis rates of AKA.

Euglycemic Ketoacidosis as a Complication of SGLT2 Inhibitor Therapy.

Sodium-glucose cotransporter-2 (SGLT2) inhibitors are drugs designed to lower plasma glucose concentration by inhibiting Na+-glucose-coupled transport in the proximal tubule. Clinical trials demonstrate these drugs have favorable effects on cardiovascular outcomes to include slowing the progression of CKD. Although most patients tolerate these drugs, a potential complication is development of ketoacidosis, often with a normal or only a minimally elevated plasma glucose concentration. Inhibition of sodium-glucose cotransporter-2 in the proximal tubule alters kidney ATP turnover so that filtered ketoacids are preferentially excreted as Na+ or K+ salts, leading to indirect loss of bicarbonate from the body and systemic acidosis under conditions of increased ketogenesis. Risk factors include reductions in insulin dose, increased insulin demand, metabolic stress, low carbohydrate intake, women, and latent autoimmune diabetes of adulthood. The lack of hyperglycemia and nonspecific symptoms of ketoacidosis can lead to delays in diagnosis. Treatment strategies and various precautions are discussed that can decrease the likelihood of this complication.

Exogenous Ketosis Impairs 30-min Time-Trial Performance Independent of Bicarbonate Supplementation.

PURPOSE: We recently demonstrated that coingestion of NaHCO3 to counteract ketoacidosis resulting from oral ketone ester (KE) intake improves mean power output during a 15-min time trial (TT) at the end of a 3-h cycling race by ~5%. This ergogenic effect occurred at a time when blood ketone levels were low, as ketosis was only induced during the initial ~2 h of the race. Therefore, in the current study, we investigated whether performance also increases if blood ketone levels are increased in the absence of ketoacidosis during high-intensity exercise. METHODS: In a double-blind crossover design, 14 well-trained male cyclists completed a 30-min TT (TT30') followed by an all-out sprint at 175% of lactate threshold (SPRINT). Subjects were randomized to receive (i) 50 g KE, (ii) 180 mg·kg-1 body weight NaHCO3 (BIC), (iii) KE + BIC, or (iv) a control drink (CON). RESULTS: KE ingestion increased blood d-ß-hydroxybutyrate to ~3-4 mM during the TT30' and SPRINT (P < 0.001 vs CON). In KE, blood pH and bicarbonate concomitantly dropped, causing 0.05 units lower pH and 2.6 mM lower bicarbonate in KE compared with CON during the TT30' and SPRINT (P < 0.001 vs CON). BIC coingestion resulted in 0.9 mM higher blood d-ß-hydroxybutyrate (P < 0.001 vs KE) and completely counteracted ketoacidosis during exercise (P > 0.05 vs CON). Mean power output during TT30' was similar between CON and BIC at 281 W, but was 1.5% lower in the KE conditions (main effect of KE: P = 0.03). Time to exhaustion in the SPRINT was ~64 s in CON and KE and increased by ~8% in the BIC conditions (main effect of BIC: P < 0.01). DISCUSSION: Neutralization of acid-base disturbance by BIC coingestion is insufficient to counteract the slightly negative effect of KE intake during high-intensity exercise.

The effect of a ketogenic diet and synergy with rapamycin in a mouse model of breast cancer.

