Everything You Need To Know about Ketones in Urine (Ketonuria)

Ketones are water-soluble lipid (fat) molecules that your body produces during ketosis, when it uses fats instead of glucose (sugar) for energy. This usually happens when glucose stays in blood vessels instead of entering cells for use. Conditions such as diabetes, eating disorders, excessive exercise, or alcohol abuse can contribute.

Your urine often comprises trace amounts of ketones, which provide energy. When blood plasma levels are above 0.1-0.2 millimoles per liter, ketones appear in the urine. High levels of ketones can create an acidic environment in your body, leading to a condition called ketoacidosis.

At-home testing kits or healthcare facilities can detect ketones in urine. Talking to your healthcare provider and getting tested can help you get prompt treatment. If left untreated, high levels of ketone can become life-threatening.

Measuring Ketones in Urine

Measurement of ketones in urine can take place either at home or a healthcare facility. It usually involves a urinalysis, the chemical evaluation of urine. The collection of urine samples involves the following steps:

• Wash your hands with soap and water 
• Open the container (for urine collection) without touching the inside 
• Clean your genital area with a cleansing wipe
• Urinate into the toilet for a few seconds, then stop and urinate in the container until it is about halfway full
• Put the cap on the container and send it for analysis
• Finish urination into the toilet

At-home tests often involve a test kit, including test strips that change color upon contact with urine containing ketones. You can dip the strip in a container with urine or hold it directly into your urine stream. Then, you can compare the strip's color to a color range that signifies the level of ketones in your urine.

Ketone urine test results include "small," "moderate," and "large." Urine tests cannot provide the current ketone levels in your body. They can only determine the average concentration of ketones in your urine since your most recent urination.

Causes

Your body generally uses glucose (sugar), mainly from carbohydrates, as its primary energy source. During ketosis, your body breaks down fats for energy, often due to decreased carbohydrate intake or low insulin levels (cells not getting enough glucose), which increases ketone production. 

Common causes of ketones in urine include:

• Diabetes: Diabetes develops when your body cannot make enough insulin or use insulin properly. As a result, it uses fat as an energy source, leading to the production of ketones. This may lead to diabetic ketoacidosis, which can be life-threatening.
• Alcohol use: High ketone levels can develop in people who drink excessive alcohol, especially after sudden alcohol withdrawal or acute intoxication (very high alcohol consumption within a short time). This is often called alcoholic ketoacidosis.
• Eating disorders (EDs): Certain eating disorders (e.g., anorexia nervosa) and starvation can lead to low levels of glucose in the body, eventually leading to ketones in urine.
• Ketogenic diet: A ketogenic diet low in carbohydrates and high in fat can lead to high ketone levels in the urine because your body starts breaking down the fats for energy.
• Vomiting or diarrhea: Vomiting and diarrhea for an extended period can lead to ketones in your urine.
• Exercising: Exercising regularly for long periods can deplete the stored glucose in your body and cause the breakdown of fats for energy, which may eventually lead to ketones in urine.

Symptoms of High Ketone Levels

Symptoms that may indicate high ketone levels in your body include:

• Nausea
• Vomiting
• Abdominal pain
• Headache
• Frequent urination
• Extreme thirst
• Feeling tired
• Difficulty breathing
• Altered mental status

Treatment

The treatment approach for ketones in the urine focuses primarily on addressing the underlying cause. Treatment options include:

• Intravenous (IV) fluid replacement: Intravenous fluids (administered through a needle in a vein) can help clear excess ketones from your body.
• Electrolyte replacement: Replenishing electrolytes, such as potassium, magnesium, and phosphates, lost through excessive urination or starvation is important, though it doesn't reduce ketone levels. Electrolytes are electrically charged minerals that help regulate the nervous system, hydration, muscle function, and blood pH.
• Insulin therapy: Insulin therapy can reverse diabetic ketoacidosis, one of the main factors leading to ketones in urine.
• Managing underlying conditions: Addressing underlying conditions such as diabetes, excessive alcohol intake, or starvation can help decrease the level of ketones in urine.

Prevention of High Ketones

Preventing ketones in urine involves maintaining stable blood glucose levels and avoiding other factors that may lead to ketone buildup. Common strategies include the following:

• Eat a well-balanced diet and avoid skipping meals
• Keep your blood glucose levels in check, especially if you have diabetes
• Avoid or limit alcohol
• Avoid exercising if your blood glucose level is too high 
• Stay hydrated

When To See a Healthcare Provider

Contact your healthcare provider if you experience symptoms such as:

• Frequent fatigue
• Frequent vomiting
• Hyperglycemia (high blood glucose), mainly above 300 mg/dL
• Abdominal pain
• Difficulty breathing
• Extreme thirst
• Fruity-smelling breath

Your healthcare provider may ask about your medical history and recommend tests to determine if you have ketones in your urine and diagnose the underlying cause. Reach out to them if symptoms continue after treatment.

A Quick Review

Ketones in the urine are detected when they reach a certain level. Detection can take place at healthcare facilities and at home. Causes include diabetes, eating disorders or starvation, a ketogenic diet, excessive alcohol use, and excessive exercise.

Early detection of ketones in urine can help manage the underlying condition. You can talk to your healthcare provider to understand the most effective treatment approach. Reach out to your provider if you experience more serious symptoms, such as frequent vomiting, extreme thirst, difficulty breathing, or excessive fatigue, even after treatment.