Bilirubin induced kidney injury is a commonly unrecognized cause of renal dysfunction in the setting of severe liver disease. Bile cast nephropathy is a type of cholemic nephrosis found in patients with severe liver disease. Here, we present a case of drug induced liver injury due to anabolic steroid use, resulting in bile cast nephropathy and acute kidney injury. The patient is a 40-year-old male who presented with two weeks of worsening jaundice and fatigue. He had no significant past medical history, and no family history of liver disease. His medications on presentation were fluticasone and ipratropium-albuterol inhalers for a recent cough; notably, he had completed a 1 month course of nandrolone, methandrostenolone, and testosterone injections six weeks prior. Labs on initial presentation were significant for ALT 636, AST 299, AlkPhos 162, total bilirubin of 11.8, and creatinine of 1.1 mg/dL. Viral hepatitis panel and markers for autoimmune disease were negative. CT Abdomen revealed a homogenous liver of normal size without bile duct dilation. Repeat labs 2 weeks later revealed a normalization of his ALT and AST levels, but an upward trend in his Alk-Phos, total bilirubin, and creatinine. The INR also continued to rise to a peak of 2.5 despite Vitamin K administration. Both abdominal ultrasound and MRCP were unremarkable. The patient ultimately underwent liver biopsy, which showed severe cholestatic hepatopathy. During this period of six weeks, the patient's creatinine rose from a baseline of 1.1 to 2.3 mg/dL. Urine electrolytes were consistent with a pre-renal etiology, though kidney function did not improve with intravenous fluid administration. Renal ultrasound showed mildly enlarged, echogenic kidneys. The patient ultimately underwent renal biopsy, which revealed acute tubular injury with bile casts, and the diagnosis of bile cast nephropathy was made. Over the next month his bilirubin trended down and his creatinine normalized in parallel with the bilirubin trend. Although bile cast nephropathy is a well described phenomenon, it often goes unrecognized by even the most astute clinicians. Given that bile cast nephropathy occurs in those with severe liver disease, the added development of acute renal failure can dramatically affect prognosis. Recognizing this condition can lead to early treatment and better long term outcomes.Figure 1