BACKGROUND: The effects of diet in cancer, in general, and breast cancer in particular, are not well understood. Insulin inhibition in ketogenic, high fat diets, modulate downstream signaling molecules and are postulated to have therapeutic benefits. Obesity and diabetes have been associated with higher incidence of breast cancer. Addition of anti-cancer drugs together with diet is also not well studied. METHODS: Two diets, one ketogenic, the other standard mouse chow, were tested in a spontaneous breast cancer model in 34 mice. Subgroups of 3-9 mice were assigned, in which the diet were implemented either with or without added rapamycin, an mTOR inhibitor and potential anti-cancer drug. RESULTS: Blood glucose and insulin concentrations in mice ingesting the ketogenic diet (KD) were significantly lower, whereas beta hydroxybutyrate (BHB) levels were significantly higher, respectively, than in mice on the standard diet (SD). Growth of primary breast tumors and lung metastases were inhibited, and lifespans were longer in the KD mice compared to mice on the SD (p<0.005). Rapamycin improved survival in both mouse diet groups, but when combined with the KD was more effective than when combined with the SD. CONCLUSIONS: The study provides proof of principle that a ketogenic diet a) results in serum insulin reduction and ketosis in a spontaneous breast cancer mouse model; b) can serve as a therapeutic anti-cancer agent; and c) can enhance the effects of rapamycin, an anti-cancer drug, permitting dose reduction for comparable effect. Further, the ketogenic diet in this model produces superior cancer control than standard mouse chow whether with or without added rapamycin.

Ketonemia and Glycemia Affect Appetite Levels and Executive Functions in Overweight Females During Two Ketogenic Diets.

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 ß-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.

Ketoacidosis associated with ketogenic diet in a non-diabetic lactating woman.

A 37-year-old woman who had 8 weeks post partum, breast feeding and on a low carbohydrate and high protein (ketogenic) diet, was admitted to the hospital with acute onset of nausea, vomiting and abdominal pain of 1-day duration. On admission, she was found to have high anion gap metabolic acidosis, elevated beta-hydroxybutyric acid level, normal glucose level and evidence of ketoacidosis. She was treated with lactated Ringer solution, along with dextrose 5% solution with the resolution of symptoms and metabolic derangement.

Acute Hyperketonemia Does Not Affect Glucose or Palmitate Uptake in Abdominal Organs or Skeletal Muscle.

CONTEXT: It has recently been hypothesized that ketone bodies may have independent cardioprotective effects due to increased myocardial efficiency and that this may explain the improved survival of individuals with type 2 diabetes treated with mildly ketogenic sodium-glucose cotransporter-2 inhibitors. OBJECTIVE: To determine whether ketone bodies are selectively utilized in tissues critical for preservation of conscience and circulation. We investigated the effect of acute hyperketonemia on substrate metabolism in less prioritized tissues such as abdominal organs, adipose tissue, and skeletal muscle. DESIGN: Acute, randomized, single-blinded, crossover design. SETTING: Ambulatory care. PARTICIPANTS: Eight healthy participants completed the study. Two additional participants withdrew because of claustrophobia during the scans. INTERVENTION: Infusions of saline and ketone bodies during a hyperinsulinemic-euglycemic clamp. MAIN OUTCOME MEASURES: Organ-specific glucose and palmitate uptake was determined by dynamic positron emission tomography/computed tomography (PET/CT) scans with 18F-fluorodeoxyglucose (18F-FDG) and 11C-palmitate. Blood flow to abdominal organs was measured with O-15-labeled water (15O-H2O) perfusion PET. The study was performed as a post hoc analysis. RESULTS: We found that ketone body infusion did not affect glucose uptake, palmitate uptake, or blood flow to abdominal organs and skeletal muscles. CONCLUSION: Acute hyperketonemia does not affect glucose or palmitate uptake in skeletal muscle or abdominal tissues, supporting the notion that ketone bodies are selectively used by critical organs such as the heart and brain.

Inhibition of adenosine A1 receptors abolished the nutritional ketosis-evoked delay in the onset of isoflurane-induced anesthesia in Wistar Albino Glaxo Rijswijk rats.

