ORIGINAL ARTICLE
Utility of a Handheld Blood Ketone Meter as a Postmortem
Indicator of Diabetic Ketoacidosis
Caris Mitchell, MD* and Brandi McCleskey, MD*†
Abstract: When investigating a death potentially due to diabetic ketoac-
idosis (DKA), it is challenging to assess the glucose level in the blood, but
β-hydroxybutyrate, the most prevalent ketone body in the blood, is rela-
tively stable after death. The aim of this project is to prove that a commer-
cially available ketone meter can be used on postmortem blood samples to
aid the diagnosis of DKA in a novel setting (during coroner/medical exam-
iner examination). Samples with acetone detected via gas chromatography
were chosen retrospectively to determine whether the meter could detect
ketones in postmortem blood (proof-of-concept). In all of the thawed sam-
ples, the meter detected an elevated ketone level. Samples were then obtained
in a prospective manner to include those with a possible cause of death from
DKA along with controls. We correctly identified 16 cases in which death
was due to DKA with use of the ketone manner. The ketone levels ranged
from 2.6 to 5.4 mmol/L in those cases. The diagnosis was confirmed with
a greatly elevated vitreous glucose concentration or glycated hemoglobin
concentration. Detecting the presence of ketones while in the autopsy suite
allowed for more accurate preliminary diagnoses and utilization of resources.
Key Words: ketone meter, forensic pathology, β-hydroxybutyrate
(Am J Forensic Med Pathol 2023;44: 17–20)
D iabetes mellitus (DM) is complicated yet prevalent chronic
disease that affects millions of individuals across the country.
The Centers for Disease Control and Prevention reports an esti-
mate of 37.3 million people, or 11.3% of the US population, living
with diabetes, which included 28.7 million officially diagnosed
and 8.5 million, or 23%, undiagnosed.1 The pathogenesis of this
disease correlates with a lack of insulin production by the pan-
creas due to autoimmune β-cell destruction (type I DM) or the
body's ineffective response to insulin (type 2 DM).2 Insulin is a
hormone produced by the pancreas that is used to adequately bal-
ance glucose. Although a variety of complications can arise from
DM, such as kidney failure, blindness, and vascular disease, one
of the most severe and potentially fatal complications is diabetic
ketoacidosis (DKA). Historically, DKA arose as a complication
of type I DM; however, there are occasions in which it arises from
poorly controlled type 2 DM. Hyperglycemia in DKA is caused
by depleted insulin, in which the body responds by increasing
counterregulatory hormones that accelerate gluconeogenesis, gly-
cogenolysis, and lipolysis. Accelerated lipolysis creates free fatty
acids that are ultimately transformed through ketogenesis in the
liver, into ketone bodies, such as acetone, acetoacetate, and β-
hydroxybutyrate (BHB).3 β-Hydroxybutyrate is the most preva-
lent ketone body in DKA.2 With this increase in ketones, which
are considered strong acids, the body undergoes bicarbonate re-
duction and ultimately metabolic acidosis. The classic clinical
Manuscript received May 10, 2022; accepted August 10, 2022.
From the *University of Alabama at Birmingham; and †Jefferson County
Coroner/Medical Examiner's Office, Birmingham, AL.
The authors report no conflict of interest.
Reprints: Brandi McCleskey, MD. 1515 6th Ave S, Room 220, Birmingham,
AL 35233. E-mail: bmccleskey@uabmc.edu.
Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0195-7910/23/4401–0017
DOI: 10.1097/PAF.0000000000000794
