Jaundice-associated acute kidney injury

After spontaneous vaginal delivery, a 32-week-gestation female baby presented immediately with respiratory distress, APGAR scores 0 (1 min) and 2 (5 min), generalized skin oedema and bilateral pleural effusion. The prenatal history was unremarkable. The clinical diagnosis was nonimmune hydrops fetalis, and treatment with mechanical ventilation, surfactant, prostaglandin and supportive measures was initiated. Complications included Escherichia coli sepsis and severe liver dysfunction during the fourth week of life with jaundice (total bilirubin 34.2 mg/dL (0.1– 1.0), conjugated bilirubin 24.1 mg/dL (0–0.3), SGOT 231 U/L (8–37), SGPT 86 U/L (8–35), serum albumin 2.9 g/dL (3.5–5.0)). Subsequent acute kidney injury (blood urea nitrogen 184 mg/dL and serum creatinine 1.3 mg/dL) and multiple anuric episodes ensued. The baby died 2 weeks later. At autopsy, the finding of primary pulmonary lymphangiectasia was thought to be the cause of hydrops fetalis. The kidneys were green after formalin fixation (Figure 1). Numerous pigmented casts were exclusively present within distal tubules or collecting ducts (Figure 2) and not within proximal tubules. Most casts were brown red and many had additional greenish-yellow discoloration. A Hall’s stain highlights bile pigment in green by converting