BACKGROUND: It has been demonstrated that administration of exogenous ketone supplement ketone salt (KS) and ketone ester (KE) increased blood ketone level and delayed the onset of isoflurane-induced anesthesia in different rodent models, such as Wistar Albino Glaxo Rijswijk (WAG/Rij) rats. The modulatory effect of adenosinergic system may have a role in the ketone supplementation-evoked effects on isoflurane-generated anesthesia. Thus, we investigated whether adenosine receptor antagonists can modulate the effect of exogenous ketone supplements on the onset of akinesia induced by isoflurane. METHODS: To investigate the effect of exogenous ketone supplements on anesthetic induction we used ketone supplement KE, KS, KEKS (1:1 mix of KE and KS), KSMCT and KEMCT (1:1 mix of KS and KE with medium chain triglyceride/MCT oil, respectively) in WAG/Rij rats. Animals were fed with standard diet (SD), which was supplemented by oral gavage of different ketone supplements (2.5 g/kg/day) for 1 week. After 7 days, isoflurane (3%) was administered for 5 min and the time until onset of isoflurane-induced anesthesia (time until immobility; light phase of anesthesia: loss of consciousness without movement) was measured. Changes in levels of blood ß-hydroxybutyrate (ßHB), blood glucose and body weight of animals were also recorded. To investigate the putative effects of adenosine receptors on ketone supplements-evoked influence on isoflurane-induced anesthesia we used a specific adenosine A1 receptor antagonist DPCPX (intraperitoneally/i.p. 0.2 mg/kg) and a selective adenosine A2A receptor antagonist SCH 58261 (i.p. 0.5 mg/kg) alone as well as in combination with KEKS. RESULTS: Significant increases were demonstrated in both blood ßHB levels and the number of seconds required before isoflurane-induced anesthesia (immobility) after the final treatment by all exogenous ketone supplements. Moreover, this effect of exogenous ketone supplements positively correlated with blood ßHB levels. It was also demonstrated that DPCPX completely abolished the effect of KEKS on isoflurane-induced anesthesia (time until immobility), but not SCH 58261. CONCLUSIONS: These findings strengthen our previous suggestion that exogenous ketone supplements may modulate the isoflurane-induced onset of anesthesia (immobility), likely through A1Rs.

Induced Ketosis as a Treatment for Neuroprogressive Disorders: Food for Thought?

Induced ketosis (or ketone body ingestion) can ameliorate several changes associated with neuroprogressive disorders, including schizophrenia, bipolar disorder, and major depressive disorder. Thus, the effects of glucose hypometabolism can be bypassed through the entry of beta-hydroxybutyrate, providing an alternative source of energy to glucose. The weight of evidence suggests that induced ketosis reduces levels of oxidative stress, mitochondrial dysfunction, and inflammation-core features of the above disorders. There are also data to suggest that induced ketosis may be able to target other molecules and signaling pathways whose levels and/or activity are also known to be abnormal in at least some patients suffering from these illnesses such as peroxisome proliferator-activated receptors, increased activity of the Kelch-like ECH-associated protein/nuclear factor erythroid 2-related factor 2, Sirtuin-1 nuclear factor-κB p65, and nicotinamide adenine dinucleotide (NAD). This review explains the mechanisms by which induced ketosis might reduce mitochondrial dysfunction, inflammation, and oxidative stress in neuropsychiatric disorders and ameliorate abnormal levels of molecules and signaling pathways that also appear to contribute to the pathophysiology of these illnesses. This review also examines safety data relating to induced ketosis over the long term and discusses the design of future studies.

Carbohydrate intake and ketosis in self-sufficient multi-stage ultramarathon runners.

Ultra-endurance athletes accumulate an energy deficit throughout their events and those competing in self-sufficient multi-stage races are particularly vulnerable due to load carriage considerations. Whilst urinary ketones have previously been noted in ultra-endurance exercise and attributed to insufficient carbohydrate (CHO) availability, not all studies have reported concomitant CHO intake. Our aim was to determine changes in blood glucose and ß-hydroxybutyrate concentrations over five days (240 km) of a self-sufficient multi-stage ultramarathon in combination with quantification of energy and macronutrient intakes, estimated energy expenditure and evaluation of energy balance. Thirteen runners (8 male, 5 female, mean age 40 ± 8 years) participated in the study. Glucose and ß-hydroxybutyrate were measured every day immediately post-running, and food diaries completed daily. CHO intakes of 301 ± 106 g·day-1 (4.3 ± 1.8 g·kg-1·day-1) were not sufficient to avoid ketosis (5-day mean ß-hydroxybutyrate: 1.1 ± 0.6 mmol.L-1). Furthermore, ketosis was not attenuated even when CHO intake was high (9 g·kg-1·day-1). This suggests that competing in a state of ketosis may be inevitable during multi-stage events where load reduction is prioritised over energy provisions. Attenuating negative impacts associated with such a metabolic shift in athletes unaccustomed to CHO and energy restriction requires further exploration.