Am J Forensic Med Pathol • Volume 44, Number 1, March 2023
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
presentation includes polyuria, polydipsia, weight loss, abdominal
pain, vomiting, increased respiration, and symptoms of dehydra-
tion.4 More severely, DKA can lead to seizures, coma, and, ulti-
mately, death, occurring within hours to days.5
According to the American Diabetes Association, in 2019,
DM was listed as the underlying cause of death on 87,647 death
certificates and mentioned on 282,801 death certificates as either
the cause or contributing cause of death, but data suggest that DM
could be underreported as a cause of death, likely due to the unre-
liability of postmortem blood glucose concentration.2,6 Most of-
ten, in clinical practice, hyperglycemia is diagnosed via HbA1c
(glycosylated hemoglobin) or blood glucose concentration. How-
ever, the task presents much differently and with great difficulty in
the postmortem setting because of the fluctuations in blood glu-
cose concentrations. While normal physiological functions such
as cardiac and respiratory functions cease postmortem, there exists
surviving cells that thrive for a period of time and continue to me-
tabolize glucose. Glycolysis is instinctively maintained, which fur-
thers blood glucose decline. Nonetheless, a solution to the hurdle
of postmortem blood glucose reliability presents with the use of vit-
reous humor, a transparent gelatinous substance located within the
globe of the eyeball in the posterior chamber. It is described as an
acellular, colorless, viscous substance, composed primarily of water
with glucose, ascorbic acid, collagen, and hyaluronic acid. Because
of its relative isolation in space and lack of widespread exposure to
the blood stream, both situations which are prone to postmortem
changes related to redistribution and hemoconcentration, vitreous
humor is considered to be an ideal substrate to analyze for postmor-
tem diagnoses.7 Although glucose in vitreous humor also declines
postmortem, it stabilizes after 24 hours, allowing levels to be accu-
rately measured to make the proper diagnosis of DKA.8–10 This
process is tedious and expensive, thus leading to investigation of
an alternative and novel solution using handheld ketone meters
(can also be considered point-of-care testing). These meters are fi-
nancially more accessible, detect the main ketone body, BHB, and
can be potentially used to determine whether one's cause of death
is due to DKA. Therefore, the aims of this project are to prove that
commercially available handheld ketone meters can be used on
postmortem blood samples and to demonstrate the ease of use
for the general medicolegal death investigation community to im-
prove vital statistics on deaths related to diabetes.
MATERIALS AND METHODS
To determine the ability of a commercially available ketone
meter to detect a ketone level in postmortem samples, the case
management database of the Jefferson County Coroner/Medical
Examiner's Office was searched for decedents with acetone detected
in their blood using gas chromatography/mass spectrometry (GC/
MS) (head-space analysis). Given the retrospective nature of the
ketone meter testing, cases were limited based on blood sample
availability because of retention of original samples. The available
samples spanned a 6-month period. Exclusion criteria included
decedents described as decomposed, given the potential for im-
pact on specimen integrity. In addition, decedents younger than
www.amjforensicmedicine.com 17
Mitchell and McCleskey Am J Forensic Med Pathol • Volume 44, Number 1, March 2023

