Gallstones and acute cholecystitis in CKD and dialysis: an underrecognized biliary burden in nephrology

Gallstones and acute cholecystitis are not usually regarded as core nephrology problems, yet accumulating observational evidence suggests that their burden is increased in chronic kidney disease (CKD), particularly in advanced predialysis CKD and end-stage kidney disease (ESKD). Plausible contributors include impaired gallbladder motility related to uremia-associated autonomic dysfunction, shared metabolic risk clustering, and, in selected patients, hemodynamic vulnerability related to intradialytic hypotension or low-output states. The central clinical issue may be underrecognition. In CKD and dialysis, abdominal complaints are often nonspecific and may overlap with uremic or intercurrent illness-related symptoms. In addition, uncomplicated acute cholecystitis may present early with absent or only mild hepatobiliary enzyme abnormalities, whereas marked bilirubin elevation or a cholestatic pattern should prompt evaluation for choledocholithiasis or cholangitis. Ceftriaxone-associated pseudolithiasis and glucagon-like peptide-1 receptor agonist exposure may further complicate the diagnostic picture. Although evidence linking CKD itself to primary acute cholangitis is less robust than that linking CKD to gallstones and acute cholecystitis, biliary obstruction and endoscopic intervention remain relevant because advanced CKD and ESKD may increase procedure-related morbidity. Emerging data also caution against reflexive therapeutic nihilism: source control should not be deferred solely because a patient has advanced CKD or dialysis dependence, and gallbladder drainage may serve as a planned bridge or alternative in selected high-risk patients. This focused review summarizes the epidemiologic links, plausible mechanisms, diagnostic pitfalls, and practical management implications of gallstones and acute cholecystitis in CKD and dialysis, and highlights why biliary disease should be recognized as an underappreciated comorbidity in nephrology care.