Bile cast nephropathy

A 55-year-old man with a history of colorectal cancer, status-post wedge resection of liver 3 weeks prior, was admitted with jaundice, ascites, and acute kidney injury. On presentation, he was icteric with a soft distended abdomen and mild ascites. Laboratory data revealed a creatinine level of 2.72mg/dl (baseline 1mg/dl). Total and direct bilirubin levels on admission were 42.5mg/dl (up from 1.6mg/dl) and 25mg/dl, respectively. Numerous dark casts were seen in the urine (Figure 1, red arrow), worrisome for bile casts, and an incidental leucine crystal (black arrow). Kidney biopsy confirmed the presence of intratubular bile casts as in Figure 2 (black arrow).