Hyperkalemia and Bradycardia in Dialysis: How Often Are We Missing Bradycardia, Renal Failure, Atrioventricular Nodal Blockade, Shock, and Hyperkalemia (BRASH)?

Introduction: BRASH syndrome is a clinical entity characterized by bradycardia, renal failure, AV nodal blockade, shock, and hyperkalemia. Despite its clinical relevance in nephrology, it can be easily overlooked, particularly in patients with end-stage kidney disease (ESKD). We present a case of recurrent intraoperative bradycardia in an ESKD patient undergoing AV fistula (AVF) surgery, in whom BRASH syndrome was initially unrecognized. Case Description: A 58-year-old male on hemodialysis, secondary to focal segmental glomerulosclerosis (FSGS), with reduced ejection fraction, coronary artery disease, and obstructive sleep apnea, presented for AVF surgery. Outpatient serum potassium levels ranged from 4.5 to 5.4mEq/L. During his first attempt at AVF creation under sedation, the patient developed profound bradycardia of 28 bpm. This was resolved with glycopyrrolate, ephedrine, and epinephrine. The preoperative serum potassium was 5.3mEq/L, and the intraoperative serum potassium was 6.2 mEq/L. The procedure was aborted. Later, during an AVF revision with general anesthesia, the patient again experienced bradycardia, with a heart rate in the 20s, which was refractory to atropine and glycopyrrolate. Preoperative serum potassium was 4.9mEq/L, and intraoperative serum potassium was 6.7 mEq/L. The case was again aborted. The initial evaluation focused on possible anesthetic or conduction abnormalities. An extensive cardiology work-up found no definitive cause. However, a multidisciplinary review identified an outside prescription of carvedilol, and BRASH syndrome was diagnosed. For the repeat surgery, carvedilol was held, and preoperatively, dialysis was performed with serum potassium of 3.4mEq/L. The following surgery was without complications. Discussion: This case underscores the need for nephrologists to recognize BRASH syndrome. Bradycardia in ESKD is often multifactorial, but failing to identify the synergistic effects of hyperkalemia and AV nodal blockade can lead to cardiac instability, aborted procedures, and unnecessary interventions. BRASH requires targeted correction of potassium, medication review, and timely dialysis. In ESKD patients with bradycardia, hyperkalemia, and AV nodal blockade, BRASH should be high on the differential. Early recognition and intervention can prevent complications, reduce risk, and improve outcomes.