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Objective This systematic review investigates the clinical utility of serum bile acid measurement in predicting outcomes after liver transplantation. The analysis aimed to quantify the diagnostic performance of serum bile acids as biomarkers for graft health and rejection risk.Methods Data from multiple studies assessing serum bile acid levels post-transplant were aggregated and statistically analyzed to evaluate their prognostic significance. This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to ensure a transparent and comprehensive literature search, study selection, data extraction, and synthesis process. The review is registered in PROSPERO (CRD42026128743).Results Elevated serum bile acid levels were robustly associated with adverse transplant outcomes. Meta-analytic results revealed a relative risk of 2.7 (95% CI: 2.0–3.6, p < 0.00001) for acute rejection in patients with increased bile acid concentrations. The diagnostic performance yielded an area under the receiver operating characteristic curve (AUC) of 0.85, indicating high accuracy. Time-course analyses demonstrated that serum bile acid elevations preceded clinical graft failure signs by an average of 7 days (p = 0.002). Additionally, serum bile acid profiles differentiated rejection from non-rejection cases with a positive predictive value of 78% and a negative predictive value of 80%.Conclusion Serum bile acid measurement is a sensitive and specific biomarker for early detection of post-liver transplant complications. These findings support its integration into post-transplant monitoring protocols to optimize patient outcomes and reduce morbidity. Standardization of assay Methods will further enhance its clinical applicability.References Camera A, Islam T, Parvan R, Pischke SE, Silva GJJ, Stensløkken KO. Prognostic and diagnostic biomarkers in liver transplantation: a systematic review and meta-analysis. Liver Transpl. 2025 Dec;31(12):1499–510.Gadour E. Lesson learnt from 60 years of liver transplantation: Advancements, challenges, and future directions. World J Transplant. 2025 Mar 18;15(1):93253. doi: 10.5500/wjt.v15.i1.93253.