Biliary casts in the kidney tubule

Matthias P. Hörl1, Christoph Loddenkemper2, Agnieszka Korfel3 and Martin Tepel1

1 Nephrologie, 2 Pathologie, and 3 Hämatologie und Onkologie, Charité Campus Benjamin Franklin, Berlin, Germany

Correspondence and offprint requests to: Dr Martin Tepel, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Med. Klinik IV Nephrologie, Hindenburgdamm 30, D-12200 Berlin, Germany. E-mail: Martin.Tepel{at}charite.de

Keywords: biliary casts; kidney tubule

A 40-year-old woman presented with lassitude, malaise, abdominal dyscomfort and fever of several weeks’ duration. Three days earlier, she noticed jaundice of the skin. Her medical history included Sjogren syndrome treated with prednisolone and azathioprine. She had no history of renal insufficiency. At admission, she was overweight, had icteric sclera and skin, blood pressure of 160/80 mmHg and a regular pulse of 92. Her liver and spleen were enlarged. No lymph nodes were palpable. There was an increase in serum creatinine (417 µmol/l), urea nitrogen (44 mmol/l), bilirubin (520 µmol/l) and total alkaline phosphatases (1158 U/l), and a reduction in white blood cell count (3.0 G/L), haemoglobin (9.3 g/dl) and platelets (148 G/L). Computed tomography of the abdomen and thorax showed hepatomegaly, splenomegaly and abdominal, retroperitoneal and mediastinal lymphadenopathy. A biopsy of the liver and bone marrow showed classical Hodgkin lymphoma infiltrates in both tissues. A kidney biopsy showed biliary casts in the tubules (Figure 1). Acute renal failure was due to tubular necrosis. There was no evidence of renal lymphoma. The patient received chemotherapy and recovered liver and kidney function.



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Fig. 1. Greenish biliary casts in the kidney tubules (H&E staining, x400)

 
In obstructive liver diseases, urinary excretion of bile salts is markedly enhanced [1,2]. Biliary casts in the tubule have been described in hepatic cirrhosis [3] and in subacute hepatic failure [4], but are rarely seen in acute renal failure.

Acknowledgments

Conflict of interest statement. None declared.

References

  1. Lee J, Azzaroli F, Wang L et al. Adaptive regulation of bile salt transporters in kidney and liver in obstructive cholestasis in the rat. Gastroenterology 2001; 121: 1473–1484[ISI][Medline]
  2. Tanaka Y, Kobayashi Y, Gabazza EC et al. Increased renal expression of bilirubin glucuronide transporters in a rat model of obstructive jaundice. Am J Physiol 2002; 282: G656–G662[ISI]
  3. Shet T, Kandalkar B, Balasubramaniam M, Phatak A. The renal pathology in children dying with hepatic cirrhosis. Ind J Pathol Microbiol 2002; 45: 39–43[Medline]
  4. Bal C, Longkumer T, Patel C, Gupta SD, Acharya SK. Renal function and structure in subacute hepatic failure. J Gastroenterol Hepatol 2000; 15: 1318–1324[CrossRef][ISI][Medline]




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