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Abstract: FR-PO754

A Unique Case of Prolonged Bile Cast Nephropathy (BCN) Status After Orthoptic Liver Transplant

Session Information

Category: Transplantation

  • 2102 Transplantation: Clinical


  • Savu, Sarah Deborah, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
  • Batool, Aisha, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
  • Gallan, Alexander James, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
  • Taleb Abdellah, Ahmed, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
  • Joachim, Emily, Medical College of Wisconsin, Milwaukee, Wisconsin, United States

BCN or Cholemic Nephropathy refers to AKI in the setting of Decompensated liver injury with elevated bilirubin levels. Even though it was first described in 1899 by Quicke while studying cadaveric kidneys, it is still not well investigated, contributing to its limited appearance in current medical literature. It is a multidimensional entity resulting in tubular and interstitial inflammation, tubular obstruction, direct bile salt-induced tubular toxicity, and altered renal hemodynamics.

Case Description

Our patient is a 56-year-old female with history of ESLD due to EtOH s/p Orthoptic liver transplant 3 years ago and ESRD due to ESLD s/p DDKT 1.5years ago. Post transplant course significant for biopsy proven TCMR with suspicion for AMR, treated with IV steroids, PLEX x4 rounds and IVIG. She was also started on everolimus during this admission and was on quadruple therapy. The patient had MRI Abdomen done for abdominal pain with incidental finding of Exophytic enhancing mass off the lower pole of Native right kidney measuring up to 1.5 cm. Ct guided biopsy was performed, which missed the mass however sampled the native kidney. Pathology of native kidney revealed Many bile casts. At this point of time the patient was more than 2.5 Years post liver transplant and had normal LFTs with a normal bilirubin level.


In patients with decompensated liver cirrhosis, renal biopsy is usually not performed due to abnormal coagulation profile, hence BCN is underdiagnosed. There is paucity of literature to demonstrate relationship between Total Bilirubin levels and degree or the timing of renal dysfunction. Biliary salt is known to have low solubility in water, and it is not well known the duration that biliary casts persist or the clinical significance of such casts. Our patient is unique with persistence of Biliary casts more than 2.5 years post Liver transplant, thereby pointing to the unknown mechanism as well as much lesser-known chronology of BCN.

Native kidney Biopsy Light Microscopy showing Many Bile casts.