The Bilirubin Blues: Plasma Exchange for Bilirubin Nephropathy

Introduction: Bilirubin or cholemic nephropathy is a rare but serious complication of severe hyperbilirubinemia. It is characterized by acute kidney injury (AKI) caused by bilirubin-induced tubular toxicity. While supportive care is the standard treatment, therapeutic plasma exchange (TPE) has emerged as a potential intervention to reduce bilirubin levels and improve renal outcomes. Case Description: A 28-year-old male with a history of alcohol abuse and a recent admission for acute alcoholic hepatitis presented with worsening abdominal pain. He was being evaluated for transfer to a liver transplant center. On admission, laboratory testing revealed a creatinine of 15 mg/dL and total bilirubin of 20 mg/dL. He had previously failed to respond to Terlipressin for presumed hepatorenal syndrome. Due to worsening renal function, hemodialysis was initiated. Given the strong clinical suspicion for bilirubin nephropathy as the cause of AKI, TPE was initiated. The patient underwent 3 sessions of TPE, which led to marked improvement in both renal and hepatic function. Discussion: TPE is an extracorporeal therapy that removes large molecular weight substances, such as bilirubin, from the bloodstream. While it remains experimental in the setting of bilirubin nephropathy, it may be beneficial in cases of severe hyperbilirubinemia associated AKI that are resistant to conventional therapies. This case highlights the importance of considering bilirubin nephropathy in patients with liver dysfunction and unexplained AKI. Though not yet standard of care, TPE may offer a promising therapeutic option for improving renal outcomes by rapidly reducing toxic bilirubin levels. Comprehensive Metabolic Panel - Laboratory Admission Discharge BUN 156 mg/dL 23 mg/dL Creatinine 15 mg/dL 1.16 mg/dL Sodium 130 mEq/L 145 mEq/L Potassium 4.2 mEq/L 4.3 mEq/L Chloride 93 mEq/L 108 mEq/L CO2 15 mEq/L 24 mEq/L Anion Gap 28 mEq/L 13 mEq/L Albumin 3.86 g/dL 3.90 g/dL Total Bilirubin 20 mg/dL 4.6 mg/dL Alkaline Phosphatase 199 U/L 235 U/L Aspartate aminotransferase 114 U/L 102 U/L Alanine aminotransferase 771 U/L 253 U/L