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Abstract: SA-PO220

Bile-Cast Nephropathy in a Patient with Perihilar Cholangiocarcinoma

Session Information

Category: Onconephrology

  • 1700 Onconephrology

Authors

  • Nguyen, Joseph D., University of Virginia, Charlottesville, Virginia, United States
  • Nehrbas, Jill, University of Virginia, Charlottesville, Virginia, United States
  • Shah, Monarch, University of Virginia, Charlottesville, Virginia, United States
  • Murphy, Joel D., Arkana Laboratories, Little Rock, Arkansas, United States
  • Erdbruegger, Uta, University of Virginia, Charlottesville, Virginia, United States
  • Chopra, Tushar, University of Virginia, Charlottesville, Virginia, United States
Introduction

Bile cast nephropathy (BCN) is a rare cause of acute renal dysfunction in the setting of liver disease. Kidney injury in BCN is thought to be caused by multiple factors, including bile acid nephrotoxicity, tubule obstruction, and renal hypoperfusion. BCN is diagnosed by kidney biopsy in the appropriate clinical setting. Due to the rarity of the condition, there are few established treatment guidelines. We report a case of BCN diagnosed by kidney biopsy in a 70-year-old male.

Case Description

A 70-year-old male with intrahepatic cholangiocarcinoma with outflow hepatic vein obstruction treated with a single course of dose-reduced cisplatin/gemcitabine and durvalumab was admitted with biliary obstruction and anuria. Physical exam was notable for ascites and labs were notable for acute kidney injury (AKI) with creatinine 5 mg/dl (baseline 0.9 mg/dl), anion gap metabolic acidosis, total bilirubin 27.8 mg/dl, direct bilirubin 17.7 mg/dl, and alkaline phosphatase 1,440 mg/dl. Intermittent hemodialysis was initiated for volume overload. The patient underwent an endoscopic retrograde cholangiopancreatography with biliary sphincterotomy and bilateral biliary stents with transient improvement in serum bilirubin to 22 mg/dl before rising again. Kidney biopsy revealed severe acute tubular injury with bile casts (Fig 1). Due to the unresectable cholangiocarcinoma involving vasculature, cholestatic liver injury worsened. The patient’s family elected comfort care due to his guarded prognosis.

Discussion

This case contains three major teaching points: 1) Cholemic nephrosis represents a spectrum of renal injury from proximal tubulopathy to intrarenal bile cast formation in patients with severe liver disease. Bile casts are thought to contribute to kidney injury by both obstruction and bilirubin toxicity. 2) Prevalence of BCN is likely underestimated as a definitive pathological diagnosis by kidney biopsy is often missing due to the increased bleeding risk in coagulopathic liver disease patients. 3) Renal replacement therapy may be necessary to manage severe AKI secondary to BCN. In refractory cases, extracorporeal liver support devices utilizing albumin dialysis may help to reverse AKI.