BRASH (Bradycardia, Renal Failure, Atrioventricular Blockage, Shock, and Hyperkalemia) Syndrome: Diagnostic and Therapeutic Challenges in a Rare Clinical Entity

Bradycardia, renal failure, atrioventricular nodal blockade, shock, and hyperkalemia form a rare but potentially life-threatening constellation known as BRASH syndrome. It typically occurs in patients with chronic kidney disease and is often precipitated by the use of AV nodal blocking agents. We present the case of a 68-year-old male with advanced chronic kidney disease (CKD stage 5), heart failure with preserved ejection fraction (HFpEF), emphysema, and hypothyroidism who developed severe bradycardia (heart rate: 28 beats per minute) and hypotension (blood pressure: 88/54 mmHg). Laboratory evaluation revealed profound hyperkalemia (7.4 mmol/L), acute kidney injury with a creatinine level of 1,538 μmol/L (baseline 494 μmol/L), and severe metabolic acidosis (pH 6.86). The electrocardiogram demonstrated an idioventricular rhythm with a heart rate of 30 beats per minute and absent P waves. Despite initial refractory instability, the patient was stabilized with prompt electrolyte correction, inotropic support, discontinuation of AV nodal blockers, and urgent hemodialysis. His clinical condition improved significantly, with normalization of potassium, resolution of bradycardia, and recovery of renal function. This case highlights the diagnostic complexity of BRASH syndrome and underscores the therapeutic importance of early recognition and comprehensive management. Clinicians should maintain a high index of suspicion in patients with renal dysfunction receiving AV-nodal blockers who present with severe bradycardia out of proportion to serum potassium levels, as timely intervention may be lifesaving.