Ketone body metabolism

Ketone body metabolism includes ketone body synthesis (ketogenesis) and

breakdown (ketolysis). When the body goes from the fed to the fasted state the
liver switches from an organ of carbohydrate utilization and fatty acid
synthesis to one of fatty acid oxidationand ketone body production. This
metabolic switch is amplified in uncontrolled diabetes. In these states the fatderived energy (ketone bodies) generated in the liver enter the blood stream
and are used by other organs, such as the brain, heart, kidney cortex and
skeletal muscle. Ketone bodies are particularly important for the brain which
has no other substantial non-glucose-derived energy source. The two main
ketone bodies are acetoacetate (AcAc) and 3-hydroxybutyrate (3HB) also
referred to as -hydroxybutyrate, with acetone the third, and least abundant.
Ketone bodies are always present in the blood and their levels increase during
fasting and prolonged exercise. After an over-night fast, ketone bodies supply
26% of the body's energy requirements, while they supply 3040% of the
energy needs after a 3-day fast. When they build up in the blood they spill over
into the urine. The presence of elevated ketone bodies in the blood is termed
ketosis and the presence of ketone bodies in the urine is called ketonuria. The
body can also rid itself of acetone through the lungs which gives the breath a
fruity odour. Diabetes is the most common pathological cause of elevated
blood ketones. In diabetic ketoacidosis, high levels of ketone bodies are
produced in response to low insulin levels and high levels of counterregulatory hormones.

Ketone bodies

Figure 1. Ketone bodies [Click to enlarge]The

term ketone bodies refers to three

molecules, acetoacetate (AcAc), 3-hydroxybutyrate (3HB) and acetone (Figure 1).
3HB is formed from the reduction of AcAc in the mitochondria. These two
predominant ketone bodies are energy-rich compounds that transport energy from
the liver to other body tissues. Acetone is a minor product, generated by
spontaneous decarboxylation of AcAc and is responsible for the sweet odor on the
breath of individuals with ketoacidosis [1][2].
Ketone bodies are present in small amounts in the blood of healthy individuals during
fasting or prolonged exercise and play a key role in sparing glucose utilization and
reducing proteolysis. Unlike most other tissues, the brain cannot utilize fatty acids for
energy when blood glucose levels become compromised [3][4]. In this case, ketone
bodies provide the brain with an alternative source of energy, amounting to nearly
2/3 of the brain's energy needs during periods of prolonged fasting and starvation [2][5].
Abnormally large quantities of ketone bodies are found in the blood of individuals
who are experiencing diabetic ketoacidosis, alcoholic ketoacidosis, salicylate
poisoning, and other rare conditions[2][3]. Ketone bodies stimulate insulin release in

vitro, generate oxygen radicals and cause lipid peroxidation. Lipid peroxidation and
the generation of oxygen radicals may play a role in vascular disease in diabetes [2].

