Purpose: We present a rare case of intra-dialytic cardiac arrest secondary to renal tubular acidosis precipitated by severe hyperkalemia. Renal tubular acidosis (RTA) type 4 results from defective distal tubular (DT) response to aldosterone and could lead to hyperkalemia and metabolic acidosis, conditions which in their severe forms, can precipitate cardiac arrest. Methodology: Here, we present the management of intra-dialysis cardiac arrest precipitated by severe hyperkalemia. Results: Patient was an 18 year old female, diabetic who had 3 episodes of intra-dialysis cardiac arrest requiring cardiac defibrillation. She was dyspneic, drowsy, pale, had flapping tremor and a tunneled internal jugular catheter insitu. Her pulse was 124/min, blood pressure was 166/98 mmHg and the third heart sounds was heard. Urinalysis showed 3 (+++) of protein. Arterial blood gases (ABGs) revealed hyperkalemia (7.0mmol/l), hypobicarbonatemia (12mmol/l), blood PH (7.2) and blood glucose (249mmol). Serum creatinine was 947umol/l and tall tented T waves were seen on electrocardiogram.   Unique contribution to theory, practice and policy: With a carefully prescribed dialysis, meal and drug regimen, intra-dialysis cardiac arrest can be prevented, and well managed when it occurs.