Effects of recombinant bovine interleukin-8 (rbIL-8) treatment on health, metabolism, and lactation performance in Holstein cattle II: Postpartum uterine health, ketosis, and milk production.

To evaluate the effect of recombinant bovine interleukin-8 (rbIL-8) on uterine health and milk production, 2 separate studies were conducted. For study 1, postpartum Holstein cows (n = 213) were randomly allocated into 1 of 3 intrauterine treatment groups: control (CTR, 250 mL of saline solution), low dose (L-IL8, 11.25 µg of rbIL-8 diluted in 250 mL of saline solution), and high dose (H-IL8, 1,125 µg of rbIL-8 diluted in 250 mL of saline solution). Intrauterine delivery of treatments was performed within 12 h of parturition. Cows were evaluated for retained fetal membranes, puerperal metritis, and clinical endometritis. Blood samples were collected immediately before treatment and 1, 2, and 3 d in milk for assessment of IL-8, haptoglobin, fatty acids, and ß-hydroxybutyrate concentrations. Treatment with rbIL-8 reduced the incidence of puerperal metritis in multiparous cows (CTR = 34.3, L-IL8 = 8.11, and H-IL8 = 6.35%). Both the L-IL8 and H-IL8 groups produced significantly more milk, fat-corrected milk, and energy-corrected milk yields when compared with placebo-treated controls. A second study was performed to confirm the effect of rbIL-8 on milk production. In study 2, 164 primiparous cows were randomly allocated into 1 of 4 treatment groups: control (CTR, 250 mL of saline solution), low dose (L-IL8, 0.14 µg of rbIL-8), medium dose (M-IL8, 14 µg of rbIL-8), and high dose (H-IL8, 1,400 µg of rbIL-8). Treatments were prepared and administered as described for study 1. Cows in the L-IL8, M-IL8, and H-IL8 groups produced significantly more milk, fat-corrected milk, and energy-corrected milk yields when compared with control cows. In conclusion, treatment with rbIL-8 decreased the incidence of puerperal metritis in multiparous cows. The administration of rbIL-8 was repeatedly associated with a dramatic and long-lasting improvement of lactation performance.

Investigating the effect of sex and ketosis on weight-loss-induced changes in appetite.

BACKGROUND: Diet-induced weight loss (WL) is usually accompanied by increased appetite, a response that seems to be absent when ketogenic diets are used. It remains unknown if sex modulates the appetite suppressant effect of ketosis. OBJECTIVE: The aim of this study was to examine if sex modulates the impact of WL-induced changes in appetite and if ketosis alters these responses. METHODS: Ninety-five individuals (55 females) with obesity (BMI [kg/m 2]: 37  ± 4) underwent 8 wk of a very-low-energy diet, followed by 4 wk of refeeding and weight stabilization. Body composition, plasma concentration of ß-hydroxybutyrate (ß-HB) and appetite-related hormones (active ghrelin, active glucagon-like peptide 1 [GLP-1], total peptide YY [PYY], cholecystokinin and insulin), and subjective feelings of appetite were measured at baseline, week 9 in ketosis, and week 13 out of ketosis. RESULTS: The mean WL at week 9 was 17% for males and 15% for females, which was maintained at week 13. Weight, fat, and fat-free mass loss were greater in males (P < 0.001 for all) and the increase in ß-HB at week 9 higher in females (1.174 ± 0.096 compared with 0.783 ± 0.112 mmol/L, P = 0.029). Basal and postprandial GLP-1 and postprandial PYY (all P < 0.05) were significantly different for males and females. There were no significant sex × time interactions for any other appetite-related hormones or subjective feelings of appetite. At week 9, basal GLP-1 was decreased only in males (P < 0.001), whereas postprandial GLP-1 was increased only in females (P < 0.001). No significant changes in postprandial PYY were observed over time for either sex. CONCLUSIONS: Ketosis appears to have a greater beneficial impact on GLP-1 in females. However, sex does not seem to modulate the changes in the secretion of other appetite-related hormones, or subjective feelings of appetite, seen with WL, regardless of the ketotic state. This trial was registered at clinicaltrials.gov as NCT01834859.