Ketogenesis
Ketogenesis is the process by which fatty acids are transformed into acetoacetate
(AcAc) and 3-hydroxybutyrate (3HB) [1][2][3][4][5]. This process takes place in the liver in
specialized organelles called mitochondria. Under normal aerobic conditions glucose
and fatty acids are metabolized to acetyl CoA by glycolysis and oxidation respectively. The acetyl CoA is then further metabolized to two molecules
of CO2 by the tricarboxylic acid cycle (TCA cycle) which comprises eight sequential
enzymic reactions. The energy released by each turn of the cycle is stored either as
high energy phosphate in one molecule of GTP, or as high energy electrons in three
molecules of NADH + H+ and one molecule of the reduced cofactor, coenzyme Q
(QH2) via FADH2. The three NADH and one FADH2 produced by each turn of the
cycle are re-oxidised and generate ATP in a process called oxidative
phosphorylation[6]. The theoretical yield is 3 ATP per molecule of NADH and 2 ATP
per molecule of FADH2 making a total per cycle of 11 ATP and 1 GTP. Inefficiencies
in oxidative phosphorylation reduce the actual yield to ~2.5 per NADH and 1.5 per
FADH2 (10 ATP equivalents) per cycle[6]. Energy production via the TCA cycle and
oxidative phosphorylation takes place in mitochondria, the same organelles where
ketogenesis occurs.
The availability of oxaloacetate (OAA) is critical to the oxidation of acetyl CoA. If
intracellular glucose levels become too low - as during fasting or as a result of low
insulin levels in diabetes - then in the liver, oxaloacetate is depleted owing to its
preferentially utilization in the process of gluconeogenesis[5]. Thus OAA is unavailable
for condensing with acetyl CoA for the latters oxidative metabolism via the TCA
cycle[5]. Instead, in the liver, acetyl CoA is diverted to ketone body formation
(ketogenesis)[1][2][5][7]. Liver also lacks one of the key enzymes required for ketone body
utilization - acetoacetyl succinyl CoA transferase - (see below)[7]. The unavailability of
OAA and the lack of the above transferase explain why ketone bodies are
synthesized in the liver but utilized in the peripheral tissues [5][7].

Figure 2. Ketogenesis and ketolysis pathways. Click for enlarged view. Fatty acid oxidation in liver

mitochondria generates acetyl CoA. Under conditions of low glucose availability, the acetyl CoA cannot
be oxidized via the TCA cycle because, in the liver, the oxaloacetate required for the first step (its
condensation with acetyl CoA to form citrate), is unavailable being redirected to the process of glucose
production (gluconeogenesis). Consequently the acetyl CoA is converted into ketone bodies which are
used by non-liver tissues for energy (ATP) production. See text for details. Note the first and last
enzymes in both processes are reversible and operate in both processes.

In healthy adults, the liver is capable of producing up to 185g of ketone bodies per
day. The process includes the following steps shown in Figure 2:
-oxidation of fatty acids to acetyl CoA,
formation of acetoacetyl CoA from two molecules of acetyl CoA
conversion of acetoacetyl CoA to 3-hydroxy-3-methylglutaryl CoA (HMG
CoA)
conversion of 3-hydroxy-3-methylglutaryl CoA to acetoacetate (AcAc)
reduction of AcAc to 3--hydroxybutyrate (3HB) and
the spontaneous decarboxylation of acetoacetate to acetone
The conversion of 2 molecules of acetyl CoA to acetoacetyl CoA and free CoA is
catalyzed by the reversible enzyme acetoacetyl CoA thiolase. 3-hydroxy-3methylglutaryl CoA (HMG CoA) is formed from acetoacetyl CoA by
mitochondrial HMG CoA synthase (Figure 2). This step is stimulated by starvation,
low levels of insulin, and the consumption of a high-fat diet. HMG CoA is also
produced from ketogenic amino acids such as leucine, lysine, and tryptophan via a
separate enzymatic process during amino acid catabolism. HMG CoA is then
cleaved to liberate acetoacetate in a step mediated by 3-hydroxy-3-methylglutaryl
CoA lyase (HMG CoA lyase). The reduction of acetoacetate (AcAc) to 3hydroxybutyrate (3HB) is catalyzed by 3-hydroxybutyrate dehydrogenase, a
phosphatidyl choline-dependent enzyme (Figure 2). During this step, NADH is
oxidized to NAD+. The ultimate ratio of 3HB to AcAc in the blood is dependent on the
redox potential (i.e. the NADH/NAD+ ratio) within liver mitochondria[1][2][5][7].
Acetoacetate and 3-hydroxybutyrate are short-chain (4-carbon) organic acids (Figure
1) that can freely diffuse across cell membranes. Therefore, ketone bodies can serve
as a source of energy for the brain (which does not utilize fatty acids) and the other
peripheral organs mentioned above. Ketone bodies are filtered and reabsorbed in
the kidney. At physiologic pH, these organic acids dissociate completely. The large
hydrogen-ion load generated during their pathologic production, in diabetic
ketoacidosis, for example, rapidly overwhelms the normal buffering capacity and
leads to a metabolic acidosis with an increased anion gap [2].