18 years were also excluded primarily because of the paucity of
cases with available specimen and/or acetone detected. A total
of 14 postmortem blood samples were thawed and agitated for
use on the ketone meter.
The gas chromatography results and causes of death for each
of the cases (n = 15) included in the retrospective analysis were
collected. In addition, those with glucose concentrations, detected
in vitreous humor, were also recorded. This testing was done dur-
ing the initial case workup, and some results were not available for
all cases used during the retrospective arm.
The prospective arm of this study included 77 decedents that
were examined over a nearly 4-year period. Cases were selected
based on preference of the attending forensic pathologist. In gen-
eral, if diabetes was considered in the differential diagnosis, a pe-
ripherally obtained blood sample was used for testing via the ketone
meter. Individuals younger than 18 years were also excluded from
the prospective arm to align with the retrospective arm. In cases in-
volving the sudden unexpected deaths in young people, the ketone
meter was used during the examination and a glucose level was re-
quested to be performed on the vitreous humor. However, in many
of these cases, toxicological analysis detected drugs in the blood,
and ultimately, these decedents became part of the control group.
Data were analyzed using the Student t test.
RESULTS
Retrospective Cases
Fourteen samples were retrieved, thawed, and agitated before
being placed on the testing strip. All of the available samples had
acetone detected in the blood sample at the time of the initial case
workup, but not all cases certified were DKA. The ketone meter
was able to detect ketones in all of the samples indicating that
the meter could be used on postmortem samples and generate data
that correlated with the acetone originally detected by GC/MS. Ac-
cording to the package insert, a ketone level of greater than
1.5 mmol/L is highly indicative of associated increased glucose
concentration in the blood and DKA. However, each of the thawed
samples generated ketone levels far in excess of that typically stated
as normal (less than 1.4 mmol/L); therefore, interpretation of the
concentrations in thawed postmortem samples is limited and calls
into question the stability of BHB in postmortem samples.
It should be noted though that half of the decedents (n = 7)
were originally diagnosed with DKA as a cause of death by the at-
tending forensic pathologist. Data available to the certifying foren-
sic pathologist included medical history, circumstances surround-
ing the death, gas chromatography results, and vitreous glucose
concentrations (Table 1). Of those diagnosed with DKA, the ke-
tone meter results were higher, although not significantly (mean
of 5.8 vs 4.9 mmol/L), and the specific concentrations should be
interpreted with caution.
Prospective Cases
Over the course of nearly 4 years, 77 blood samples were
tested with the ketone meter during the examination. The ketone
meter indicated a significantly greater level of ketones present in
the 16 cases who were ultimately diagnosed as having a cause of
death related to DKA (P < 0.00001E-10). Vitreous humor was col-
lected from each of the decedents and used for glucose testing. The
results, circumstances surrounding the death, gas chromatography re-
sults (if available), and vitreous glucose concentrations (if available)
were recorded (Table 2). Half of the individuals who were reported
to have a history of alcoholism and a cause of death related to chronic
alcohol use also had a ketone concentration outside of that typically
stated as normal (Table 3).
DISCUSSION
Identifying tools to assist coroners and/or medical examiners
in determining the cause of death accurately, with ease, and while
in the setting of limited resources is often challenging. This study
demonstrated that a relatively inexpensive handheld ketone meter
could be used to detect ketones in postmortem blood samples and
presents novel data to support the use of the meter to assist with
triage of cases during day-to-day operations either in the field or
in the morgue during the examination. It could assist coroners with
utilization of limited resources for cases involving natural diseases
(DM) where more accurate death certification may be supported
with a point-of-care device when additional autopsy workup and
ancillary testing, such as vitreous humor analysis, are cost prohibitive.
Although this represents the unique use of ketone meter, a study
by Walta et al11 in 2016 also highlighted the use of point-of-care
testing for glucose and BHB in vitreous humor.

