A Rare Cause of Life-Threatening Ketoacidosis: Novel Compound Heterozygous OXCT1 Mutations Causing Succinyl-CoA:3-Ketoacid CoA Transferase Deficiency

Succinyl-CoA:3-ketoacid CoA transferase (SCOT) deficiency is a rare inborn error of ketone body utilization, characterized by episodic or permanent ketosis. SCOT deficiency is caused by mutations in the OXCT1 gene, which is mapped to 5p13 and consists of 17 exons. A 12-month-old girl presented with severe ketoacidosis and was treated with continuous renal replacement therapy. She had two previously unrecognized mild-form episodes of ketoacidosis followed by febrile illness. While high levels of ketone bodies were found in her blood and urine, other laboratory investigations, including serum glucose, were unremarkable. We identified novel compound heterozygous mutations in OXCT1:c.1118T>G (p.Ile373Ser) and a large deletion ranging from exon 8 to 16 through targeted exome sequencing and microarray analysis. This is the first Korean case of SCOT deficiency caused by novel mutations in OXCT1, resulting in life-threatening ketoacidosis. In patients with unexplained episodic ketosis, or high anion gap metabolic acidosis in infancy, an inherited disorder in ketone body metabolism should be suspected.

Nicorandil alleviated cardiac hypoxia/reoxygenation-induced cytotoxicity via upregulating ketone body metabolism and ACAT1 activity

To study the effect of nicorandil pretreatment on ketone body metabolism and Acetyl-CoA acetyltransferase (ACAT1) activity in hypoxia/reoxygenation (H/R)-induced cardiomyocytes. In our study, we applied H9c2 cardiomyocytes cell line to evaluate the cardioprotective effects of nicorandil. We detected mitochondrial viability, cellular apoptosis, reactive oxygen species (ROS) production and calcium overloading in H9c2 cells that exposed to H/R-induced cytotoxicity. Then we evaluated whether nicorandil possibly regulated ketone body, mainly β-hydroxybutyrate (BHB) and acetoacetate (ACAC), metabolism by regulating ACAT1 and Succinyl-CoA:3-keto-acid coenzyme A transferase 1 (OXCT1) protein and gene expressions. Nicorandil protected H9c2 cardiomyocytes against H/R-induced cytotoxicity dose-dependently by mitochondria-mediated anti-apoptosis pathway. Nicorandil significantly decreased cellular apoptotic rate and enhanced the ratio of Bcl-2/Bax expressions. Further, nicorandil decreased the production of ROS and alleviated calcium overloading in H/R-induced H9c2 cells. In crucial, nicorandil upregulated ACAT1 and OXCT1 protein expressions and either of their gene expressions, contributing to increased production of cellular BHB and ACAC. Nicorandil alleviated cardiomyocytes H/R-induced cytotoxicity through upregulating ACAT1/OXCT1 activity and ketone body metabolism, which might be a potential mechanism for emerging study of nicorandil and other K(ATP) channel openers.

Mimicking Ketonuria in the Ketogenesis Defect 3-Hydroxy-3-MethylglutarylCoenzyme A Lyase Deficiency: An Artefact in the Analysis of Urinary Organic Acids

Abstract 3-Hydroxy-3-methylglutaryl-coenzyme A lyase (HMGCL, HMGCL) deficiency is a rare inborn error of ketogenesis. Even if the ketogenic enzyme is fully disrupted, an elevated signal for the ketone body acetoacetic acid is a frequent observation in the analysis of urinary organic acids, at least if derivatization is performed by methylation. We provide an explanation for this phenomenon and trace it back to degradation of the derivatized 3-hydroxy-3-methylglutaric acid and high temperature of the injector of the gas chromatograph.

