Not Increased, Circulating Ketone Bodies

A fundamental process in biological systems is the production of metabolic fuel for use in meeting the energy demands of cells and, in multi-cellular organisms, supporting overall systemic energy needs.  Physiological studies of the progression of human starvation have identified that the preferred metabolic fuel is glucose in the fed state and progressing through two days of fasting, afterward ketone bodies become increasingly important for meeting energy demands (Cahill 2006, Owen et al 2005).  Substrates derived from carbohydrates, fats and protein can contribute to gluconeogenesis (Cahill 2006, Gerich et al 2001) whereas substrates derived from fatty acids are the primary contributors to ketogenesis (Desvergne and Wahli 1999).  Mobilization of fatty acids as a metabolic fuel source increase dramatically during fasting to support both gluconeogenesis and ketogenesis (Evans et al 2004).   Cahill (2006) and colleagues have demonstrated the importance of ketone body production, especially β-hydroxybutyrate, for maintaining energy homeostasis during starvation.  β-hydroxybutyrate serves as an alternative substrate to glucose for providing energy to the brain in the starvation state, providing ATP at higher efficiency relative to the glucose substrate (Cahill 2006).  Interference with ketogenesis, for example by PPARα inhibition, has been demonstrated to inhibit β-hydroxybutyrate production (measured in serum) during fasting events in mice (Badman et al 2007, Potthoff 2009, Sengupta et al 2010) and cause hypoketonemia (Muoio et al 2002).  The Badman et al (2007) study indicated that metabolism of fatty acid substrates (measured as liver triglycerides) that would otherwise contribute to β-hydroxybutyrate production was inhibited under PPARα knockout.   Increased concentrations of circulating ketone bodies is indicative of potential metabolic fuel deficits in fasting animals (Cahill 2006), and a lack of increase in circulating ketone bodies during fasting, especially in conjunction with elevated blood triglycerides, indicates impaired ketogenesis and potentially impaired bioenergetic potential. Although the potential therapeutic implications of increased ketone body metabolism via ketogenic diets for various disease states has been discussed (Veech 2004), no studies were found demonstrating effects on whole organism responses to impaired ketogenesis over long-term starvation events.  A potential implication of decreased ketone body production is stress on cardiac function given that energy-stressed heart tissue shifts reliance away from fatty acids toward ketone bodies (β-hydroxybutyrate) to fuel production of the ATP needed to maintain the heart’s mechanical function (Aubert et al 2016).  Related to this observation, PPARα-knockout mice reached exhaustion sooner than wild types in an exercise challenge which corresponded with significantly decreased β-hydroxybutyrate in serum indicating hypoketonemia in PPARα-knockout mice versus wild types (Muoio et al 2002).  Overall, diminished PPARα function, especially in combination with fasting /diminished nutrition and/or excessive exercise may contribute to impaired maintenance on systemic energy budget.

Methods that have been previously reviewed and approved by a recognized authority should be included in the Overview section above. All other methods, including those well established in the published literature, should be described here. Consider the following criteria when describing each method: 1. Is the assay fit for purpose? 2. Is the assay directly or indirectly (i.e. a surrogate) related to a key event relevant to the final adverse effect in question? 3. Is the assay repeatable? 4. Is the assay reproducible?

