Clinical Practice and Cases in Emergency Medicine

Introduction: Hyperkalemia is a common and potentially life-threatening complication of end- stage renal disease, often producing nonspecific symptoms but profound cardiac effects. While nonadherence and dietary indiscretion are typical precipitants, clinicians must also consider the adequacy and effectiveness of dialysis.

Case Report: We report a patient with end-stage renal disease on thrice-weekly hemodialysis who presented with significant bradycardia and altered mental status. Initial prehospital electrocardiogram (ECG) was suspicious for acute coronary syndrome after automated ECG interpretation suggested anterior ST-segment elevation. In the emergency department, the patient was in a junctional escape rhythm with diffuse peaked T-waves. Serum potassium was 7.8 millimoles per liter with concomitant uremia. Despite administration of potassium-shifting therapies bradycardia persisted, and temporary pacing attempts failed. An epinephrine infusion was initiated while arranging for emergent hemodialysis. Following dialysis, the potassium normalized, cardiac conduction returned to sinus rhythm, and the patient’s mental status improved. In the absence of missed dialysis sessions, increased potassium intake, or access site dysfunction, nephrology determined the likely etiology to be dialysis access recirculation from improper cannulation.

Conclusion: Dialysis recirculation is an uncommon but important cause of inadequate clearance leading to life-threatening hyperkalemia. Clinicians should consider this mechanism when confronted with otherwise unexplained electrolyte derangements in compliant dialysis patients.