Effect of ketogenic diet on growth of human colon cancer cells in nude mice / 中国肿瘤临床

Objective:To observe the effect of ketogenic diet on the growth of human colon cancer cells in nude mice and to de-termine its possible mechanisms. Methods:A total of 24 male BALB/C nude mice were injected subcutaneously with the tumor cells of the colon cancer cell line HCT116. These animals were randomized into two feeding groups. One group was fed with a ketogenic diet (KD group;n=12), and the other group was given a standard diet (SD group;n=12) ad libitum. Experiments were completed upon at-taining a target tumor volume of 600 mm3 to 700 mm3. The two diets were compared based on body weight, serum glucose, ketone body, insulin, tumor growth, and survival time, which is the interval between tumor cell injection and attainment of target tumor vol-ume. Results:The tumor growth was significantly more delayed in the KD group than in the SD group. Tumors in the KD and SD groups reached the target tumor volume at 33.8 ± 6.7 days and 24.8 ± 3.1 days, respectively. The ketone body in the KD group was ele-vated with a slight reduction in serum insulin, and the difference in serum glucose in the two groups was insignificant. Importantly, the KD group had significantly larger necrotic areas and less vessel density than the SD group. Conclusion:The application of an unre-stricted ketogenic diet delayed tumor growth in a mouse xenograft model. Further studies are needed to address the mechanism of this diet intervention and its effect on other tumor-relevant functions, such as invasive growth and metastasis.

Effect of different doses of propofol and propofol medium/long-chain fat emulsion on blood ketone body ratio / 临床麻醉学杂志

Objective To observe the effect of different doses of propofol injection and propofol medium/long-chain fat emulsion injection in short time infusion on plasma ketone body ratio,to eva-lute its effecton hepatic energy metabolism.Methods Forty patients,aged 18-50 years old,ASA Ⅰ orⅡ undergoing selective surgery were randomly divided into 4 groups with 10 cases in each;propofol injection 4 mg·kg-1·h-1 maintain anesthesia (group L4 ),propofol injection 6 mg·kg-1·h-1 maintain anesthesia (group L6 ),propofol medium/long-chain fat emulsion injection 4 mg·kg-1·h-1 maintain anesthesia (group M4 ),propofol medium/long-chain fat emulsion injection 6 mg·kg-1·h-1 maintain anesthesia (group M6 ).MAP,HR,SpO2 and PET CO2 were recorded before anesthesia induction (T0 ),after tracheal intubation (T1 ),after 2 hours infusion of propofol (T2 )and operation completed (T3 ).The blood samples were collected at T1 and T2 to detect the level of acetoacetate,β-hydroxybu-tyrate and to calculate the blood ketone body ratio (the ratio of acetoacetate andβ-hydroxybutyrate). Results MAP,HR,SpO2 ,PET CO2 at T0-T3 and acetoacetate,β-hydroxybutyrate,blood ketone body ratio at T1 ,T2 showed no significant statistic difference.Conclusion Different doses of propofol and different doses of propofol medium/long-chain fat emulsion injection in short time continuous in-fusion has no obvious effect on hepatic energy metabolism;same dose of propofol injection and propo-fol medium/long-chain fat emulsion injection in short time continuous infusion has no obvious effect on hepatic energy metabolism.

Study on the acetoacetate/β hydroxybutyrate determination in classification of type 1 and type 2 diabetes mellitus / 中华内分泌代谢杂志

The clinical values of acetoacetate ( AcAA ) and β hydroxybutyrate ( βHBA ) determination in classification of type 1 and2 diabetes were explored. 102 normal control subjects,33 cases of type 1 diabetes, and 104cases of type 2 diabetes were enrolled. Serum AcAA, βHBA, fasting plasma glucose ( FPG), C-peptide, and insulin levels were measured. The results showed that serum AcAA, βHBA, total ketone tody (TKB) levels in the diabetic groups were significantly higher than those of the normal group( P＜0. 01 ). AcAA, βHBA, TKB levels in type 1diabetes were higher as compared with those of type 2 diabetes( P＜0.01 ). The AcAA, βHBA, and TKB levels were negatively related with C-peptide and insulin in diabetic patients( P＜0. 01 ). All the type 1 diabetic patient were found to have TKB and lower C-peptide levels. TKB positive and lower C-peptide in type 2 diabetes were found in 47% and 26% respectively. Receiver operating characteristic (ROC) curve suggested that the area under the ROC curve of type 1 and type 2 diabetes was 0.926. The optimal operating point of the total ketone body was 0. 532 mmol/L with higher sensitivity and specificity. Enzymatic determination of acetoacetate and β hydroxybutyrate seems to have important clinical values for classification of type 1 and 2 diabetes.

