*Purpose: Biliary complications (BC) are a major threat to successful liver transplantation (LT), as they are associated with a subsequent higher risk of mortality and graft loss. However, changes in recipient/donor demographics, allocation policy, and clinical protocols over the last decade might have altered the incidence and impact of post-LT BCs.

*Methods: To characterize temporal changes in the incidence and impact of post-LT BCs, we linked Medicare claims data for LT recipients to SRTR to study 13,406 Medicare-primary LT recipients from 2002-2016. BCs were ascertained by ICD-9/10 codes, and the use of endoscopic or surgical procedures for management was ascertained by CPT/HCPCS codes. Recipients were divided into three groups: (1) a biliary diagnosis alone, (2) biliary diagnosis + an endoscopic or surgical procedure, (3) biliary diagnosis + a surgical procedure. We used multi-level adjusted Cox regression to quantify temporal trends in the risk of post-LT BCs and their impact on mortality and graft loss.

*Results: The incidence of BCs increased over time, with a cumulative incidence of 27.0% in 2002-2005, 29.3% in 2006-2009, 30.4% in 2010-2013, and 41.2% in 2014-2016 (p<0.001) (Figure 1A). After accounting for donor, recipient, and transplant factors, the risk of BCs was 12% higher in 2006-2009 (adjusted hazard ratio [aHR] vs. 2002-2005: _1.021.12_1.23, p=0.02), 23% higher in 2010-2013 (aHR: _1.111.23_1.36, p<0.001), and 73% higher in 2014-2016 (aHR: _1.551.73_1.94, p<0.001). Although BCs were most common in LDLT recipients (50.5% vs. 29.5% in DBD recipients, p<0.001), the higher risk of BCs over time was similar across DBD, DCD, and LDLT recipients (p=0.4). BCs managed procedurally were also more common over time (aHR for 2014-2016 vs. 2002-2005: _1.131.31_1.53, p<0.001), whereas BCs managed surgically were less common (aHR: _0.390.58_0.87, p=0.007) (Figure 1B-C). In contrast to the higher risk of BCs over time, the impact of a BC on mortality and graft loss remained constant (p=0.5). Across eras, the development of a BC was associated with a 52% higher risk of mortality (aHR: _1.381.52_1.67, p<0.001) and 58% higher risk of graft failure (aHR: _1.441.58_1.74, p<0.001).

*Conclusions: The incidence of post-LT BCs has increased over time for all types of LT, and remain particularly common after DCD and LDLT. Despite a shift towards increased procedural management, the mortality and graft loss risk attributable to a BC has not decreased over time, and BCs remain a substantial driver of worse post-LT outcomes.

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