Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find the Urine Ketones article more useful, or one of our other health articles.
Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
What are ketones?
Ketones are produced normally by the liver as part of fatty acid metabolism. In normal states these ketones will be completely metabolised so that very few, if any at all, will appear in the urine. If for any reason the body cannot get enough glucose for energy it will switch to using body fats, resulting in an increase in ketone production making them detectable in the blood and urine.
How to test for ketones
The urine test for ketones is performed using test strips available on prescription. Strips dedicated to ketone testing in the UK include:
- GlucoRx KetoRx Sticks 2GK®.
Testing should be performed according to manufacturers' instructions. The sample should be fresh and uncontaminated. Usually the result will be expressed as negative or positive (graded 1 to 4).
Ketonuria is different from ketonaemia (ie presence of ketones in the blood) and often ketonuria does not indicate clinically significant ketonaemia.
Depending on the testing strips used, urine testing for ketones either has an excellent sensitivity with a low specificity, or a poor sensitivity with a good specificity. However, this should be viewed in the context of uncertainty of the biochemical level of significant ketosis.
- The reading is an average of urine ketone concentration since last passing urine. This may lead to delayed management of ketoacidosis.
- Collection of the urine sample may be delayed because of dehydration.
- Urine testing has lower sensitivity and specificity.
- Urine testing only measures acetoacetic acid and not beta-hydroxybutyrate (the predominant ketone in diabetic ketoacidosis).
Therefore the most accurate way of testing for ketones is to use a meter that measures blood ketone levels. Blood glucose meters that are also able to test blood ketone levels in addition to blood glucose levels include Abbott - FreeStyle Optium Neo, and Menarini - GlucoMen LX Plus.
Interpretation of results
Normally only small amounts of ketones are excreted daily in the urine (3-15 mg). High or increased values may be found in:
- Poorly controlled diabetes.
- Diabetic ketoacidosis (DKA).
- Prolonged vomiting.
- Rapid weight loss.
- Frequent strenuous exercise.
- Poisoning (eg, with isopropanol).
- Ether anaesthesia.
- Some metabolic disorders.
Positive test result but 'no' ketones
- Some medications:
- Valproic acid.
- Vitamin C.
Most urine testing kits detect aceto-acetate, not the predominant ketone beta-hydroxybutyrate. It is possible for the test to be negative with high levels of beta-hydroxybutyrate and then, as ketoacidosis improves and ketone levels fall, the urine test becomes positive (to aceto-acetate).
Special cases of ketonuria
Diabetes mellitus and ketones
Metabolically severe insulin deficiency (relative or absolute) produces hyperglycaemia and ketoacidosis. Insulin lack increases release of fatty acids from adipose stores and reduces the rate of fat synthesis.
Lipolysis is further increased by increased catecholamines, cortisol, growth hormone and glucagon. The free fatty acids are transported to the liver for conversion to ketone bodies, which serve as fuels for muscle and fat.
Home blood glucose and ketone monitoring can possibly decrease the number of hospital admissions due to DKA.
Monitoring of ketones is important in all people with diabetes:
- When the diet is low in carbohydrates, exercise levels are high, or a combination of both.
- In pregnant women with diabetes and in gestational diabetes.
- When blood sugars are high (over 15 mmol/L).
- In DKA or with suspected ketoacidosis.
If the urine ketone level is greater than 2+, or blood ketone levels are greater than 3 mmol/L, the GP or diabetes care team should be contacted immediately.
Ketogenic diets cause a 'physiological ketosis' but the levels of ketones in the blood are much lower than in uncontrolled DKA.
Ketogenic diets can be used for drug-resistant epilepsy or if epilepsy surgery is not suitable..
Further reading and references
British National Formulary (BNF); NICE Evidence Services (UK access only)
Wilson LA; Urinalysis. Nurs Stand. 2005 May 11-1719(35):51-4.
Mitchell R, Thomas SD, Langlois NE; How sensitive and specific is urinalysis 'dipstick' testing for detection of hyperglycaemia and ketosis? An audit of findings from coronial autopsies. Pathology. 2013 Oct45(6):587-90. doi: 10.1097/PAT.0b013e3283650b93.
Dhatariya K; Blood Ketones: Measurement, Interpretation, Limitations, and Utility in the Management of Diabetic Ketoacidosis. Rev Diabet Stud. 2016 Winter13(4):217-225. doi: 10.1900/RDS.2016.13.217. Epub 2017 Feb 10.
Pulungan AB, Juwita E, Pudjiadi AH, et al; Diabetic Ketoacidosis in Adolescents and Children: A Prospective Study of Blood versus Urine Ketones in Monitoring Therapeutic Response. Acta Med Indones. 2018 Jan50(1):46-52.
Brooke J, Stiell M, Ojo O; Evaluation of the Accuracy of Capillary Hydroxybutyrate Measurement Compared with Other Measurements in the Diagnosis of Diabetic Ketoacidosis: A Systematic Review. Int J Environ Res Public Health. 2016 Aug 2313(9). pii: E837. doi: 10.3390/ijerph13090837.
Type 1 diabetes in adults: diagnosis and management; NICE Guidelines (August 2015 - last updated August 2022)
Voulgari C, Tentolouris N; The performance of a glucose-ketone meter in the diagnosis of diabetic ketoacidosis in patients with type 2 diabetes in the emergency room. Diabetes Technol Ther. 2010 Jul12(7):529-35. doi: 10.1089/dia.2010.0011.
Diabetes - type 1; NICE CKS August 2022 (UK access only)
Paoli A, Bosco G, Camporesi EM, et al; Ketosis, ketogenic diet and food intake control: a complex relationship. Front Psychol. 2015 Feb 26:27. doi: 10.3389/fpsyg.2015.00027. eCollection 2015.
Martin-McGill KJ, Bresnahan R, Levy RG, et al; Ketogenic diets for drug-resistant epilepsy. Cochrane Database Syst Rev. 2020 Jun 246:CD001903. doi: 10.1002/14651858.CD001903.pub5.