Fatty acid oxidation disorders / 한양의대학술지

Inborn errors of fatty acid mitochondrial oxidation (FAOD) have drawn considerable attention in recent years because of rapid pace of discovery of new defects and an ever-increasing spectrum of clinical phenotypes. This review describes a clinical and biochemical phenotypes, diagnosis and treatment of FAOD. Some of FAOD can not be detected by conventional biochemical investigations, even when a patient is symptomatic with fasting intolerance or functional failure of fatty acid dependent tissue (s). Diagnosis must ultimately be based on direct assay of the involved enzyme, however, preliminary indicators may come from determination of carnitine and intermediate metabolites in plasma, profiling of urine organic acid, and radioisotopic screening assays with lymphocytes or cultured fibroblasts. We are faced with the following major challenges: whether to include FAOD in newborn screening programs, the investigation of the rules played by individual disorders in maternal complication during pregnancy, sudden and unexpected death in early life, and pediatric acute/fulminant liver failure.

Predictive Comparisons of Procalcitonin (PCT) Level, Arterial Ketone Body Ratio (AKBR), APACHE III Score and Multiple Organ Dysfunction Score (MODS) in Systemic Inflammatory Response Syndrome (SIRS)

Procalcitonin (PCT) is a newly introduced marker of systemic inflammation and bacterial infection. A marked increase in circulating PCT level in critically ill patients has been related with the severity of illness and poor survival. The goal of this study was to compare the prognostic power of PCT and three other parameters, the arterial ketone body ratio (AKBR), the acute physiology, age, chronic health evaluation (APACHE) III score and the multiple organ dysfunction score (MODS), in the differentiation between survivors and nonsurvivors of systemic inflammatory response syndrome (SIRS). The study was performed in 95 patients over 16 years of age who met the criteria of SIRS. PCT and AKBR were assayed in arterial blood samples. The APACHE III score and MODS were recorded after the first 24 hours of surgical ICU (SICU) admission and then daily for two weeks or until either discharge or death. The patients were divided into two groups, survivors (n=71) and nonsurvivors (n=24), in accordance with the ICU outcome. They were also divided into three groups according to the trend of PCT level: declining, increasing or no change. Significant differences between survivors and nonsurvivors were found in APACHE III score and MODS throughout the study period, but in PCT value only up to the 7th day and in AKBR only up to the 3rd day. PCT values of the three groups were not significantly different on the first day between survivors and nonsurvivors. Receiver operating characteristic (ROC) curves for prediction of mortality by PCT, AKBR, APACHE III score and MODS were 0.690, 0.320, 0.915 and 0.913, respectively, on the admission day. In conclusion, PCT could have some use as a mortality predictor in SIRS patients but was less reliable than APACHE III score or MODS.

ANTIOBESITY ROLES OF DIACYLGLYCEROL AND ITS POSSIBLE METABOLIC MECHANISM / 营养学报

Objective To study the effects of diacylglycerol(DG)on body weight of rats and its possible metabolic mechanism. Method (1) SD rats (n=30) were randomly divided into 3 groups. They were given free access to diets containing 7% (wt) triacylglycerol (TG, control group), 20% (wt) TG or 20% (wt) DG diets, respectively for 8 w. The changes of body weight, height, food intake, and feces were recorded. At the end of experiment, abdominal fat weight (including perirenal fat and epididymal fat), blood lipids were detected. (2) 13 w male Wistar rats (n=50) were divided into 2 groups(administrated with 10% TG or DG emulsion, respectively)in postprandial blood fat profile experiment. Blood lipids of 5 rats were analyzed at desired interval. (3) 6 w male Wistar rats (n=30) were randomly divided into 3 group, control group, DG group and TG group, administrated with glucose solution, 20%DG emulsion and 20%TG emulsion respectively for 6 d. Urine in 144 hr was collected continuously and analyzed for total ketone bodies. Results High DG diet resulted in a significant reduction in both body weight gain, ratio of abdominal fat to body weight and serum TG levels compared with the high TG diet. DG group have higher FFA level in portal vein and lower TG level in jugular vein than those of high TG group. But urine ketone body level of high DG group was higher than high TG group. Conclusion Dietary DG reduced fat accumulation inabdominal region, body and blood, and these effects may be involved with different metabolic ways of DG compared with TG.