Ketolysis
Ketolysis is the process by which ketone bodies produced in the liver are converted
(in non-liver tissues), into acetyl CoA which, on complete oxidation via
the tricarboxylic acid cycle and oxidative phosphorylation, provides energy for
various intracellular metabolic activities (Figure 3). Ketolysis occurs in the
mitochondria of many extrahepatic organs. The central nervous system is particularly
dependent on the delivery of ketone bodies produced in the liver for the process of
ketolysis, since ketogenesis occurs very slowly if at all in the central nervous
system[3][4].

Figure 3. Interplay between ketone body production (ketogenesis) in the liver and ketone body
utilization utilization (ketolysis) in non-hepatic tissue such as skeletal muscle. Click to enlarge. Free
fatty acids are released into the circulation by lipolysis and broken down into multiple copies of acetyl
CoA by -oxidation. Under conditions of low glucose availability ketogenesis occurs in the liver
producing the three ketone bodies, 3-hydroxybutyrate, acetoacetate and acetone. The production of
the first two is catalysed by four enzymes: acetoacetyl CoA thiolase (denoted by
1), HMG CoA synthase (2), HMG CoA lyase (3) and 3 hydroxybutyrate dehydrogenase (4). The
acetone is formed by non-enzymic decarboxylation of acetoacetate and cannot be used as an energy
source. Acetoacetate and 3-hydroxybutyrate pass from the liver to the general circulation and are
absorbed by non-hepatic tissues where they can be used as fuel. The 3-hydroxybutyrate is oxidized to
acetoacetate by 3 hydroxy butyrate dehydrogenase (denoted as I in the figure) and then converted to
acetoacetyl CoA by acetoacetyl succinyl CoA transferase (II). The acetoacetyl CoA is then split by
acetoacetyl CoA thiolase (III) into two molecules of acetyl CoA which are metabolized into CO 2 and
H2O via the TCA cycle and oxidative phosphorylation generating many molecules of ATP. Based on
slide 25 in Chaudhuri[8].As summarized in Figures 2 and 3, ketolysis involves three steps,

two of which are reversible reactions carried out by two (3-hydroxy butyrate
dehydrogenase and acetoacetyl CoA thiolase) of the four enzymes involved in
ketogenesis. The first step in ketolysis is the oxidation of 3-hydroxybutyrate to
acetoacetate by the reversible enzyme 3-hydroxy butyrate dehydrogenase followed
by the reconstitution of acetoacetyl CoA from acetoacetate by the
enzyme acetoacetyl succinyl CoA transferase(also called succinyl CoA: 3-oxoacid
CoA transferase (SCOT)). This enzyme uses succinyl CoA, an intermediate product
of the tricarboxylic acid cycle, as the CoA donor. The third and final step in ketosis is
the generation of 2 molecules of acetyl CoA from CoA and acetoacetyl CoA by the
reversible enzyme acetoacetyl CoA thiolase (Figures 2 and 3[8]). The acetyl CoA
formed is then oxidized in nonhepatic tissues via the TCA cycle.
Acetoacetyl succinyl CoA transferase is the rate-determining step in ketolysis [1][2][7]. Its
activity is highest in the heart and kidney, followed by the central nervous system
and skeletal muscle. Due to the sheer mass of skeletal muscle, this tissue accounts
for the highest fraction of total ketone body utilization in the resting
state. Acetoacetyl succinyl CoA transferase activity is down-regulated by high (>5
mM) intracellular levels of acetoacetate (AcAc). This phenomenon is responsible for
the observed increase in circulating levels of ketone bodies during the early phases
(3 days to 2 weeks) of starvation, despite relatively constant rates of hepatic
ketogenesis during this period[2]. Acetoacetyl succinyl CoA transferase activity is also
present, but at very low levels, in the liver[1][2][7].
Acetoacetyl CoA thiolase, the enzyme responsible for the final key step in ketolysis
in extrahepatic tissues, tends to enhance the production of acetyl CoA from

