A Case Report of BRASH (Bradycardia, Renal Failure, Atrioventricular (AV) Blockage, Shock, and Hyperkalemia) Syndrome With a Challenging Diagnosis and Management Dilemma.

BRASH syndrome, characterized by bradycardia, renal failure, atrioventricular (AV) blockage, shock, and hyperkalemia, is an emerging clinical entity that challenges healthcare practitioners. This case report presents a unique instance of BRASH syndrome with an atypical presentation in a 56-year-old woman with a past medical history of hypertension, diabetes, and chronic kidney disease. Initial laboratory results revealed severe normocytic anemia, thrombocytopenia, renal dysfunction, acidosis, and hyponatremia, alongside hyperkalemia and hypothyroidism. An electrocardiogram depicted sinus arrest with atrial escape rhythms, indicative of severe bradycardia. Imaging studies revealed pleural effusion and ground glass opacities. Management involved anti-hyperkalemic measures, discontinuation of AV nodal-blocking agents, thyroid hormone replacement, and vasopressor support. The patient eventually improved following continuous renal replacement therapy (CRRT) and hemodialysis. The diagnosis of BRASH syndrome emerged as the most likely due to recurrent admissions with similar clinical features. BRASH syndrome represents a complex interplay between AV nodal block and hyperkalemia, leading to severe bradycardia and shock, often affecting older patients with limited renal reserve. While the current literature primarily consists of case reports, raising awareness of BRASH syndrome is crucial for timely intervention and improved patient outcomes. Further research is needed to better understand the mechanisms underlying this syndrome.

Liver Kidney Crosstalk: Hepatorenal Syndrome.

The dying liver causes the suffocation of the kidneys, which is a simplified way of describing the pathophysiology of hepatorenal syndrome (HRS). HRS is characterized by reversible functional renal impairment due to reduced blood supply and glomerular filtration rate, secondary to increased vasodilators. Over the years, HRS has gained much attention and focus among hepatologists and nephrologists. HRS is a diagnosis of exclusion, and in some cases, it carries a poor prognosis. Different classifications have emerged to better understand, diagnose, and promptly treat this condition. This targeted review aims to provide substantial insight into the epidemiology, pathophysiology, diagnosis, and management of HRS, shed light on the various milestones of this condition, and add to our current understanding.