Introduction Tuberculosis (TB) is a major public health issue in the world. Its prevalence in Kidney transplant (KT) patients is estimated higher than in the general population. It poses a great diagnostic and therapeutic challenge in KT recipients due to its atypical presentation leading to diagnostic delay and the risk of toxicity and drug interactions. Our study aimed to evaluate the epidemiology, risk factors, clinical manifestations, management and impact of TB in KT recipients. Methods A retrospective and descriptive study was conducted in our department between November 2007 and November 2018. Were included, all KT patients who presented a post-transplant TB disease with bacteriologically confirmed or clinically diagnosed cases. Results Among the 274 KT recipients evaluated, four patients developed post-transplant TB i.e., a prevalence of 1.45%. The mean age was 34.5 years with male predominance. Half of cases were diagnosed during the first-year post-transplantation with bacterial documentation in two cases. Pulmonary TB was predominant (3 cases) with frequent extra-pulmonary localizations. The diagnosis was delayed in most cases by one month. Circumstances were prolonged fever (3 cases), deterioration of general condition (2 cases), cough (2 cases), night sweats (2 cases), isolated diarrhea (1 case), bi or pancytopenia (2 cases) and acute kidney injury (2 cases). All patients had a quadruple drug regimen with a total therapy duration between 6 and 20 months. Underdosage of calcineurin inhibitor or sirolimus and hyperuricemia were the most noticed drug side effects. No graft or patient survival was compromised. However, chronic graft dysfunction was observed in 2 cases. All patients were screened for latent TB infection before transplantation. One case was identified using QuantiFERON test. Risk factors associated with post-transplant TB were mainly the male gender, the use of depleting antibodies, the use of calcineurin inhibitors with overdose and the presence of concomitant infections (Cytomegalovirus, Epstein-barr virus and pneumonia). Conclusion Our study underlined the difficulties of TB diagnosis and management in KT patient. Risk factor resumed mainly in intense immunosuppressive state. Drug-drug interactions and chronic graft dysfunction were the most observed impact.