The Importance of BHB Testing on the Post-Mortem Diagnosis of Ketoacidosis

Abstract

Although beta-hydroxybutyrate (BHB) analysis has proved its importance in forensic pathology, its effects on cause-of-death diagnostics are unaddressed. Therefore, this study aims at evaluating the effects of BHB analysis on the number of deaths by DKA (diabetes ketoacidosis), AKA (alcoholic ketoacidosis), HHS (hyperosmolar hyperglycaemic state), hypothermia, diabetes, alcoholism, and acidosis NOS (not otherwise specified). All 2900 deaths from 2013 through 2019 in which BHB was analysed at the National Board of Forensic Medicine, and 1069 DKA, AKA, HHS, hypothermia, diabetes, alcoholism, and acidosis cases without BHB analysis were included. The prevalence of BHB-positive cases for each cause of death, and trends and proportions of different BHB concentrations, were investigated. The number of BHB analyses/year increased from 13 to 1417. AKA increased from three to 66 and acidosis from one to 20. The deaths from alcoholism, DKA, and hypothermia remained stable. It is unclear why death from alcoholism remained stable while AKA increased. The increase in unspecific acidosis deaths raises the question why a more specific diagnosis had not been used. In conclusion, BHB analysis is instrumental in detecting AKA and acidosis. The scientific basis for the diagnosis of DKA and hypothermia improved, but the number of cases did not change.

Postmortem Metabolomics of Insulin Intoxications and the Potential Application to Find Hypoglycemia-Related Deaths

“…Of the three short-chain acylcarnitines identified in the present study, C4-OH has been previously reported to be associated with insulin resistance and type 2 diabetes mellitus [39]. Moreover, C4-OH is primarily generated from the corresponding ketone body-beta-hydroxybutyrate [40], which has been evaluated for its potential in identifying ketoacidosis in postmortem cases [41]. The study by Ahlström et al [41] and the current study have an overlap in cohorts; however, too few test cases classified as potentially hypo or hyper had beta-hydroxybutyrate analyses performed, presumably due to the lack of acidosis suspicion regarding the various causes of death.…”

Postmortem metabolomics as a high-throughput cause-of-death screening tool for human death investigations

“…Moreover, BHB is used as marker for acidosis in forensic investigations with testing, at our institution in Sweden, increasing substantially in recent years. 43 …”

Examination of Postmortem β-Hydroxybutyrate Increase in Forensic Autopsy Cases

“…Samples other than blood could also be alternative tools for diagnosing ketoacidosis. BHB measurement is the most important test to establish the diagnosis of postmortem ketoacidosis [22,23]. This is because that BHB should be stable even after death for a period of 24-72 h [24].…”