Prediction of blood ß-hydroxybutyrate content and occurrence of hyperketonemia in early-lactation, pasture-grazed dairy cows using milk infrared spectra.

The objective of this study was to evaluate the ability of milk infrared spectra to predict blood ß-hydroxybutyrate (BHB) concentration for use as a management tool for cow metabolic health on pasture-grazed dairy farms and for large-scale phenotyping for genetic evaluation purposes. The study involved 542 cows (Holstein-Friesian and Holstein-Friesian × Jersey crossbreds), from 2 farms located in the Waikato and Taranaki regions of New Zealand that operated under a seasonal-calving, pasture-based dairy system. Milk infrared spectra were collected once a week during the first 5 wk of lactation. A blood "prick" sample was taken from the ventral labial vein of each cow 3 times a week for the first 5 wk of lactation. The content of BHB in blood was measured immediately using a handheld device. After outlier elimination, 1,910 spectra records and corresponding BHB measures were used for prediction model development. Partial least square regression and partial least squares discriminant analysis were used to develop prediction models for quantitative determination of blood BHB content and for identifying cows with hyperketonemia (HYK). Both quantitative and discriminant predictions were developed using the phenotypes and infrared spectra from two-thirds of the cows (randomly assigned to the calibration set) and tested using the remaining one-third (validation set). A moderate accuracy was obtained for prediction of blood BHB. The coefficient of determination (R2) of the prediction model in calibration was 0.56, with a root mean squared error of prediction of 0.28 mmol/L and a ratio of performance to deviation, calculated as the ratio of the standard deviation of the partial least squares model calibration set to the standard error of prediction, of 1.50. In the validation set, the R2 was 0.50, with root mean squared error of prediction values of 0.32 mmol/L, which resulted in a ratio of performance to deviation of 1.39. When the reference test for HYK was defined as blood concentration of BHB ≥1.2 mmol/L, discriminant models indicated that milk infrared spectra correctly classified 76% of the HYK-positive cows and 82% of the HYK-negative cows. The quantitative models were not able to provide accurate estimates, but they could differentiate between high and low BHB concentrations. Furthermore, the discriminant models allowed the classification of cows with reasonable accuracy. This study indicates that the prediction of blood BHB content or occurrence of HYK from milk spectra is possible with moderate accuracy in pasture-grazed cows and could be used during routine milk testing. Applicability of infrared spectroscopy is not likely suited for obtaining accurate BHB measurements at an individual cow level, but discriminant models might be used in the future as herd-level management tools for classification of cows that are at risk of HYK, whereas quantitative models might provide large-scale phenotypes to be used as an indicator trait for breeding cows with improved metabolic health.

Impaired ketogenesis and increased acetyl-CoA oxidation promote hyperglycemia in human fatty liver.

