Hepatobiliary Problems After Kidney Transplantation
Synopsis
Hepatobiliary complications are frequently encountered in kidney transplant recipients and represent an underappreciated cause of morbidity in this population. The post-transplant milieu — characterized by chronic immunosuppression, polypharmacy, and metabolic derangement — creates a unique substrate for hepatic injury that differs substantially from that seen in the general population. This chapter provides a comprehensive review of the principal categories of hepatobiliary disease following kidney transplantation, including drug-induced liver injury (DILI) attributable to immunosuppressants, antifungals, antibiotics, and statins; viral hepatitis reactivation and de novo infection with hepatitis B (HBV) and hepatitis C (HCV) viruses; biliary tract disease including cholelithiasis, cholangitis, and choledocholithiasis; and metabolic-associated fatty liver disease (MAFLD/NAFLD) driven by post-transplant metabolic syndrome. Diagnostic evaluation is structured around liver function test (LFT) pattern analysis — hepatocellular, cholestatic, or mixed — supplemented by viral serology, abdominal imaging, and liver biopsy where indicated. A stepwise algorithmic approach and multidisciplinary management framework are presented. Figures illustrating the diagnostic algorithm and pathophysiological mechanisms are provided to facilitate clinical application. With up to 50% of kidney transplant recipients experiencing clinically relevant LFT abnormalities at some point post-transplant, systematic surveillance and early intervention are paramount to preserving both hepatic and allograft function.
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