TOPLINE

A retrospective study found that alcoholic ketoacidosis (AKA) complicated 11%-26% of alcohol-related presentations to the emergency department (ED) but was formally diagnosed in only 9%-15% of patients who met the biochemical criteria for AKA. Presentations involving alcohol withdrawal were more frequently associated with anion gap metabolic acidosis (AGMA) and AGMA plus ketonuria than presentations involving alcohol intoxication.

METHODOLOGY

• Researchers conducted a retrospective chart review of adults who presented to 11 EDs in the US with alcohol-related chief complaints between January and March 2023.
• The study included 905 patients (median age, 44 years; 70% men) with alcohol intoxication or suspected withdrawal.
• Patients with alternative causes of metabolic acidosis, recurrent alcohol-related visits, or withdrawal from or overdose of other substances were excluded.
• The primary outcome was the frequency of AGMA, which was used as a proxy for the upper bound of potential AKA.
• Stringent criteria, defined as the presence of AGMA plus ketonuria, were used as a lower-bound estimate of potential AKA.

TAKEAWAY

• A total of 26% of the patients had AGMA, and 11% had AGMA plus ketonuria.
• Only 9% of the patients with AGMA and 15% of those with AGMA plus ketonuria were diagnosed with AKA in the ED. Even among patients with the most severe acidosis, the diagnosis was frequently missed.
• Patients presenting with alcohol withdrawal had higher rates of AGMA (44% vs 21%; P < .001) and AGMA plus ketonuria (21% vs 8%; P < .001) than those presenting with alcohol intoxication.
• Mean bicarbonate levels were lower among patients with AGMA than among those without AGMA (20 vs 21.5 mEq/L). Additionally, patients with AGMA had higher ethanol concentrations than those without AGMA (216 mg/dL vs 188 mg/dL; P = .02), whereas those with AGMA and positive vs negative ketones had lower ethanol concentrations (172 mg/dL vs 243 mg/dL; P = .01).

IN PRACTICE

"The discrepancy between the identified incidence of AKA and the diagnosis of AKA demonstrates a possible lack of awareness of how common this complication may be," the author wrote. "Increased recognition of this pathology may improve the care of these patients," the author added.

SOURCE

The study was led by Alexander Sidlak, Inova Fairfax Medical Campus, Falls Church, Virginia. It was published online on June 29, 2026, in The American Journal of Emergency Medicine.

LIMITATIONS

The study was limited by its retrospective design, lack of standardized laboratory and urine ketone testing, absence of serum beta-hydroxybutyrate measurements, and lack of validated diagnostic criteria for AKA.

DISCLOSURES

The study did not receive any funding. The author reported having no competing interests.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.