Tuesday, August 6, 2013

Clinical Case 73: Answers and Summary

Which of the following statements are true regarding bile cast nephropathy?

It is also called cholemic nephrosis
  10 (41%)
It is no different than hepatorenal syndrome
  2 (8%)
The casts that form in the kidney are correlated with higher total and direct bili levels
  12 (50%)
Mechanism of the casts is similar to myeloma casts or myoglobin casts
  5 (20%)
It is also called jaundice associated nephrosis
  4 (16%)
No such entity exists
  4 (16%)

Bile cast nephropathy has been described in older literature as cholemic nephrosis or jaudice associated nephrosis. In the most latest publication in KI 2013, this entity takes a new leap and re introduction to the nephrology world. This entity represents a spectrum of disease from proximal tubulopathy to intrarenal bile cast formation found in patients with severe liver dysfunction. The researchers looked at 44 cases and found that 24 patients had bile casts with involvement of distal nephron segments in 18 mild cases and extension to proximal tubules for 6 severe cases. Eleven of 13 patients with hepatorenal syndrome(HRS) and all 10 with alcoholic cirrhosis had tubular bile casts. These casts significantly correlated with higher serum total and direct bilirubin levels, and a trend toward higher serum creatinine, AST, and ALT levels. Bile casts may contribute to the kidney injury of severely jaundiced patients by direct bile and bilirubin toxicity, and tubular obstruction. The mechanisms are analogous to the injury by myeloma or myoglobin casts. It is different from HRS as in HRS, the injury is more pre renal and kidney biopsy is usually normal. 

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