In hyperglycemic hyperosmolar nonketotic state, what is the expected potassium balance?

In hyperglycemic hyperosmolar nonketotic state (HHNS), there is a significant fluid deficit, often accompanied by a high serum osmolality due to elevated blood glucose levels. This condition leads to osmotic diuresis, resulting in increased urinary loss of water and electrolytes, including potassium.

As a result, although serum potassium levels can be high or normal due to the shifting of potassium from inside cells to the bloodstream as a consequence of hyperglycemia and acidosis, the total body potassium is actually low. This occurs because the overall loss of potassium from the body exceeds the temporary serum elevation. The body's total potassium reserve diminishes due to excessive urinary losses, while serum potassium may not accurately reflect the depleted total body status.

This understanding of potassium dynamics during HHNS illustrates why the scenario where total body potassium is low, while serum potassium can be high or normal, is expected.