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In conclusion, ESRD patients are at high risk of developing severe, life-threatening hyperkalemia. When dialysis is not immediately available, non-dialytic [http://en.wikipedia.org/wiki/Ankyrin ankyrin] therapies are used as temporizing measures. Treatment with insulin is effective, but can be associated with severe hypoglycemia if appropriate therapeutic guidelines are not implemented and practiced. Education of physicians and nursing personnel, and adherence to an institution-specific treatment algorithm for hyperkalemia are extremely important in preventing this critical iatrogenic complication. Disclosures. None declared.""The relatively low levels of lactic acid led us to reconsider some of the other anions from the well-known acronym ��KUSSMALE��. However, all could be swiftly discarded by retrospective (hetero) anamnesis with some doubt left for the K&U. Indeed, although the dipstick was negative, it only reliably detects acetone and aceto-acetate. However, ��-hydroxy butyric acid is a ketone typically found in combination [http://www.selleckchem.com/products/JNJ-26481585.html selleck] with alcohol abuse and starvation��which did not fit our patient's state exactly except for some degree of chronic malnutrition. Although his serum creatinine had significantly risen, the corresponding estimated glomerular filtration rate was still above the levels at which uraemic acidosis develops and oliguria did not develop. The high urinary anion and osmolal gap obtained after administration of IV fluids were suggestive of urinary excretion of an organic anion with an adequate increase in renal NH4+ production. Could it still be lactic acid? d-lactate is not measured by most lactate assays and is abundantly excreted in the urine. However, our patient's clinical history did not correlate with the usual presentation of a patient with short bowel, showing signs of inebriation without alcoholaemia after consumption of carbohydrates. A web search gave the final hint to the solution in the form of alternative acronyms for high anion gap acidoses, such as MUDPILES, CUTE DIMPLES and GOLDMARKS [1]. It was the ��O�� for 5-oxoproline [http://www.selleckchem.com/GSK-3.html find protocol] in the latter acronym that drew our attention to the medical prescription file of the patient. Although he had only occasionally received acetaminophen (never exceeding 2 g daily) for pain relief during the first 2 weeks of the hospital admission, high doses of flucloxacillin had been administered for 6 weeks, resulting in a cumulative dose of ?500 g! Subsequent measurement of 5-oxoproline in the urine revealed a concentration of 11 869 mmol/mol creatinine (normal value