Severe cholestatic hyperbilirubinaemia secondary to thyrotoxicosis complicated with bile cast nephropathy treated with plasma exchange and haemodialysis

Cholemic Nephropathy: Role in Acute Kidney Injury in Cholestasis and Cirrhosis

The concept of structural kidney damage and renal dysfunction as a result of jaundice attracted attention in the medical community in the early and mid-20th century. The postulated doctrine of the time was that the excretion of elevated concentrations of bile results in bile-stained casts occupying collecting and distal convoluted tubules, degeneration of tubular epithelium, and decreased renal function. Compared to the hepatorenal syndrome, the poster child of hepatology and nephrology collaboration, the notion of structural kidney damage and renal dysfunction as a result of cholemia lost its traction and has almost disappeared from modern textbooks. Today, cholemic nephropathy is experiencing a renaissance, with multiple case reports and case series of jaundiced patients with kidney dysfunction and evidence of bile acid casts upon histologic examination. Published cases include acute hepatitis, chronic liver injury, cirrhosis, and obstructive etiologies. Diagnosis of cholemic nephropathy is based on histological examination, typically showing intraluminal bile casts predominantly located in the distal tubules. In common bile duct-ligated mice, the histomorphological and functional alterations of cholemic nephropathy mimic those seen in humans. Some argue against the concept of cholemic nephropathy and postulate that bile casts are a secondary phenomenon. What we need are carefully designed trials to establish diagnostic criteria and subsequently translate this knowledge into evidence-based therapies.

Bile acid nephropathy induced by anabolic steroids: A case report and review of the literature

Bile acid nephropathy also known as cholemic nephropathy is a rare and overlooked form of acute kidney injury that occurs in the setting of severe hyperbilirubinemia. The exact etiology remains unknown, and there is a lack of treatment guidelines for this clinical condition. Anabolic steroids are known to cause hepatoxicity occasionally leading to acute kidney injury. We report the case of a 27-year-old male patient who developed bile acid nephropathy as a result of severe hyperbilirubinemia secondary to anabolic steroids-induced liver injury. He was conservatively managed. We review the current literature touching on the etiology, pathophysiology, diagnosis, and management of bile acid nephropathy in an attempt to shed light on this clinical condition, which may present as a diagnostic and therapeutic challenge.

Biological evaluation of a novel bilirubin adsorbent and its therapeutic effect on animal models of hyperbilirubinemia

Hyperbilirubinemia caused severe hepatobiliary diseases with various causes, especially hepatic fibrosis and cirrhosis caused by end-stage hepatitis B and C. Plasma adsorption perfusion (PP) has a tremendous advantage in treating patients with hyperbilirubinemia and liver failure, wherein, a safe and effective adsorbent is the key to filter out bilirubin successfully in PP. In this work, a simple engineering strategy, a new porous polymer adsorption resin ERM-0100 based on the homopolymer predispersion system, is proposed to produce high-performance bilirubin adsorbents. Preliminary experimental results show that ERM-0100 exhibits a large surface area and uniformly porous structure. Experimental results verify that ERM-0100 has high biocompatibility and bilirubin adsorption efficiency (TBIL:35%, direct bilirubin [DBIL]:30%, IBIL:87%) that is significantly higher than most of the reported adsorbents. Animal experiments prove that ERM-0100 has high bilirubin adsorption efficiency and can improve the liver function of animals. The combination of high biocompatibility and high adsorption capacity positions the ERM-0100 as a promising candidate for bilirubin removal.

Graves' disease associated with cholestatic jaundice and persistent diarrhoea

Liver involvement in Graves' disease can be seen as a part of autoimmune process or rarely, due to the direct effects of thyrotoxicosis on liver. Hyperthyroidism can also have gastrointestinal manifestations like frequent bowel movements, diarrhoea, even malabsorption with steatorrhoea. We report a 36-year-old man with hyperthyroidism, presenting with cholestatic jaundice and persistent small bowel diarrhoea. He was diagnosed to have Graves' disease and after ruling out more common causes, the cause of cholestatic jaundice was supposed to be Graves' disease. Considering this possibility, the patient was started on treatment with carbimazole. As patient's thyroid function tests started improving, he showed significant clinical and biochemical improvement from liver point of view as well.

Renal tubular injury in hyperbilirubinemia: Bile cast nephropathy

The toxic renal accumulation of bile pigment sparked clinical intrigue almost a century ago. More recently, however, the identification of bile casts within renal tubules in patients with liver dysfunction has been largely overlooked. We have reviewed the literature, including natural history, pathophysiology, and potential treatment of bile cast nephropathy (BCN). We report two cases of acute kidney injury (AKI) associated with acute-on-chronic liver failure in which prolonged hyperbilirubinemia and bile cast identification on renal biopsy evoked the diagnosis of BCN.

Abnormal Liver Blood Tests in Patients with Hyperthyroidism: Systematic Review and Meta-Analysis

Background: Abnormal liver blood tests (LBTs) in hyperthyroid patients are not uncommonly encountered. One major adverse event of antithyroid drug (ATD) therapy is drug-induced hepatotoxicity. Abnormal LBT in the hyperthyroidism scenario is a main diagnostic and therapeutic dilemma. We aimed to assess the prevalence and the response to ATD therapy of LBT abnormalities in newly diagnosed and uncomplicated hyperthyroidism through a systematic review and meta-analysis. Methods: A literature search was performed reporting LBTs at presentation and after ATD therapy in hyperthyroid patients. A proportion meta-analysis was performed with random-effects model. Pooled data were presented with 95% confidence intervals (CI). I² statistic index was used to quantify the heterogeneity. Sensitivity analyses for prevalence of hyperthyroid patients with at least one abnormal LBT were performed. p-Value of <0.05 was regarded as significant. Results: The literature search yielded 2286 studies, of which 25 were included for systematic review and meta-analysis. The prevalence of untreated hyperthyroid and Graves' disease patients with at least one abnormal LBT was 55% ([CI 46-63%], I² 96%) and 60% ([CI 53-67%], I² 92%), respectively. The prevalence of alanine transaminase (ALT), aspartate transaminase (AST), alkaline phosphatase (ALP), total bilirubin (BIL), and γ-glutamyltransferase (GGT) abnormalities in hyperthyroid patients were 33% ([CI 24-44%], I² 95%), 23% ([CI 17-29%], I² 89%), 44% ([CI 35-52%], I² 93%), 12% ([CI 7-20%], I² 92%), and 24% ([CI 16-36%], I² 95%), respectively. ATD therapy, along with euthyroidism restoration, was accompanied by normalization of LBT abnormalities in the following percentage of cases: ALT 83% ([CI 72-90%], I² 46%), AST 87% ([CI 74-94%], I² 2%), ALP 53% ([CI 32-73%], I² 76%), BIL 50% (CI cannot be calculated), and GGT 70% ([CI 47-87%], I² 74%). The sensitivity analyses showed similar results as those of the main analyses. The publication bias was not statistically significant for all outcomes, except for the prevalence of resolved BIL abnormalities that was not calculable. Conclusions: LBT abnormalities are common in newly diagnosed and untreated hyperthyroidism setting. A high chance of safely normalizing elevated transaminases, up to fivefold above the upper limit of normal, accompanies the use of ATDs in the treatment of hyperthyroidism.