Bradycardia without “classical” EKG changes in hyperkalemic hemodialysis patients

While the classic electrocardiographic (EKG) findings of hyperkalemia are well known to clinicians, the association between hyperkalemia and bradycardia is not widely appreciated. Three cases of profound bradycardia due to hyperkalemia in patients with End Stage Renal Disease (ESRD) on hemodialysis are described to provide a base for discussion of specific issues in the management of such patients. The patients presented with hyperkalemia and severe bradycardia that did not improve after administration of atropine. Urgent hemodialysis in two cases led to resolution of the bradycardia. In the third case, the failure to recognize that bradycardia was the consequence of the hyperkalemia led to unnecessary interventions and delays in initiating dialysis. These cases highlight the causal relation between hyperkalemia and bradycardia in ESRD patients and emphasize the need for increased awareness of this association.