Abstract
Bile cast nephropathy (BCN) or cholemic nephrosis (CN) is a form of acute renal dysfunction that occurs in the setting of hepatic dysfunction and hyperbilirubinemia. We present a case of a 58-year-old woman with a four-day history of intractable nausea, vomiting, and yellowish discoloration of her skin and eyes. Laboratory workup was notable for elevated total bilirubin (mainly direct), liver enzymes, creatinine, and blood urea nitrogen (BUN). The ultrasonography (US) of the abdomen showed hepatic steatosis. The hepatitis panel was remarkable for hepatitis A IgM. She was initially treated with supportive therapy. However, her bilirubin levels reached over 20 mg/dl, creatine was >8 mg/dl, and her estimated glomerular filtration rate (eGFR) was <10. Kidney biopsy showed pigmented casts consistent with BCN. She was started on hemodialysis with significant improvement in her symptoms and liver enzymes. This case underscores the importance of a broad differential diagnosis in cases with hyperbilirubinemia and acute kidney injury. BCN requires renal biopsy for a definitive diagnosis, and these patients usually require hemodialysis.