Changes of arterial blood ketone body ratio following hypoperfusion in old and adult rats / 老年心脏病学杂志（英文版）

Objective To evaluate the sensitivity of arterial ketone body ratio as an indicator for multiple organ failure.Materials and methods The experimental model of multiple organ failure was made in adult and old rats by hypoperfusion-induced hemorrhagic shock. After blood sampling, the arterial acetoacetate, β-hydroxybutyrate, total ketone body, ALT, AST, BUN, creatinine at 2, 4, 8 hr in hypoperfusion were examined to compare the differences of ketone body ratio and organ failure between adult and old rats. Hepatic and mitochondrial metabolism were assessed by comparing ketone body ratios (AcAc/β-OHB) and free NAD+/NADH ratios. Results Ketone body ratio in old rats at 2, 4, 8 hr after the induction of hemorrhagic shock decreased from 0.68 to 0.31, 0.27 and 0.22, respectively. In adult rats, it decreased from 1.12 to 0.17, 0.12 and 0.09, respectively. Changes of ketone body ratio in the adult group were larger than in the elderly group ( P ＜ 0.001). The development of multiple organ failure is associated with the time of hemorrhagic shock development. Conclusions There was a different ketone body ratio between multiple organ failure in the elderly (MOFE) and multiple organ failure (MOF) in general adults. Ketone body ratio is a better indicator than ALT and AST in reflecting hepatic function in the early status of MOF. (J Geriatr Cardiol 2004;1(2) :125-128. )

The Effects of Acute Normovolemic Anemia Induced by Hemodilution on Tissue Oxygenation in Dogs: A Comparison of Systemic Oxygen Consumption, Arterial Lactate, Arterial Ketone Body Ratio and Gastric Intramucosal pH / 대한마취과학회지

BACKGROUND: The reduction in hematocrit (Hct) by hemodilution tends to cause an increase in cardiac output and a proportional decrease in arterial oxygen content. Additionally the reduction of systemic oxygen delivery (DO2) leads to significant differences in regional blood flow. It is therefore important to characterize the effects of hemodilution on regional oxygen metabolism in individual organs. This study was undertaken to evaluate and compare the effects of acute normovolemic anemia induced by hemodilution. METHODS: Six dogs were anesthetized and mechanically ventilated. Catheters were inserted in the right femoral and pulmonary arteries for blood sampling, and a gastric tonometer catheter was inserted into the gastric lumen. Baseline measurements of systemic hemodynamics, arterial ketone body ratio (AKBR), gastric intramucosal pH (pHi) and arterial lactate were recorded. Hemodilution was then begun by 6% pentastarch and was made in four levels of hematocrit values of 20%, 15%, 10% and 6%. RESULTS: Mean arterial pressures of Hct 10% and 6% was decresaed (P < 0.05) and Hct 15% and 10% increases in cardiac output and pulmonary capillary wedge pressure (PCWP) were observed. Central venous pressure and mean pulmonary arterial pressure were incresed (P < 0.05) at Hct 15%, 10% and 6%. DO2 progressively decreased (P < 0.05). AKBR and pHi began to decreased at Hct 15%. Arterial lactate decrease at Hct 15% and was above 7.4 mmol/L at Hct 6%. CONCLUSIONS: By the measurements of AKBR and pHi, the disturbance of splanchnic oxygenation can be detected early compared to those of O2 in terms of oxygen metabolism and the critical point of DO2 during acute normovolemic anemia induced by hemodilution.

Clinical Significance of Several Hepatic Function Tests in Hepatectomized Patients / 한국간담췌외과학회지