acetoacetyl CoA.Acetoacetyl CoA thiolase is also present in the liver the primary
locus of ketogenesis where it plays a key role as the first step in ketogenesis - the
creation of acetoacetyl CoA from two molecules of acetyl CoA [1][2][7]. Acetoacetyl CoA
thiolase is a multipurpose enzyme that participates in several other metabolic
pathways including fatty acid metabolism and the degradation of some amino acids[9].

Regulation of ketogenesis
The rate of ketogenesis depends upon the activity of three enzymes. One
is hormone-sensitive lipase (or triglyceride lipase), which is found in peripheral
adipocytes. The other two are acetyl CoA carboxylase and 3-hydroxy-3methylglutaryl-CoA synthase (HMG CoA synthase), which are found in the liver.
Hormone-sensitive lipase catalyzes the conversion of triglycerides to diglycerides for
further degradation to the free fatty acids (lipolysis) that serve as substrates for
ketogenesis. On the other hand, acetyl CoA carboxylase catalyzes the conversion of
acetyl CoA to malonyl CoA, increasing the hepatic level of the primary substrate
of fatty acid biosynthesis. Malonyl CoA levels vary in the liver directly according to
the rate of fatty acid synthesis and inversely with the rate of fatty acid oxidation.
Therefore, malonyl CoA plays a pivotal role in the regulation of ketogenesis. Low
levels of malonyl CoA stimulate transport of fatty acids into the mitochondria via the
carnitine shuttle for oxidation to ketone bodies (see lipolysis and lipogenesis for
details). Malonyl CoA normally inhibits carnitine palmitoyltransferase 1 [1][7], the
enzyme that transports fatty acyl CoA across the mitochondrial membrane.
Hormone-sensitive lipase and acetyl CoA carboxylase, are exquisitely controlled by
the level of circulating insulin (which acts to inhibit ketogenesis), and epinephrine
and glucagon (which act to stimulate ketogenesis). Thus in fasting or diabetes the
high levels of glucagon and low levels of insulin favor ketogenesis through the
promotion of lipolysis in the adipocyte and the stimulation of fatty acid oxidation in
the liver
Insulin inhibits lipolysis and ketogenesis and stimulates lipogenesis by triggering the
inhibitory dephosphorylation of hormone-sensitive lipase and the activating
dephosphorylation of acetyl CoA carboxylase. In the adipocytes, dephosphorylation
of hormone-sensitive lipase inhibits the breakdown of triglycerides to fatty acids and
glycerol, the rate-limiting step in the release of free fatty acids (lipolysis) from the
adipocyte. This thereby reduces the amount of substrate that is available to generate
acetyl CoA (via fatty acid oxidation) for ketogenesis. In addition, insulin-mediated
dephosphorylation of inhibitory sites on hepatic acetyl CoA carboxylase increases
the production of malonyl CoA and simultaneously reduces the rate at which fatty
acids can enter hepatic mitochondria for oxidation and ketone body production [1][2][7].
Glucagon stimulates ketogenesis by doing the opposite of insulin. Glucagon triggers
the phosphorylation of both hormone-sensitive lipase and acetyl CoA
carboxylase by cyclic AMP-dependent protein kinase. In the adipocytes,
phosphorylation of hormone-sensitive lipase by cyclic AMP-dependent protein
kinase stimulates the release of fatty acids from triglycerides (see lipolysis). Glycerol
freely diffuses out of the adipose tissue into the circulation for transport to the liver.
Free fatty acids enter the circulation and travel (bound to albumin) for uptake and
metabolism in other tissues such as the heart, skeletal muscle, kidney, and the liver.
In hepatocytes, phosphorylation of acetyl CoA carboxylase by cyclic AMP-dependent
protein kinasereduces the production of malonyl CoA which, in turn, stimulates fatty

