Objectives: Treatment and follow-up strategies for silent gallbladder stones in patients before kidney transplant (KT) have not been established. Methods: We conducted a retrospective cohort analysis of 2,295 KT recipients at a tertiary hospital from January 2005 to July 2022. Silent gallstones were identified from abdominal images 3 years before and 1 year after KT. The incidence of biliary complications (acute cholecystitis, cholangitis, and gallstone pancreatitis), postoperative complications and severity between the pre-KT cholecystectomy group and the observation group were compared in patients with gallstones. Cox proportional hazards models were used to assess risk factors for biliary complications. Results: A total of 230 patients with gallstone stones were enrolled in this study. Among them, 16 performed cholecystectomy before KT, and two of them underwent cholecystectomy at the same time as KT.In 214 patients who were observed without any intervention,biliary complications occurred in 20 patients (9.3%) during a median follow-up period of 72.1 months.The patients who had multiple stones (adjusted hazard ratio [aHR] 2.96, 95% CI 1.56-8.30, p=0.039) and gallbladder wall thickening ([aHR] 5.04, 95% CI 1.57-16.11, p=0.006) were more likely to have biliary complications.The incidence rates of postoperative complications were 6.25% in the pre-KT cholecystectomy group and 38.8% in the post-KT cholecystectomy group, respectively (p=0.043).The severity of postoperative complication were based on Clavien-Dindo classification and post-KT cholecystectomy group showed higher frequency of fetal complications greater than grade 4 compared to pre-KT cholecystectomy group. Conclusions: Gallstone-related biliary complications after KT and subsequent cholecystectomy can results in more serious complications and worse treatment outcomes. Especially, preventive cholecystectomy before KT may be considered in the presence of multiple gallstones or gallbladder wall thickening.