Recurrent Sickle Cell Hepatopathy After Liver Transplantation Despite Guideline-Directed Red Blood Cell Exchange

Sickle cell hepatopathy is an uncommon but severe cause of liver dysfunction after transplantation. We present a case of a 37-year-old man who developed recurrent sickle cell hepatopathy 12 months postliver transplant despite maintaining hemoglobin S (HbS) levels below 30% per American Society of Hematology recommendations. Liver biopsy demonstrated sinusoidal sickling without rejection. Liver tests improved after intensifying red cell exchange to achieve HbS below 20%. This case illustrates that standard posttransplant HbS targets may be insufficient in high-risk patients and highlights the need for individualized HbS goals.