TABLE 1. Retrospective Cases

Acetone Vitreous Glucose Ketone Level

Case Number Cause of Death Concentration, g/dL Concentration, mg/dL Detected, mmol/L
1 DKA 0.01 364 5.2
2 DKA 0.04 561 4.2
3 Hypertension 0.02 <20 5.6
4 Cardiovascular disease <0.01 N/A 4.4
5 Hypertension 0.01 N/A 6.2
6 DKA 0.06 781 8
7 DKA 0.02 622 7.2
8 DKA 0.03 N/A 5.5
9 DKA 0.01 340 5.6
10 Cardiovascular disease Trace N/A 3
11 Blunt force trauma Trace N/A 3.3
12 DKA 0.04 494 4.8
13 Chronic alcoholism 0.02 N/A 5.6
14 Hypertension 0.02 <20 6
N/A, not available/not obtained.

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Am J Forensic Med Pathol • Volume 44, Number 1, March 2023 Utility of a Handheld Blood Ketone Meter

Using the meter was particularly useful in a few of the pro-

spective cases of young persons who died suddenly and unexpect- TABLE 3. Deaths Related to Chronic Alcohol Use
edly. In the midst of the current opioid epidemic, a number of
Ethanol Acetone Vitreous Glucose Ketones
these cases were presumed overdoses; however, with the use of
Detected, Detected, Concentration, Detected,
the ketone meter, they were accurately worked up as undiagnosed
Case Number g/dL mmol/L mg/dL mmol/L
diabetes and their death was documented as complications sec-
ondary to DKA. Specifically, 24 cases were presumed as possible 5 N/A N/A N/A 0.4
drug overdoses (secondary to opioids) after a full autopsy exami- 9 0.09 N/A <20 1
nation. Of the 24 potential overdoses, 16 were confirmed with tox- 26 0.05 N/A N/A 0.6
icological testing and 6 deaths were ultimately due to DKA. This 33 N/A 0.04 8 4.9
diagnosis was accomplished using ketone meter data, vitreous
35 N/A N/A <20 2.4
glucose concentration, and histologic examination.
The diagnosis of DKA was supported by elevated glucose 37 0.05 N/A N/A 0.7
concentrations within the vitreous humor, although this matrix is 48 0.1 N/A 10 4.7
not easy to work with given its viscosity. Furthermore, the sophis- 53 0.02 N/A N/A 0.6
ticated testing platforms needed to test vitreous humor are often 65 0.09 0.01 42 2.7
not available to the general coroner or medical examiner office. 79 0.07 0.01 <20 2.3
The ketone meter will allow said coroner or medical examiner of-
fices to release accurate death certificates without significant fi-
nancial burden. determination. Because of the difficulty associated with postmor-
Death certification data are generally used for many public tem diagnosis of a diabetes related death, DM is often not accu-
health policies, public health initiatives, and research support rately listed on the death certificate as either a cause or contribut-
ing factor in death. Assisting the coroner and/or medical examiner
with gathering relevant data can support their addition of diabetes
TABLE 2. Prospective Cases on the death certificate effectively improving vital statistics data
and the accuracy of mortality data associated with diabetes.
Ketone Level The use of the handheld ketone meter not only assists corners
Detected, Average or medical examiners with limited resources but also assists those
n (Range), mmol/L needing alternatives to improve management of overwhelming
case burden despite resource availability. Using the meter will al-
Causes of death low death investigators, coroners, and medical examiners to be
Heart disease 23 0.8 (0.1–2.9) more time efficient with determining causes of death in a subset
(cardiomegaly, MI) of cases. In addition, individuals can better triage and organize
Substance (drug and 28 1.4 (0.3–4.9) based on ancillary tests that need to be ordered. For instance, at a
alcohol) related death investigation scene, the ketone meter can be used to quickly
DKA 16 3.6 (2.6–5.4) test a blood sample. If the meter reads at a certain level, the next step
Other natural causes PTE, T2DM, obesity, 0.53 (0.2–1.7) could be to collect a sample for a basic metabolic panel on vitreous
of death natural causes, humor as a supportive test or a HbA1c if resources allow.
probable natural
cause (10)
Limitations
Sex
Although there is an abundance of benefits of handheld ke-
Male 55 1.5 (0.5–5.4)
tone meters, there also exist limitations. The meter not only iden-
Female 22 1.7 (0.4–4.9) tifies BHB associated with DKA but also identifies acetoacetate,
Age ranges which can be present in many ketoacidotic states including that as-
19–30 9 1.5 (0.3–3.8) sociated with alcohol consumption. Therefore, potential cases list-
30–39 13 2 (0.3–4.3) ing DKA as the cause of death could be misidentified in patients
40–50 21 1.6 (0.2–4.6) who might have died because of alcohol use and/or abuse due to
50–60 14 1.2 (0.2–5.4) the crossover of ketone bodies in these conditions. Of note, in
>60 20 1.6 (0.1–4.9) the prospective study, 21 of the 78 decedents had a history of alco-
Race holism. Of those, 2 had DKA listed as the cause of death, and 10
White 33 1.4 (0.2–4.7)
had alcohol-related cause of death.
Black 44 1.7 (0.1–5.4)
Vitreous glucose concentration (n = 45)
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