BACKGROUND/AIMS: To reduce the rate of recurrence and to prevent postoperative liver failure, it is necessary to determine the extent of hepatic resection preoperatively in primary liver cancer patients. The aim of this study was to examine the clinical significance and correlation among several preoperative liver function tests. METHODS: Twenty-nine patients who underwent hepatic resection for hepatocellular carcinoma from November 1994 to March 1995 at the Department of Surgery, Seoul National University Hospital were analyzed. Fifteen patients had gross cirrhosis. Major resections were performed in two patients, segmentectomy in 6 patients, subsegmentectomy and limited resection in 21 patients. Maximal removal rate of indocyanine green (ICG Rmax), ICG retention rate at 15 min(ICG R15), oral glucose tolerance test(oral GTT), arterial ketone body ratio(AKBR) and computed tomographic volumetry, as well as conventional liver function test and prothrombin time were done preoperatively. RESULTS: There were significant correlations among Child's class, prothrombin time and ICG R15. AKBR, oral GTT, ICG Rmax, liver volume had no correlations with any other tests. Liver failure occurred in 2 patients(6.9%). No tests, except ICG R15, could predict the patients with liver failure. ICG R15 value of these two patients were 27% and 29%, respectively while those of the remaining 27 patients ranged from 1 to 22% (mean 11.9%). CONCLUSION: Neither standard liver function tests nor hepatic function studies such as AKBR, oral GTT, CT volumetry were useful as preoperative prognostic indicators in hepatic resection. ICG R15 test is a simple test and good predictor of liver failure after hepatic resection.

Study on Hepatic Injury following Occlusion of Hepatic Inflow in Rabbits / 대한마취과학회지

BACKGROUND: Portal triad clamping was first described by Pringle in 1908 as a mean of reducing bleeding from the cut surface of the liver during parenchymal resection. More recently some studies have reported that one period of portal triad clamping could be well tolerated for a longer duration, 60~90 minutes. The liver, generally, is believed to be very sensitive to anoxic damage and susceptible to ischemia and decreased hepatic energy charge results in decreasing arterial ketone body ratio (AKBR) during portal triad clamping. METHODS: In order to observe an adverse effects to liver in 30 minutes and 60 minutes of portal triad clamping on AKBR and histologic changes,rabbits were divided into thirty minutes of portal triad clamping in one group (Group I) and 60 minutes of that in the other group (Group II). RESULTS: During clamping, the mean AKBR of group I and II were 0.39 and 0.44, and decreased significantly compared with the mean AKBR (1.08 and 1.02) before clamping. Five minute after declamping, the mean AKBR of group II (0.49) was lower (P0.05). Under light microscopic examination of liver biopsy, there was no visible diffrences between two groups during clamping, 5 minutes and 30 minutes after declamping. CONCLUSIONS: It was concluded that there was no difference in hepatic energy change(AKBR) and histologic change under light microscopy after 30 minutes declamping between two groups.

The Effects of Glutathione and Prostaglandin E1 on Recovery of Hepatic Function during Hepatic Ischemia and Reperfusion in Rabbits / 대한마취과학회지

The interruption of hepatic blood flow has been adopted as a method of bleeding control in hepatectomy and liver transplantation. But this occlusion of hepatic inflow may result in significant hepatic injury by various kinds of oxygen radicals produced as a result of hepatic ischemia and following reperfusion. Arterial ketone body ratio(AKBR) is adequatc and convenient parameter by which both acute and prolonged changes of the hepatic function can be estimated. Pharmacological modulation of hepatic injury during warm ischemia and early reperfusion has shown some benefical effects. The authors conducted an experiment to evaluate the inhibitory effect of glutathione and prostaglandin E on hepatic injury due to acute hepatic ischemia and reperfusion. Thirty rabbits were divided into three groups, such as control(n=10), GSH(n=10) and PGE(n=10) groups. Acute hepatic ischemia was induced through the application of portal triad cross-clamping for 30 minutes, and thereafter hepatic reperfusion was induced with the removal of cross-clamping. A single bolus of 200 mg glutathione was injected 10 min before clamp in GSH group, and 200 ng/kg/min of PGE continuously from 10 min before clamp to 30 min after declamp in PGE group. AKBR and hepatic histological findings hefore clamp, 30 min after clamp, 5 min and 30 min after declamp, respectively were compared among 3 groups AKBR was markedly decreased during the clamping period in all groups (P<0.05). In control and PGE groups AKRR was significantly increased after reperfusion than before clamp (P<0.05), but was significantly lower than before clamp. Thirty minutes after reperfusion in GSH group AKBR returned to normal level and was significantly higher than in control group (P<0.05). On light tnicroscopic examination of liver biopsy, mild swollen hepatocytes in the centrilobular zone were seen at ischemia and reperfusion in control and GSH groups, but nearly normal hepatic architectures in PGE group. These results suggest that glutathione has some benefical effect on protection of hepatic dysfunction, and PGE1 on protection of hepatocellular injury during hepatic ischemia and reperfusion.

