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Trace Ketonuria SGLT2i Non-Diabetic — ESENeph MCQ

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ModerateChronic Kidney DiseaseTrace Ketonuria SGLT2i Non-DiabeticESENeph

A 45-year-old woman with CKD G3a on Dapagliflozin has a urinalysis showing glycosuria (2+) and ketonuria (trace). She is not diabetic. Her blood glucose is 5.2 mmol/L. Is the trace ketonuria concerning?

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Correct answer: B — Trace ketonuria in a non-diabetic patient on SGLT2i is usually clinically insignificant – SGLT2i mildly increases ketone production through metabolic fuel shifting; however significant ketonuria with symptoms (nausea, vomiting, abdominal pain) or blood ketones >3 mmol/L warrants evaluation for euglycaemic DKA

SGLT2i causes a mild metabolic shift from glucose to fat oxidation (due to reduced glucose availability from glycosuria). This physiologically increases ketone body production. Trace ketonuria in an asymptomatic, well, non-diabetic patient is usually benign and expected. However, clinicians should maintain awareness of euglycaemic DKA risk – which is rare in non-diabetic SGLT2i users but can occur with illness, fasting, surgery, or excessive alcohol. Red flags: blood ketones >3 mmol/L, metabolic acidosis (low bicarbonate), or symptoms (nausea, vomiting, abdominal pain, Kussmaul breathing).

Reference: KDIGO 2024 – CKD; MHRA 2024 – SGLT2i Safety