Non-alcoholic fatty liver disease (NAFLD) is a highly prevalent, and potentially morbid, disease that affects one-third of the U.S. population. Normal liver safely accommodates lipid excess during fasting or carbohydrate restriction by increasing their oxidation to acetyl-CoA and ketones, yet lipid excess during NAFLD leads to hyperglycemia and, in some, steatohepatitis. To examine potential mechanisms, flux through pathways of hepatic oxidative metabolism and gluconeogenesis were studied using five simultaneous stable isotope tracers in ketotic (24-hour fast) individuals with a wide range of hepatic triglyceride contents (0-52%). Ketogenesis was progressively impaired as hepatic steatosis and glycemia worsened. Conversely, the alternative pathway for acetyl-CoA metabolism, oxidation in the tricarboxylic (TCA) cycle, was upregulated in NAFLD as ketone production diminished and positively correlated with rates of gluconeogenesis and plasma glucose concentrations. Increased respiration and energy generation that occurred in liver when ß-oxidation and TCA cycle activity were coupled may explain these findings, inasmuch as oxygen consumption was higher during fatty liver and highly correlated with gluconeogenesis. These findings demonstrate that increased glucose production and hyperglycemia in NAFLD is not a consequence of acetyl-CoA production per se, but how acetyl-CoA is further metabolized in liver.

Effect of heat-shock protein B7 on oxidative stress in adipocytes from preruminant calves.

Dairy cows with ketosis display excessive lipolysis in adipose tissue. Heat-shock protein B7 (HSPB7), a small heat-shock protein, plays important roles in mediating cytoprotective responses to oxidative stress in rodent adipose tissue. Accordingly, it is assumed that HSPB7 may also play important roles in the antioxidant response in adipose tissue of ketotic cows. Therefore, the aim of this study is to investigate (1) the redox state of adipose tissue in ketotic cows and (2) the role and mechanism of HSPB7 on the regulation of oxidative stress in adipocytes from preruminant calves. An in vivo study consisting of 15 healthy and 15 clinically ketotic cows was performed to harvest subcutaneous adipose tissue and blood samples. In addition, adipocytes isolated from calves were treated with different concentrations of H2O2 (0, 12.5, 25, 50, 100, or 200 µM) for 2 h, transfected with adenovirus-mediated overexpression of HSPB7 for 48 h, or transfected with small interfering RNA of HSPB7 for 48 h followed by exposure to H2O2 (200 µM) for 2 h. Serum concentrations of nonesterified fatty acids and ß-hydroxybutyrate were greater in cows with clinical ketosis, whereas serum concentration of glucose was lower. Compared with healthy cows, the malondialdehyde content was greater but the activity of glutathione peroxidase and superoxide dismutase was lower in adipose tissue of clinically ketotic cows. The abundance of HSPB7 and nuclear factor, erythroid 2 like 2 (NFE2L2) was greater in adipose tissue of clinically ketotic cows. In vitro, H2O2 treatment induced the overproduction of reactive oxygen species and malondialdehyde, and inhibited the activity of antioxidant enzymes glutathione peroxidase and superoxide dismutase in adipocytes from preruminant calves. The low concentration of H2O2 (12.5, 25, and 50 µM) increased the abundance of HSPB7 and NFE2L2, but high concentrations of H2O2 (100 or 200 µM) reduced the abundance of HSPB7 and NFE2L2. The overexpression of HSPB7 improved the H2O2-induced oxidative stress in adipocytes via increasing the abundance of NFE2L2 and its downstream target genes heme oxygenase-1 (HMOX1) and NADH quinone oxidoreductase 1 (NQO1). Knockdown of HSPB7 markedly inhibited the expression of NFE2L2, HMOX1, and NQO1 and further exacerbated H2O2-induced oxidative stress. Overall, these results indicate that activation of the HSPB7-NFE2L2 pathway increases cellular antioxidant capacity, thereby alleviating oxidative stress in bovine adipocytes.

Associations of pre- and postpartum lying time with metabolic, inflammation, and health status of lactating dairy cows.

