What happens to sodium concentration in hyperglycemic hyperosmolar nonketotic state?

In hyperglycemic hyperosmolar nonketotic state (HHNS), the presence of significantly elevated glucose levels leads to an increase in plasma osmolality. The high osmolarity causes a shift of water from the intracellular space to the extracellular space, which dilutes sodium concentration. Consequently, the effective sodium concentration may appear low because it is measured in a hyperosmolar environment.

This osmotic effect of glucose results in pseudohyponatremia, where sodium levels can drop under biochemical conditions, despite the total body sodium possibly being normal or even elevated. Hence, the osmotic dilution effect of the high glucose levels directly results in a lower measured serum sodium concentration, which is why the concept of sodium being low due to these effects is correct in this context.