Rituximab for Delayed Hemolytic Transfusion Reactions in Adults with Sickle Cell Disease: A Case Series of 10 Patients in Kinshasa, Democratic Republic of Congo

Abstract Objectives To describe the clinical, biological, and immunohematological characteristics of delayed hemolytic transfusion reactions (DHTR) in adults with sickle cell disease (SCD) and their outcomes following multimodal management including rituximab as rescue therapy in a resource-limited setting. Methods We retrospectively reviewed ten adults with homozygous SS SCD who developed DHTR after red blood cell transfusion at Monkole Hospital Centre, Kinshasa, between January 2023 and December 2025. Diagnosis was based on clinical, transfusional, and biological findings, after excluding alternative causes of acute hemolysis. Results Patients were predominantly female, with a median age of 26 years. DHTR occurred a median of 7 days post-transfusion. All patients developed severe acute anemia (median hemoglobin nadir, 4.0 g/dL) with elevated hemolysis markers. Direct antiglobulin tests (DAT) and red blood cell alloantibody screenings (IAT) were negative in most cases; anti-Kell antibody was detected in one patient. All patients received short-course corticosteroids and erythropoietin, followed by rituximab (fixed dose, 500 mg) as part of multimodal rescue management. Clinical and biological improvement was observed from day 3 after rituximab initiation. Seven patients required intensive care, and one died from acute chest syndrome. Conclusion DHTR is a severe, often under-recognized complication in adults with SCD in sub-Saharan Africa. This case series highlights diagnostic challenges and describes favorable clinical and biological evolution following multimodal rescue therapy including rituximab, underscoring the need for prospective studies.