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Kidney Week

Abstract: PO0103

The Successful Treatment of Bile Cast Nephropathy with Plasma Exchange

Session Information

Category: Trainee Case Report

  • 102 AKI: Clinical, Outcomes, and Trials

Authors

  • Reddy, Swetha, Mayo Clinic Arizona, Scottsdale, Arizona, United States
  • Kinard, Theresa, Mayo Clinic Arizona, Scottsdale, Arizona, United States
  • Ryan, Margaret, Mayo Clinic Arizona, Scottsdale, Arizona, United States
  • Thomas, Leslie F., Mayo Clinic Arizona, Scottsdale, Arizona, United States
Introduction

Bile cast nephropathy is a condition of renal dysfunction in the setting of hyperbilirubinemia. There are very few cases of this condition reported in literature, and there is a lack of established treatment guidelines. We report the successful management of three patients with bile cast nephropathy using therapeutic plasma exchange (TPE).

Case Description

CASE 1: A 59 year old man with stage 3 colon carcinoma on Capecitabine developed chemotherapy-induced liver toxicity resulting in severe cholestasis and biopsy-proven bile cast nephropathy. He underwent TPE.
CASE 2: A 69 year old man with history of colon cancer status post remote hemicolectomy was admitted with pruritus and acute kidney injury (AKI). CT abdomen without contrast showed a 6 cm liver mass with bile duct dilatation, a biopsy proven metastasis from his previous colon cancer. A kidney biopsy confirmed bile cast nephropathy. The patient was started on hemodialysis (HD), and a biliary stent was placed. He was treated with TPE. He opted for hospice due to cancer
CASE 3: A 38 year old man was admitted with severe acute alcoholic hepatitis and AKI. A kidney biopsy confirmed bile cast nephropathy. He underwent TPE and a total of four sessions of HD.
The clinical course in our patients with biopsy proven bile cast nephropathy prior to and after TPE therapy is noted in Table 1.

Discussion

Our patients had acute liver and kidney failure with no underlying chronic liver disease. 1-1.2 plasma volume exchange was performed with each procedure with a combination of plasma and 5% albumin. A good response to TPE in decreased total bilirubin level and improvement in renal function was noted. There were no serious apheresis adverse events, and all procedures were tolerated well by the patients. Medical management of bile cast nephropathy such as steroids and cholestyramine have shown limited or no benefit. Renal replacement therapy has also been shown to be of limited benefit and should be mainly instituted for the treatment of AKI. In bile cast nephropathy,TPE may help in the clearance of bile acid crystals and reduction of proinflammatory molecules which contribute to acute liver and kidney injury. In this small case series, institution of TPE appeared to improve the clinical course of patients with bile cast nephropathy.

Case NumberAKI Stage on admissionNumber of TPE sessionsCreatinine (mg/dl)
At Baseline
Creatinine (mg/dl)
Admission
Creatinine (mg/dl)
At last TPE
Creatinine (mg/dl)
3 weeks post TPE
Direct Bilirubin (mg/dl)
Admission
Direct Bilirubin (mg/dl)
After last TPE
Complications from TPE
Case 1

Case 2

Case 3
3

3

3
12

7

7
0.9

1.1

0.8
3.5

7.1

3.76
1.3

2.8

1.8
0.8

Hospice

1.3
16.3

31.8

46.4
7.7

3.6

7.1
None

Mild Hypocalcemia

None