{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,15]],"date-time":"2026-09-15T01:29:07Z","timestamp":1789435747824,"version":"build-2803163510"},"reference-count":29,"publisher":"The Endocrine Society","issue":"2","license":[{"start":{"date-parts":[[2025,7,21]],"date-time":"2025-07-21T00:00:00Z","timestamp":1753056000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/academic.oup.com\/pages\/standard-publication-reuse-rights"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,1,21]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Context<\/jats:title>\n                    <jats:p>Hyperglycemic hyperosmolar state (HHS) with concurrent hypernatremia is an emerging and under-investigated subtype of HHS.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To investigate the clinical characteristics, prevalence, and diagnostic parameters of this under-recognized HHS subtype.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We conducted a retrospective study of consecutive adults with diabetes admitted with HHS from 2018 to 2024 at a single institution. We assessed the measured and corrected sodium, free water deficit, calculated effective serum osmolarity, calculated total serum osmolarity, and coexisting diabetic ketoacidosis (DKA) and metabolic acidosis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Among 174 patients with HHS, hypernatremia based on measured sodium (&amp;gt;\u202f145\u2005mmol\/L) was uncommon (14\/174, 8%), consistent with prior reports. However, hypernatremia based on corrected sodium for hyperglycemia was highly prevalent (166\/174; 95.4%), suggesting that HHS with hypernatremia is the predominant subtype of HHS. Effective serum osmolarity &amp;gt; 300 mOsm\/L was more sensitive than total serum osmolarity &amp;gt; 320 mOsm\/L for diagnosing HHS. Additionally, 65.5% (114\/174) of HHS cases had concurrent DKA, suggesting that the traditional exclusion of significant ketonemia and acidemia in HHS diagnosis may warrant reconsideration.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>HHS with hypernatremia, defined by corrected sodium, is highly prevalent and clinically relevant, as corrected sodium better reflects the true free water deficit. HHS management should include evaluating both measured and corrected sodium, adopting effective serum osmolarity &amp;gt; 300 mOsm\/L as a more sensitive diagnostic criterion, and reevaluating the exclusion criteria of significant ketonemia and acidosis. These refinements may enhance diagnostic accuracy and enable more personalized fluid management in HHS.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1210\/clinem\/dgaf422","type":"journal-article","created":{"date-parts":[[2025,7,19]],"date-time":"2025-07-19T11:57:04Z","timestamp":1752926224000},"page":"e406-e413","source":"Crossref","is-referenced-by-count":4,"title":["Hyperglycemic Hypernatremic Hypertonic State: A Predominant HHS Subtype and Its Clinical and Diagnostic Features"],"prefix":"10.1210","volume":"111","author":[{"given":"Siyuan","family":"Cao","sequence":"first","affiliation":[{"name":"Pulmonary and Critical Care Medicine, University of California Los Angeles , Los Angeles, CA 90095 ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9151-9120","authenticated-orcid":false,"given":"Shanjin","family":"Cao","sequence":"additional","affiliation":[{"name":"Hospital Medicine, Department of Internal Medicine, St. Anne's Hospital, Brown University Health , Fall River, MA 02721 ,","place":["USA"]},{"name":"Department of Internal Medicine, Prima CARE, P.C. , Fall River, MA 02721 ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"80","published-online":{"date-parts":[[2025,7,21]]},"reference":[{"issue":"8","key":"2026012101515135200_dgaf422-B1","doi-asserted-by":"crossref","first-page":"1257","DOI":"10.2337\/dci24-0032","article-title":"Hyperglycemic crises in adults with diabetes: a consensus report","volume":"47","author":"Umpierrez","year":"2024","journal-title":"Diabetes Care"},{"issue":"7","key":"2026012101515135200_dgaf422-B2","doi-asserted-by":"crossref","first-page":"1335","DOI":"10.2337\/dc09-9032","article-title":"Hyperglycemic crises in adult patients with diabetes","volume":"32","author":"Kitabchi","year":"2009","journal-title":"Diabetes Care"},{"issue":"3","key":"2026012101515135200_dgaf422-B3","doi-asserted-by":"crossref","first-page":"e15005","DOI":"10.1111\/dme.15005","article-title":"Management of Hyperosmolar Hyperglycaemic State (HHS) in adults: an updated guideline from the Joint British Diabetes Societies (JBDS) for Inpatient Care Group","volume":"40","author":"Mustafa","year":"2023","journal-title":"Diabet Med"},{"key":"2026012101515135200_dgaf422-B4","doi-asserted-by":"crossref","first-page":"25","DOI":"10.1016\/j.jemermed.2024.12.001","article-title":"Euglycemic Hyperosmolar Hypernatremic State: a variant subtype of traditional hyperosmolar hyperglycemic state with higher mortality","volume":"72","author":"Cao","year":"2025","journal-title":"J Emerg Med"},{"issue":"3","key":"2026012101515135200_dgaf422-B5","first-page":"335","article-title":"Hypernatremia in hyperosmolar hyperglycemic syndrome","volume":"49","author":"Blas-Macedo","year":"2011","journal-title":"Rev Med Inst Mex Seguro Soc"},{"issue":"2","key":"2026012101515135200_dgaf422-B6","doi-asserted-by":"crossref","first-page":"319","DOI":"10.5527\/wjn.v4.i2.319","article-title":"Prolonged hypernatremia triggered by hyperglycemic hyperosmolar state with coma: a case report","volume":"4","author":"Vigil","year":"2015","journal-title":"World J Nephrol"},{"key":"2026012101515135200_dgaf422-B7","doi-asserted-by":"crossref","first-page":"2050313X19848887","DOI":"10.1177\/2050313X19848887","article-title":"Full recovery from extreme hypernatremia in an elderly woman with hyperosmolar hyperglycemic syndrome and abnormal electroencephalogram","volume":"7","author":"Galili","year":"2019","journal-title":"SAGE Open Med Case Rep"},{"issue":"3","key":"2026012101515135200_dgaf422-B8","first-page":"e7278","article-title":"Salty, sweet and difficult to treat: a case of profound hypernatremia in the setting of hyperosmotic hyperglycemic state","volume":"12","author":"Sohal","year":"2020","journal-title":"Cureus"},{"issue":"8","key":"2026012101515135200_dgaf422-B9","first-page":"e9672","article-title":"Severe hypernatremia in combined diabetic ketoacidosis and hyperglycemic hyperosmolar state: a case report of two Japanese children","volume":"12","author":"Shima","year":"2020","journal-title":"Cureus"},{"issue":"2","key":"2026012101515135200_dgaf422-B10","doi-asserted-by":"crossref","first-page":"81","DOI":"10.1297\/cpe.2021-0075","article-title":"Severe hypernatremia in soft drink ketoacidosis and hyperglycemic hyperosmolar state at the onset of type 2 diabetes mellitus: a case series of three adolescents","volume":"31","author":"Choo","year":"2022","journal-title":"Clin Pediatr Endocrinol"},{"issue":"1","key":"2026012101515135200_dgaf422-B11","doi-asserted-by":"crossref","first-page":"29","DOI":"10.5492\/wjccm.v12.i1.29","article-title":"Severe hypernatremia in hyperglycemic conditions; 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