Chronic arsenic exposure: implications for liver and kidney disease

Chronic liver disease (CLD) is prevalent worldwide, but clinicians often struggle to identify the precise aetiology. Renal involvement in CLD is also puzzling, with varied pathologies and risk factors. Glomerular involvement in the form of IgA nephropathy is one of the many pathologies that could result in renal dysfunction. The co-occurrence of hepatic and renal dysfunction without discernible sequence presents a diagnostic challenge for physicians in elucidating the underlying pathology and causative factors.A man in his 20s presented to us with a complicated urinary tract infection. His background illnesses included a CLD with portal hypertension for 4 years, along with a simultaneously diagnosed IgA nephropathy, for which he was receiving low-dose steroids. We noticed a characteristic raindrop pigmentation of his skin, primarily on the trunk. On investigation, a persistently elevated level of arsenic in urine was detected, which was attributed to the water source. Chronic arsenic exposure as the aetiology behind CLD and IgA nephropathy was considered, after excluding other potential causes. The patient responded well to dimercaprol. It is imperative to thoroughly investigate for potential underlying causes before labelling any CLD or chronic kidney disease as cryptogenic or idiopathic.