Lipoprotein X-Induced Hyperlipidemia Following Liver Transplantation in the Setting of Persistent Cholestasis and Antibody-Mediated Rejection

Lipoprotein X (Lp-X) is an abnormal lipoprotein that accumulates in the setting of cholestasis, leading to marked hypercholesterolemia, lipid deposition, and hyperviscosity-related complications. While well described in primary biliary cholangitis and primary sclerosing cholangitis, Lp-X has rarely been reported following liver transplantation. We describe a liver transplant recipient who developed severe Lp-X hyperlipidemia secondary to persistent cholestasis from an early post-transplant anastomotic stricture compounded by antibody-mediated rejection. Despite plasmapheresis and immunosuppressive therapy, his cholestasis and hyperlipidemia persisted, and his course was complicated by seizures and acute kidney injury. He was evaluated for retransplantation but ultimately died of septic shock. This case highlights the importance of recognizing Lp-X as a marker of significant biliary dysfunction post-transplant and the need for targeted interventions to prevent progressive end-organ injury.