From the Guidelines
Transaminitis in sickle cell crisis typically does not require specific treatment beyond managing the underlying sickle cell crisis. When encountering transaminitis in a patient with sickle cell crisis, focus on treating the crisis with aggressive hydration, adequate pain control, and oxygen supplementation if hypoxemia is present. The transaminitis usually resolves as the crisis improves, as the liver enzyme elevation occurs due to hepatic sickling causing ischemia and subsequent hepatocyte damage, as well as from hemolysis releasing intracellular enzymes. According to the American Society of Hematology 2020 guidelines for sickle cell disease, transfusion support is a mainstay of therapy for patients with sickle cell disease, but does not specifically address the management of transaminitis in sickle cell crisis 1.
Key considerations in managing transaminitis in sickle cell crisis include:
- Aggressive hydration with 2-3L of IV fluids daily
- Adequate pain control, often with opioids like morphine or hydromorphone
- Oxygen supplementation if hypoxemia is present
- Monitoring of liver enzymes and bilirubin levels
- Additional hepatic workup and hepatology consultation if transaminitis persists beyond crisis resolution or if there are signs of severe liver dysfunction.
It is essential to note that transaminase levels can reach 1000-3000 IU/L but typically normalize within 2 weeks after crisis resolution. If signs of severe liver dysfunction are present, such as significant coagulopathy, encephalopathy, or bilirubin >30 mg/dL, additional evaluation is necessary to rule out other causes such as viral hepatitis, medication toxicity, or sickle cell hepatopathy syndromes like acute hepatic sequestration or intrahepatic cholestasis.
From the Research
Transaminitis in Sickle Cell Crisis
- Transaminitis, or elevated liver enzymes, is a common finding in patients with sickle cell disease, occurring in more than 50% of patients 2.
- The underlying causes of transaminitis in sickle cell disease can include sickle cell hepatic crisis, viral hepatitis, sickle cell intrahepatic cholestasis, and hepatic sequestration in the acute setting, as well as cholelithiasis and iron overload in the chronic setting 2.
- Sickle cell intrahepatic cholestasis (SCIC) is a rare and potentially fatal complication of sickle cell disease, characterized by progressive hepatic injury due to sickling within sinusoids 3.
- Acute hepatic crisis is a severe complication of sickle cell disease, with symptoms ranging from increasing jaundice to multiple organ failure and death, and is often treated with exchange transfusion 4.
- Chronic liver damage is a common manifestation in patients with sickle cell disease, with intrasinusoidal sickling and Kupffer cell erythrophagocytosis being nearly universal findings at liver biopsy 5.
Diagnosis and Treatment
- The diagnosis of transaminitis in sickle cell disease can be challenging, as the symptoms and laboratory findings can be similar to those of other liver diseases, such as viral hepatitis and autoimmune hepatitis 6, 2.
- Exchange transfusion is a successful management approach for patients with sickle cell intrahepatic cholestasis and acute liver failure 3, 4.
- Corticosteroids and other immunosuppressive agents may be used to treat autoimmune hepatitis in patients with sickle cell disease, but their use can be complicated by the risk of vaso-occlusive crises 2.