Cholangitis Lenta Causing Bile Cast Nephropathy: A Unique Model of Hepatorenal Failure in Sepsis

Inadequate perfusion and abnormal cellular metabolism are among the mechanisms of organ dysfunction in sepsis. Concomitant hepatorenal failure during the late phase of sepsis is poorly understood.

The autopsy of a child who developed sepsis-induced hepatorenal failure revealed bile cast nephropathy, hepatic centrilobular necrosis and cholangitis lenta, a type of sepsis-induced cholestasis, with no biliary obstruction, fibrosis or cirrhosis. The liver and renal function declined at the same rate as procalcitonin increased.

Failure of resolution and persistent inflammation in sepsis can result in ductular injury and stagnation of bile with subsequent cholemia. The kidney failure was associated with the formation of intratubular bile casts.

This case illustrates how severe cholestasis in combination with bile cast nephropathy may be potential and unrecognized contributors to hepatorenal failure in sepsis. Whether bile toxicity causes renal failure in the context of cholangitis lenta should be further studied.