acid uptake by the mitochondria, and thus increases the amount of substrate
available for ketogenesis[1][2][7].
Hepatic mitochondrial 3-hydroxy-3-methylglutaryl-CoA synthase (HMG CoA
synthase) is the third key enzyme involved in the control of ketogenesis. The activity
of this enzyme is increased by starvation and a high-fat diet, and decreased by
insulin. These factors modulate the activity of HMG CoA synthase by altering the
production of mRNA and the post-translational phase of protein synthesis via
reversible succinylation of the enzyme itself. Increasing the activity of HMG CoA
synthase leads to the production of ketone bodies

Ketogenesis is the release of ketones into the body when fat is broken down for energy.
When carbohydrate stores are exhausted, cells turn to fat cells for fuel. These fat cells break
down and release energy, and ketones are the by-product of that
breakdown. Acetoacetate and acetone are usually also released.
Breaking down fat as a source of energy is generally not a normal energy production
process. Carbohydrate stores in cells are replenished when carbohydrates are eaten.
Eliminating carbohydrate intake for dietary or health reasons may significantly reduce these
stores, leading to ketogenesis. Low carbohydrate diets and diabetic diets are two common
forms of ketogenic diet.
Low carbohydrate diets are used as a form of weight loss for some dieters. Popular versions
will often reduce intake of simple and complex carbohydrates to the point where cells quickly
use up all energy stores. When the body starts to break down fat for energy, ketones are
released as a result of ketogenesis. As long as carbohydrate levels remain low, fat stores will
continue to be used for energy needs in excess of carbohydrate intake.
Diabetic diets may also result in ketogenesis. Another name for carbohydrate energy
is glucose. Glucose can be regulated with a controlled carbohydrate diet. Reaction to lower
carbohydrate levels in a diabetic diet is often the same as a low carbohydrate diet used for
weight loss. Patients trying to regulate blood glucose levels may choose a ketogenic diet.
Ketones may be released either through exhaling acetone or during urination. Ketones tend
to have a sweet smell on the breath. Passing ketones out of the body through urination or
exhaling is not known to cause health problems. Increased water intake is often needed to
flush acetone from the body.
Ketogenesis is not the same as ketoacidosis. Ketoacidosis is typically associated
with alcoholismand diabetes. This condition can result in kidney failure and death if left
untreated. Ketoacidosis is a severe form of ketosis that can cause blood pH levels to drop
below 7.2. There are no known cases of ketogenesis causing a drop in blood pH levels.
Debate over effects of ketogenesis on the body has resulted in several medical research
teams evaluating effects of ketosis on cholesterol levels, overall health, and weight loss. As
of 2010, ketogenesis has been found to be a healthy reaction in the body. No negative
health-related side effects have been associated with cells using fat for energy in place of
carbohydrate stores.
Ketones may be released either through exhaling acetone or during urination. Ketones tend
to have a sweet smell on the breath. Passing ketones out of the body through urination or
exhaling is not known to cause health problems. Increased water intake is often needed to
flush acetone from the body.

Ketogenesis is not the same as ketoacidosis. Ketoacidosis is typically associated

with alcoholismand diabetes. This condition can result in kidney failure and death if left
untreated. Ketoacidosis is a severe form of ketosis that can cause blood pH levels to drop
below 7.2. There are no known cases of ketogenesis causing a drop in blood pH levels.
Debate over effects of ketogenesis on the body has resulted in several medical research
teams evaluating effects of ketosis on cholesterol levels, overall health, and weight loss. As
of 2010, ketogenesis has been found to be a healthy reaction in the body. No negative
health-related side effects have been associated with cells using fat for energy in place of
carbohydrate stores.