Figure 1. Metabolic pathways of DβHB in mitochondria.

The metabolism of DβHB in mitochondria is stereospecific to the D isoform. Under normal physiological conditions, the level of DβHB is low but becomes dramatically elevated during starvation, increased fatty acid metabolism or pathological conditions such as diabetes. From its site of production in the liver, DβHB is released into the blood and circulated for utilization by other tissues. In general, the rate of ketone body usage in the brain is proportional to the concentration in the circulation [59]. Circulating DβHB readily crosses the blood-brain barrier and enters brain mitochondria where it is metabolized by mitochondrial β-hydroxybutyrate dehydrogenase to acetoacetate, which is subsequently converted to acetyl-coenzyme A to feed into the tricarboxylic acid cycle (TCA) cycle. The intermediate products generated from this cycle, NADH and succinate, in turn feed into the electron transport chain to subsequently generate ATP at complex V. Through this metabolic pathway, DβHB is an excellent alternative source of energy in the brain when glycolysis is not operative or when glucose supply is depleted such as during starvation [59].