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Kidney Week

Abstract: PO0215

Kratom, an Herbal-Induced Cholestatic Liver Failure, Leads to Cholemic Nephropathy Requiring Liver Transplant and Hemodialysis

Session Information

Category: Acute Kidney Injury

  • 101 AKI: Epidemiology, Risk Factors, and Prevention


  • Le, Thuy, Tulane University School of Medicine, New Orleans, Louisiana, United States
  • Baudy, Adrian J., Tulane University School of Medicine, New Orleans, Louisiana, United States

Kratom, an herbal supplement, has opioid-like and stimulant effects. Its recreational misuse has increased in the United States (US). Its alkaloid compounds consist primarily of mitragynine and 7-hydroxymitragynine and are metabolized in the liver. Reports have shown many side effects, notably confusion, seizures, coma, and hyperbilirubinemia. Hepatic injury presents as cholestatic liver injury, which has a consequence on renal function. Patients with hyperbilirubinemia, bile casts damage the nephron directly and is known as bile cast nephropathy, a rare or underdiagnosed pathology. We present a case of Kratom usage that play a role in causing cholestatic liver failure, leading to cholemic nephropathy and liver transplant and hemodialysis.

Case Description

A 26-year-old woman with history of Kratom usage presented with complaint of 5-days of abdominal distention and pain, jaundice, and heavy mucosal bleeding. Laboratory testing revealed Na+ 123 mmol/L, BUN 84 mg/dL, Cr. 6.9 mg/dL, AST 104, ALT 31, total bilirubin 32 mg/dL and ALP 124 units/L, WBC 27.8, platelets 109, and H/H 7.2/20.7, INR 2.23. There was no serology evidence of viral infection. Tylenol and alcohol level were unremarkable. Urinalysis positive for bile acid cast. Abdominal ultrasound and Computed Tomography findings are consistent with liver cirrhosis. She underwent liver transplantation and required hemodialysis due to acute renal failure from profound hyperbilirubinemia.


Bile cast nephropathy represents a wide spectrum of disease, ranging from mild reversible to irreversible needing dialysis. It occurs when total bilirubin levels >20mg/dL, exceeding the binding capacity of albumin to bilirubin. It causes tubular obstruction and injury, oxidative damages, and ATPase activity. Most of the damage occurs in distal tubules but can occur in the proximal tubules.

While kratom has stimulant and opioid-like effects, its use can be hazard to health. There are currently no treatment guidelines for bile cast nephropathy. In irreversible nephropathy in cirrhotic patient, patient may be evaluated for both liver and kidney transplant. Renal replacement therapy has no role in treating bile cast nephropathy directly. Clinicians should keep cholemic nephropathy as a differential diagnosis in patient with hyperbilirubinemia and be aware of the increasing consumption of kratom in the US.