The quantification of β-hydroxybutyrate described in Cahill 2006 was measured in a cell-free system catalyzed by D(-)-p-hydroxybutyric dehydrogenase where all components of the reaction  [ D(-)-fl-hydroxybutyrate + diphosphopyridine nucleotide + = acetoacetate + reduced diphosphopyridine nucleotide + H+ ] were able to be quantitatively determined (Williamson et al 1962).  Serum β-hydroxybutyrate was measured using Stanbio Laboratory small-scale enzymatic assays in Badman et al (2007) and by Wako Chemicals D-3-hydroxybutyric acid kit in Potthoff et al (2009).  SMART micro-FPLC (Amersham Biosciences) consisting of a Superose 6 PC 3.2/30 column (Amersham Biosciences) equilibrated in PBS buffer was conducted where triglyceride and cholesterol fractions were investigated by enzymatic assay (Wako Diagnostics) as described in Badman et al (2007).  Clinical observations of ketone bodies have been simplified by the development of urine test strips that can provide quantitative values for the ketone bodies aceto-acetate, acetone and 3-hydroxybutyrate using reflectometry (Penders et al 2005).  The transition from using fatty acids to ketone bodies to fuel ATP production in cardiac muscle was measured in isolated heart preparation using ex vivo NMR combined with targeted quantitative myocardial metabolomic profiling using mass spectrometry  (Aubert et al 2016).  In Muoio et al (2002), β-hydroxybutyrate was measured in blood serum where wild type and PPARα knockout mice were compared.

Evidence for mouse was provided in (Badman et al 2007, Potthoff 2009).   Evidence for human was provided in (Cahill 2006, Owen et al 2005, Gerich et al 2001).  Comparative investigations of ketone body formation comparing human and mouse is not well established relative to fatty-acid oxidation comparisons.

Aubert, G., Martin, O.J., Horton, J.L., Lai, L., Vega, R.B., Leone, T.C., Koves, T., Gardell, S.J., Kruger, M., Hoppel, C.L., Lewandowski, E.D., Crawford, P.A., Muoio, D.M., Kelly, D.P., 2016. The Failing Heart Relies on Ketone Bodies as a Fuel. Circulation 133, 698-705.

Badman MK, Pissios P, Kennedy AR, Koukos G, Flier JS, Maratos-Flier E: Hepatic fibroblast growth factor 21 is regulated by PPARalpha and is a key mediator of hepatic lipid metabolism in ketotic states. Cell metabolism 2007, 5(6):426-437.

Cahill GF, Jr. Fuel metabolism in starvation. Annu Rev Nutr 2006, 26:1-22.

Desvergne B, Wahli W (1999) Peroxisome proliferator-activated receptors: nuclear control of metabolism. Endocrine Reviews 20(5): 649-688.

Evans RM, Barish GD, Wang YX: PPARs and the complex journey to obesity. Nat Med 2004, 10(4):355-361.

Gerich JE, Meyer C, Woerle HJ, Stumvoll M: Renal gluconeogenesis: its importance in human glucose homeostasis. Diabetes Care 2001, 24(2):382-391.

Muoio, D.M., MacLean, P.S., Lang, D.B., Li, S., Houmard, J.A., Way, J.M., Winegar, D.A., Corton, J.C., Dohm, G.L., Kraus, W.E., 2002. Fatty acid homeostasis and induction of lipid regulatory genes in skeletal muscles of peroxisome proliferator-activated receptor (PPAR) alpha knock-out mice. Evidence for compensatory regulation by PPAR delta. J. Biol. Chem. 277, 26089-26097.

Owen OE: Ketone bodies as a fuel for the brain during starvation. Biochem Mol Biol Educ 2005, 33(4):246-251.

Potthoff MJ, Inagaki T, Satapati S, Ding X, He T, Goetz R, Mohammadi M, Finck BN, Mangelsdorf DJ, Kliewer SA et al: FGF21 induces PGC-1α and regulates carbohydrate and fatty acid metabolism during the adaptive starvation response. Proceedings of the National Academy of Sciences 2009, 106(26):10853-10858.

Veech RL: The therapeutic implications of ketone bodies: the effects of ketone bodies in pathological conditions: ketosis, ketogenic diet, redox states, insulin resistance, and mitochondrial metabolism. Prostaglandins Leukot Essent Fatty Acids 2004, 70(3):309-319.

Williamson DH, Mellanby J, Krebs HA: Enzymic determination of d(−)-β-hydroxybutyric acid and acetoacetic acid in blood. Biochem J 1962, 82(1):90-96.