Altered cholesterol homeostasis in critical illness-induced muscle weakness: effect of exogenous 3-hydroxybutyrate

Crit Care. 2021 Jul 17;25(1):252. doi: 10.1186/s13054-021-03688-1.


Background: Muscle weakness is a complication of critical illness which hampers recovery. In critically ill mice, supplementation with the ketone body 3-hydroxybutyrate has been shown to improve muscle force and to normalize illness-induced hypocholesterolemia. We hypothesized that altered cholesterol homeostasis is involved in development of critical illness-induced muscle weakness and that this pathway can be affected by 3-hydroxybutyrate.

Methods: In both human critically ill patients and septic mice, the association between circulating cholesterol concentrations and muscle weakness was assessed. In septic mice, the impact of 3-hydroxybutyrate supplementation on cholesterol homeostasis was evaluated with use of tracer technology and through analysis of markers of cholesterol metabolism and downstream pathways.

Results: Serum cholesterol concentrations were lower in weak than in non-weak critically ill patients, and in multivariable analysis adjusting for baseline risk factors, serum cholesterol was inversely correlated with weakness. In septic mice, plasma cholesterol correlated positively with muscle force. In septic mice, exogenous 3-hydroxybutyrate increased plasma cholesterol and altered cholesterol homeostasis, by normalization of plasma mevalonate and elevation of muscular, but not hepatic, expression of cholesterol synthesis genes. In septic mice, tracer technology revealed that 3-hydroxybutyrate was preferentially taken up by muscle and metabolized into cholesterol precursor mevalonate, rather than TCA metabolites. The 3-hydroxybutyrate protection against weakness was not related to ubiquinone or downstream myofiber mitochondrial function, whereas cholesterol content in myofibers was increased.

Conclusions: These findings point to a role for low cholesterol in critical illness-induced muscle weakness and to a protective mechanism-of-action for 3-hydroxybutyrate supplementation.

Keywords: Cholesterol; Ketone; Muscle weakness; Sepsis.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • 3-Hydroxybutyric Acid
  • Aged
  • Aged, 80 and over
  • Animals
  • Cholesterol / analysis*
  • Cholesterol / metabolism
  • Critical Illness / therapy
  • Disease Models, Animal
  • Female
  • Homeostasis / drug effects*
  • Humans
  • Lipid Metabolism / drug effects
  • Male
  • Mice
  • Mice, Inbred C57BL / metabolism
  • Mice, Inbred C57BL / physiology
  • Middle Aged
  • Multivariate Analysis
  • Muscle Weakness / physiopathology


  • Cholesterol
  • 3-Hydroxybutyric Acid