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Diagnosis: Bilirubin-Associated Acute Tubular Necrosis

The patient had chronic liver disease due to infection by hepatitis C virus. Fontana-Masson staining is positive in bile pigment (in addition to its more known positivity in melanin pigment).

High levels of bilirubin can cause renal failure. In the past, this was known as bile or cholemic nephrosis. The term cholemic or bile nephrosis signifies renal injury secondary to the constituents of bile. The histologic picture is characterized by tubules filled with degenerated epithelial cells and bile pigment casts. Some tubules may be dilated and obstructed by these elements. Features of acute tubular injury may also be seen. The risk of acute tubular injury increases when bilirubin levels are greater than 20 mg/dL especially in the presence of hypoalbuminemia and acidosis (Sequeira A, Gu X. Bile cast nephropathy: an often forgotten diagnosis. Hemodial Int. 2015;19:132-5. [PubMed link]).

According to van Slambrouck CM and cols.: Cholemic nephrosis represents a spectrum of renal injury from proximal tubulopathy to intrarenal bile cast formation found in patients with severe liver dysfunction. However, the contribution of this diagnosis has been largely forgotten in the modern literature. Bile casts may contribute to the kidney injury of severely jaundiced patients by direct bile and bilirubin toxicity, and tubular obstruction. Both mechanisms are analogous to the injury by myeloma or myoglobin casts. Bile cast nephropathy is an important pathologic entity that may account for the renal function impairment of many patients with severe liver dysfunction. It can occur in a wide spectrum of liver disorders and in both pediatric and adult population as well as in patients with or without cirrhosis (van Slambrouck CM, et al. Bile cast nephropathy is a common pathologic finding for kidney injury associated with severe liver dysfunction. Kidney Int. 2013;84(1):192-7. [PubMed link]).

Visit the chapter: Tubulointerstitial Diseases of our Tutorial.

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References

• Sequeira A, Gu X. Bile cast nephropathy: an often forgotten diagnosis. Hemodial Int. 2015;19(1):132-5. [PubMed link]
• van Slambrouck CM, Salem F, Meehan SM, Chang A. Bile cast nephropathy is a common pathologic finding for kidney injury associated with severe liver dysfunction. Kidney Int. 2013;84(1):192-7. [PubMed link]
• Rafat C, Burbach M, Brochériou I, Zafrani L, Callard P, Rondeau E, Hertig A. Bilirubin-associated acute tubular necrosis in a kidney transplant recipient. Am J Kidney Dis. 2013;61(5):782-5. [PubMed link]

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