Hepatobiliary Problems After Kidney Transplantation
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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