Association of Higher Arterial Ketone Body Ratio (acetoacetate/β -hydroxybutyrate) with Relevant Nutritional Marker in Hemodialysis Patients

Background: An association of higher levels of b-hydroxybutyrate (b-HB) in serum with greater mortality in hemodialysis (HD) patients has been reported. This study examined the significance of arterial ketone body ratio (AcAc/b-HB), a relevant marker of energy state, in HD patients.Methods: The levels of arterial AcAc and b-HB, and AcAc/b-HB ratio were determined in 49 HD patients just before undergoing an HD session. Additionally, their changes during the session were examined to investigate their associations with clinical nutritional markers.Results: Arterial b-HB, but not AcAc, was significantly higher at the baseline in 25 patients with diabetes mellitus (DM) as compared to 24 non-DM patients, with a significant reduction in arterial AcAc/b-HB ratio seen in those with DM. Although the arterial AcAc/b-HB ratio before the HD session was significantly higher in the non-DM group, it did not differ significantly after the session between the groups, indicating a faster rate of b-HB disappearance from circulation in non-DM HD patients during the interdialytic period. Multiple regression analysis, which included age, gender, presence/absence of DM, log HD duration, log b-HB, and log AcAc/b-HB ratio as independent variables, revealed an independent and significant association of log AcAc/ b-HB ratio, but not log b-HB, with serum albumin and uric acid. Conclusion: We found that a decreased AcAc/b-HB ratio resulting from increased b-HB, but not increased b-HB itself, was significant factor independently associated with decreased serum albumin and uric acid, which are both known as risks for higher mortality in HD patients. Furthermore, it is possible that higher mortality in DM HD patients might be explained by their lower arterial AcAc/b-HB ratio.