• Acute kidney injury
• Bile acids
• Cholemic nephropathy
• Kidney biopsy
• Liver disease
• Outcomes
• Oxidative stress
• Prognostic factors

Bile cast nephropathy (BCN) or cholemic nephropathy (CN) is an acute renal dysfunction, including acute kidney injury (AKI) in the setting of liver injury. It is a common phenomenon in patients with liver disease and is associated with significant morbidity and mortality. CN is characterized by hemodynamic changes in the liver, kidney, systemic circulation, intratubular cast formation, and tubular epithelial cell injury. CN has been overlooked as a differential diagnosis in chronic liver disease patients due to more importance to hepatic injury. However, frequent and considerable reporting of case reports recently has further investigated this topic in the last two decades. This review determines the evidence behind the potential role of bile acids and bilirubin in acute renal dysfunction in liver injury, summarizing the implied pathophysiology risk factors, and incorporating the therapeutic mechanisms and outcomes.

Bile acid nephropathy also known as cholemic nephropathy is a rare and overlooked form of acute kidney injury that occurs in the setting of severe hyperbilirubinemia. The exact etiology remains unknown, and there is a lack of treatment guidelines for this clinical condition. Anabolic steroids are known to cause hepatoxicity occasionally leading to acute kidney injury. We report the case of a 27-year-old male patient who developed bile acid nephropathy as a result of severe hyperbilirubinemia secondary to anabolic steroids-induced liver injury. He was conservatively managed. We review the current literature touching on the etiology, pathophysiology, diagnosis, and management of bile acid nephropathy in an attempt to shed light on this clinical condition, which may present as a diagnostic and therapeutic challenge.

• anabolic steroids
• bile acid nephropathy
• cholemic nephropathy
• drug-induced liver injury

• bile casts
• cirrhosis
• hepatorenal syndrome
• nephropathy
• transplant

• Acute Kidney Injury/blood
• Acute Kidney Injury/chemically induced
• Acute Kidney Injury/diagnosis
• Acute Kidney Injury/mortality
• Aged
• Bilirubin/blood
• Carcinoma, Hepatocellular/metabolism
• Contrast Media/adverse effects
• Female
• Fibrosis/metabolism
• Humans
• Hyperbilirubinemia/blood
• Hyperbilirubinemia/complications
• Hyperbilirubinemia/diagnostic imaging
• Incidence
• Kidney
• Liver Neoplasms/metabolism
• Male
• Middle Aged
• Renal Dialysis
• Risk Factors
• Tomography, X-Ray Computed

• Taichung Veterans General Hospital

Bile cast nephropathy (BCN) is seen in patients who have acute kidney injury and severe hyperbilirubinemia due to a wide range of hepatobiliary system diseases. Findings seen by renal biopsy include acute tubular injury with necrotic and sloughed epithelial cells, yellow-green pigment within tubular epithelial cells, and pigmented granular casts. Hall's special stain for bile turns these casts green. In recent years, BCN has been described in a small number of case reports and clinical studies primarily in the setting of severe liver dysfunction. We present 2 diverse cases of BCN. The first involves an adult with hepatorenal syndrome secondary to alcoholic steatohepatitis and early cirrhosis. Second, we describe the first reported case of BCN in a child with fulminant hepatic failure due to Wilson's disease. Our cases expand the spectrum of causative diseases, and they provide further evidence that BCN is a distinct pathologic entity which may be found in both adult and pediatric patients with a variety of severe liver diseases.

• Bile cast nephropathy
• Cholestatic liver disease
• Hepatorenal syndrome
• Wilson's disease

• ACLF, acute on chronic liver failure
• AKI, acute kidney injury
• GCS, Glasgow coma scale
• HE, Hematoxylin–Eosin

• Acute kidney injury
• Bile cast nephropathy
• Hepatorenal syndrome

Bile cast nephropathy is a condition of renal dysfunction in the setting of hyperbilirubinemia. There are very few cases of this condition reported in the last decade and a lack of established treatment guidelines. While the exact etiology remains unknown, bile cast nephropathy is presumed to be secondary to multiple concurrent insults to the kidney including direct toxicity from bile acids, obstructive physiology from bile casts, and systemic hypoperfusion from vasodilation. Therapy directed at bilirubin reduction may improve renal function, but will likely need dialysis or plasmapheresis as well. We report our case of bile cast nephropathy and the therapeutic measures undertaken in a middle-aged male with chronic renal insufficiency that developed hyperbilirubinemia and drug-induced liver injury secondary to antibiotic use. He developed acute renal injury in the setting of rising bilirubin. He subsequently had a progressive decline in renal and hepatic function, requiring dialysis and plasmapheresis with some improvement, ultimately requiring transplantation.

• Bile cast
• Dialysis
• Drug-induced liver injury
• Plasmapheresis
• Hyperbilirubinemia

• Acute Kidney Injury/etiology
• Acute Kidney Injury/pathology
• Acute Kidney Injury/therapy
• Adrenal Cortex Hormones/therapeutic use
• Anion Exchange Resins/therapeutic use
• Anti-Bacterial Agents/adverse effects
• Biopsy
• Chemical and Drug Induced Liver Injury, Chronic/etiology
• Cholagogues and Choleretics/therapeutic use
• Cholestyramine Resin/therapeutic use
• Humans
• Hyperbilirubinemia/chemically induced
• Hyperbilirubinemia/complications
• Jaundice, Obstructive/chemically induced
• Jaundice, Obstructive/drug therapy
• Male
• Middle Aged
• Osteomyelitis/drug therapy
• Penicillanic Acid/adverse effects
• Penicillanic Acid/analogs & derivatives
• Piperacillin/adverse effects
• Piperacillin, Tazobactam Drug Combination
• Plasmapheresis
• Renal Dialysis
• Renal Insufficiency, Chronic/complications
• Ursodeoxycholic Acid/therapeutic use

• bile casts
• cholemic nephrosis
• hepato-renal syndrome
• jaundice-related nephropathy

• infectious mononucleosis
• minimal change disease
• nephrotic syndrome