The objective was to evaluate the associations of pre- and postpartum lying time (LT) with serum total calcium (Ca), nonesterified fatty acids (NEFA), ß-hydroxybutyrate (BHB), and haptoglobin concentrations, hemogram, and health status of dairy cows. A total of 1,052 Holstein cattle (401 nulliparous heifers and 651 parous cows) from 3 commercial dairy farms were fitted with electronic data loggers (IceQube, IceRobotics, Edinburgh, UK) on a hind leg 14 ± 3 d before parturition (dpp) and removed at 14 ± 3 d in milk (DIM) to assess their LT. Lying time data were summarized and reported daily (min/d or h/d). Serum concentrations of NEFA (at 14 ± 3 and 7 ± 3 dpp), total serum calcium within 48 h after calving, and BHB (at 7 ± 3 and 14 ± 3 DIM) were determined. Serum concentration of haptoglobin was determined and a hemogram was performed on a subsample of 577 cows (237 primiparous and 340 multiparous) at 7 ± 3 DIM. Cases of milk fever, retained placenta, metritis, mastitis, pneumonia, and digestive disorders within 30 DIM were recorded and cows were categorized into 1 of 4 groups: (1) nondiseased (ND, n = 613; cows without ketosis and any other health conditions); (2) cows with only ketosis (KET, n = 152); (3) sick cows experiencing ≥1 health conditions, but without ketosis (SICK, n = 198); or (4) cows with ketosis plus at least one other health condition (KET+, n = 61). Data were analyzed using mixed linear regression models or logistic regression (MIXED or GLIMMIX procedures). Lying time within 14 dpp had a significant positive quadratic association with serum NEFA concentrations at 14 ± 3 and 7 ± 3 dpp but was not significantly associated with serum Ca concentration within 48 h after calving. Lying time during the first 14 DIM after parturition had a significant linear association with the risk of ketosis within 14 DIM. For every 1-h increment in mean LT (from 8 to 15 h/d) within the first 14 DIM after calving, the risk of diagnosis with ketosis within 14 DIM increased by 3.7 percentage points. Regardless of parity, a greater proportion of KET and KET+ groups had increased serum prepartum NEFA concentration (≥400 µEq/L) and increased body condition loss from 14 dpp to 28 DIM compared with SICK and ND cows. A greater proportion of multiparous KET and KET+ cows had hypocalcemia within 48 h after calving compared with ND and SICK cows, but we did not detect a significant association between hypocalcemia and health status on primiparous cows. Multiparous KET+ cows had significantly reduced neutrophils and white blood cell count compared with ND cows, but lymphocytes did not differ. Regardless of parity, KET+ and SICK cows had significantly higher concentrations of serum haptoglobin compared with ND cows. These results suggest that LT along with energy and Ca balance are critical for transition cow health.

Lactation Ketoacidosis: A case series.

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.

High concentrations of fatty acids and ß-hydroxybutyrate impair the growth hormone-mediated hepatic JAK2-STAT5 pathway in clinically ketotic cows.

The hepatic growth hormone (GH)-insulin-like growth factor (IGF)-I axis is essential for regulating intrahepatic lipid metabolism. Ketotic cows are characterized by high blood concentrations of fatty acids and ß-hydroxybutyrate (BHB), which display lipotoxicity. The aim of this study was to investigate changes in the hepatic GH-IGF-I axis in ketotic cows and to determine the effects of fatty acids and BHB on the GH-IGF-I axis in calf hepatocytes. Liver and blood samples were collected from healthy (n = 15) and clinically ketotic (n = 15) cows. Hepatocytes were isolated from calves and treated with various concentrations of GH, fatty acids, and BHB. The results showed that clinically ketotic cows displayed a high blood concentration of GH, a low blood concentration of IGF-I, and decreased hepatic GHR1A expression as well as impaired hepatic Janus kinase 2 (JAK2)-signal transducer and activator of transcription 5 (STAT5) signaling. In vitro, GH treatment induced activation of the JAK2-STAT5 pathway to increase the mRNA expression and secretion of IGF-I in calf hepatocytes. More importantly, treatment with fatty acids or BHB significantly inhibited GHR1A mRNA and JAK2 protein expression, as well as the STAT5 phosphorylation level and phospho-STAT5 nuclear translocation; these effects markedly reduced IGF1 mRNA expression and secretion in calf hepatocytes. In summary, these results indicate that high blood concentrations of fatty acids or BHB can impair the intrahepatic GH-mediated JAK2-STAT5 pathway and downregulate IGF-I expression and secretion in ketotic cows.