Bile Cast Nephropathy Caused by Obstructive Cholestasis

Published:October 22, 2016DOI:
      Acute kidney injury (AKI) is a major complication in patients with liver disease. Although hepatorenal syndrome is frequently involved, bile cast nephropathy, characterized by tubular bile cast formation, has been scarcely described in the setting of severe liver failure. Few renal histology studies are available in these patients. We describe a case of bile cast nephropathy in a patient with obstructive cholestasis caused by stones in the common bile duct. The kidney biopsy confirmed this diagnosis, with several green casts in tubular lumens, tubular injury, and bilirubin composition of the tubular casts with Hall stain. The patient had no confounding cause of kidney failure, and complete kidney recovery followed removal of the bile duct obstruction. This case shows that severe cholestasis is sufficient to cause AKI, and that AKI can be reversible after treatment of the biliary obstruction.

      Index Words

      To read this article in full you will need to make a payment


      Subscribe to American Journal of Kidney Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Gines P.
        • Schrier R.W.
        Renal failure in cirrhosis.
        N Engl J Med. 2009; 361: 1279-1290
        • Cardi E.
        The hepatorenal syndrome: a historical review.
        AMA Arch Surg. 1956; 73: 224-227
        • Haessler H.
        • Rous P.
        • Broun G.O.
        The renal elimination of bilirubin.
        J Exp Med. 1922; 35: 533-552
        • van Slambrouck C.M.
        • Salem F.
        • Meehan S.M.
        • Chang A.
        Bile cast nephropathy is a common pathologic finding for kidney injury associated with severe liver dysfunction.
        Kidney Int. 2013; 84: 192-197
        • Bredewold O.W.
        • de Fijter J.W.
        • Rabelink T.
        A case of mononucleosis infectiosa presenting with cholemic nephrosis.
        NDT Plus. 2011; 4: 170-172
        • van der Wijngaart H.
        • van Dam B.
        • van den Berg J.G.
        • Krul-Poel Y.H.
        • Klemt-Kropp M.
        • Bax W.A.
        A 73-year-old male with jaundice and acute kidney injury. Bile cast nephropathy.
        Neth J Med. 2014; 72 (99): 95
        • Sequeira A.
        • Gu X.
        Bile cast nephropathy: an often forgotten diagnosis.
        Hemodial Int. 2015; 19: 132-135
        • Luciano R.L.
        • Castano E.
        • Moeckel G.
        • Perazella M.A.
        Bile acid nephropathy in a bodybuilder abusing an anabolic androgenic steroid.
        Am J Kidney Dis. 2014; 64: 473-476
        • Alkhunaizi A.M.
        • ElTigani M.A.
        • Rabah R.S.
        • Nasr S.H.
        Acute bile nephropathy secondary to anabolic steroids.
        Clin Nephrol. 2016; 85: 121-126
        • Jain K.
        • Gupta A.
        • Singh H.K.
        • Nickeleit V.
        • Kshirsagar A.V.
        Bile cast nephropathy.
        Kidney Int. 2015; 87: 484
        • Ryan M.
        • Lazar I.
        • Nadasdy G.M.
        • Nadasdy T.
        • Satoskar A.A.
        Acute kidney injury and hyperbilirubinemia in a young male after ingestion of Tribulus terrestris.
        Clin Nephrol. 2015; 83: 177-183
        • Rafat C.
        • Burbach M.
        • Brocheriou I.
        • et al.
        Bilirubin-associated acute tubular necrosis in a kidney transplant recipient.
        Am J Kidney Dis. 2013; 61: 782-785
        • Kaler B.
        • Karram T.
        • Morgan W.A.
        • Bach P.H.
        • Yousef I.M.
        • Bomzon A.
        Are bile acids involved in the renal dysfunction of obstructive jaundice? An experimental study in bile duct ligated rats.
        Ren Fail. 2004; 26: 507-516
        • Krones E.
        • Wagner M.
        • Eller K.
        • Rosenkranz A.R.
        • Trauner M.
        • Fickert P.
        Bile acid-induced cholemic nephropathy.
        Dig Dis. 2015; 33: 367-375
        • Fickert P.
        • Krones E.
        • Pollheimer M.J.
        • et al.
        Bile acids trigger cholemic nephropathy in common bile-duct-ligated mice.
        Hepatology. 2013; 58: 2056-2069
        • Hofmann A.F.
        • Mysels K.J.
        Bile acid solubility and precipitation in vitro and in vivo: the role of conjugation, pH, and Ca2+ ions.
        J Lipid Res. 1992; 33: 617-626
        • Burnstine R.C.
        • Schmid R.
        Solubility of bilirubin in aqueous solutions.
        Proc Soc Exp Biol Med. 1962; 109: 356-358
        • Fajers C.M.
        Experimental studies in cholemic nephrosis. 3. The effect of cholemia by itself and combined with ten minutes' unilateral renal ischemia on the kidneys of hydrated rabbits as judged by some renal function tests.
        Acta Pathol Microbiol Scand. 1957; 41: 44-55
        • LeBlanc R.M.
        • Navar L.G.
        • Botros F.T.
        Bilirubin exerts renoprotective effects in angiotensin II-hypertension.
        Am J Med Sci. 2010; 340: 144-146
        • Brem A.S.
        • Cashore W.J.
        • Pacholski M.
        • Tetreault J.
        • Lawler R.G.
        Effects of bilirubin on transepithelial transport of sodium, water, and urea.
        Kidney Int. 1985; 27: 51-57
        • Elias M.M.
        • Comin E.J.
        • Grosman M.E.
        • Galeazzi S.A.
        • Rodriguez Garay E.A.
        Possible mechanism of unconjugated bilirubin toxicity on renal tissue.
        Comp Biochem Physiol A Comp Physiol. 1987; 87: 1003-1007
        • Bairaktari E.
        • Liamis G.
        • Tsolas O.
        • Elisaf M.
        Partially reversible renal tubular damage in patients with obstructive jaundice.
        Hepatology. 2001; 33: 1365-1369