Warm Autoimmune Hemolytic Anemia Presenting 21 Years After Liver Transplantation: A Case Report.

Document Type

Article

Publication Date

6-16-2026

Abstract

BACKGROUND Autoimmune hemolytic anemia (AIHA) is characterized by immune-mediated premature red blood cell destruction. Although AIHA has been reported after solid organ transplantation, it remains uncommon, and very late-onset presentations occurring decades after transplantation are rare. Both warm and cold AIHA have been reported after transplant. Reported etiologies include immune dysregulation, infections, post-transplant lymphoproliferative disorders, and medication-associated immune hemolysis, including calcineurin inhibitor-related effects. CASE REPORT A 30-year-old woman with orthotopic liver transplantation at age 9 for biliary atresia, on long-term tacrolimus, presented 21 years after transplant with exertional dyspnea and symptomatic anemia. Laboratory evaluation revealed severe anemia with biochemical evidence of hemolysis, including undetectable haptoglobin and reticulocytosis. A direct antiglobulin test was positive for IgG, confirming warm autoimmune hemolytic anemia. Antibody identification revealed a warm autoantibody, and crossmatch-compatible red blood cells were transfused without reaction. Extensive evaluation excluded gastrointestinal bleeding, infection including Epstein-Barr virus, post-transplant lymphoproliferative disorder, and thrombotic microangiopathy. She was treated with high-dose corticosteroids with partial response, followed by early rituximab due to persistent hemoglobin instability. The tacrolimus dose was modestly reduced but not discontinued. Bone marrow biopsy excluded hematolymphoid malignancy. The patient achieved complete remission with normalization of hemoglobin and hemolysis markers after 4 rituximab doses and steroid tapering. CONCLUSIONS Warm autoimmune hemolytic anemia can present decades after solid organ transplantation and should be considered in transplant recipients with unexplained anemia. Remission can be achieved with corticosteroids and early rituximab without discontinuation of tacrolimus. Further studies are needed to clarify optimal treatment strategies for late-onset post-transplant AIHA, including the role of early rituximab.

Publication Title

Am J Case Rep

Volume

27

First Page

953089

Last Page

953089

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