Breaking the BRASH Cycle: Early Hemodialysis Saving a Chronic Kidney Disease Patient with Severe Bradycardia

BRASH syndrome – a clinical entity defined by bradycardia, renal failure, AV nodal blockade, shock, and hyperkalemia – represents a dangerous, self-perpetuating cycle that can rapidly lead to hemodynamic instability and multiorgan dysfunction. The syndrome is often overlooked because its presentation may resemble isolated bradyarrhythmia, hyperkalemia, or drug toxicity. Understanding its interconnected pathophysiology is essential, especially in patients with chronic kidney disease (CKD) who are particularly vulnerable due to impaired potassium excretion and frequent use of AV nodal blocking agents. We report a case of BRASH syndrome in a patient with pre-existing CKD who presented with severe bradycardia and shock secondary to hyperkalemia and AV nodal blocker use. Immediate management included withdrawal of the AV nodal blocking agent, correction of serum potassium using insulin–dextrose infusion and salbutamol nebulization, and finally hemodialysis for refractory hyperkalemia. The patient’s condition stabilized following these interventions. This case highlights the importance of early recognition and holistic management of BRASH syndrome. Rather than treating each symptom in isolation, clinicians must address the underlying cycle connecting renal dysfunction, hyperkalemia, and cardiac depression. Prompt withdrawal of offending medications, aggressive potassium correction, and timely dialysis can be lifesaving, particularly in patients with CKD.