Protection of Hepatic Dysfunction during and after Hemorrhagic Shock with Intravenous Glutathione in Dogs / 대한마취과학회지

During hemorrhagic shock, liver is susceptible to ischemia and decreased hepatic energy charge results in decreasing arterial ketone body ratio(AKBR). Reperfusion after hemorrhagic shock can greatly amplify the generation of toxic oxygen metabolites. As a result, the fluxes of these highly toxic metabolites can overwhelm the endogenous antioxident defense mechanisms and lead to tissue injury. In order to observe the effect of glutathione(GSH) on the AKBR in hemorrhagic shock, dogs(n=16) were anesthetized with 1% enflurane in 02. We pretreated glutathione (100 mg/kg) intravenously before hemorrhagic shock in glutathione (GSH) group (n=8). Shock was induced with bleeding and mean arterial pressure was maintained 50 mmHg for 30 minutes. Recovery from shock was done with transfusion of preserved blood and maintained for 30 minutes. We measured arterial ketone bodies and ketone body ratio before, during and after shock, and compared them to control group (n=8) which was not pretreated with glutathione. AKBR during and after hemorrhagic shock in GSH group (0.8 and 1.0) were higher than those in control group (0.5 and 0.8). Light microscopic examination of liver biopsy revealed less portal degeneration during and after hemorrhagic shock in GSH group than control group. Pharmacologic modulation of hepatocytic function with glutathione before hemorrhagic shock has shown some beneficial effect with protection of decreased AKBR and histological change during and after hemorrhagic shock.

The Changes of Arterial Ketone Body Ratio and Osmolal Gap during Hemorrhagic Shock in Rabbit / 대한마취과학회지

The ratio of acetoacetate to 8-hydroxybutyrate (ketone body ratio) in the blood may reflects the mitochondrial free NAD+/NADH ratio in the liver. Also arterial ketone body ratio will reflects the energy status of the hepatocytes, because mitochondrial free NAD+/NADH ratio is closely related to oxidative phosphorylation. Arterial ketone body ratio and osmolal gap, the difference between measured osmolality and calculated osmolality, were measured 30 min after the induction of hemorrhagic shock with mean arterial blood pressure at 40 mmHg in ten rabbits. Arterial ketone body ratios decreased significantly (p<0.05) from 0.74+/-0.17 to 0.38+/-0.09 and osmolal gap increased significantly (p<0.05) from 17.7+/-5.9 mOsm/Kg to 32.8+/-12.3 mOsm/Kg at 30 min after the induction of hemorrhagic shock. These results suggest that in hemorrhagic shock, decreased arterial ketone body ratio which reflects the inhibition of the TCA cycle is associated with increase of osmolal gap.

Effect of Wanglaoji Cool Tea on plasma gluco metabolism and peroxidative state in stress mice / 中成药

AIM:To study the effect of Wanglaoji cool tea(WLJ)(Ilex asprella,Oroxylum indicum,polygnum chinese,Desmadium Styracifolium,Microcos Paniculata,Lophatherum gracile,Lygodium japonicum,Vitex negundo,Helicteres angustifolia,Rosa laevigate) on plasma gluco-metabolism and peroxidative state in stress mice. METHODS: The male BALB/c mice were randomly divided into normal control group,stress control group,positive control group,125 and 500 mg/kg WLJ group,which were administered samples once a day successively for 5 days.After oral administration 2 g/kg glucose into the 20 h stress mice,the elimination rate of plasma glucose,plasma ketone bodies and liver glycogen were determined.The peroxidative state in plasma and antioxidtive capacity of plasma was also measured. RESULTS: As compared with the control groups,WLJ accelerated the basic glucose metabolism of plasma,reduced the plasma ketone body and elevated the liver glycogen synthesis in stress mice.And it also decreased the level of MDA and increased the antioxidant capacity of plasma. CONCLUSION: WLJ improves the glucometabolic dysfunction in stress mice,and the mechanism might be related to the amelioration of peroxidative state in plasma.