The pathology of jaundice-related renal insufficiency: cholemic nephrosis revisited

The spectrum of jaundice-related nephropathy can range from limited proximal tubulopathy to renal failure. The latter condition was known as cholemic nephrosis in the early literature on this subject. Elevated plasma concentrations of bile salts and bilirubin conjugated or not, putatively mediate the nephrotoxicity. A functional derangement of renal tubule cells is considered to underlie the nephropathy, but published data on renal histology are scarce. In this report, we describe the renal biopsies of two jaundiced patients with reduced creatinine clearance, and we critically review the literature on the pathogenesis of jaundice-related nephropathy. Normal renal architecture, indicating functional renal impairment, and extensive renal tubule necrosis were both observed in jaundice-related renal failure. The findings fit the original description of cholemic nephrosis. Both bilirubin and bile salts are potential nephrotoxins in animal models, but their precise role in the pathogenesis of jaundice-related nephropathy is not known. Patients with bilirubin plasma concentrations >20 mg/dL, a low serum albumin concentration or endo-toxemia, could be more prone to develop renal failure due to jaundice-related tubulopathy. In conclusion, jaundice-related nephropathy is essentially a tubulopathy, but the exact nature of the Pathogenesis is still uncertain.