REVIEW article
Front. Med.
Sec. Hematology
Volume 12 - 2025 | doi: 10.3389/fmed.2025.1651895
This article is part of the Research TopicEndothelium, Innate Immunity and Coagulation in Hematological DisordersView all 19 articles
The use of Eculizumab and Tocilizumab in the treatment of Hyperhemolysis syndrome, a comprehensive literature review
Provisionally accepted
ALI AQEL1
Yousef Al-Asa'd1*
Salam Alkindi2
Jaafar Altouk3,4
Abdullah Al Zayed5
Abdulrahman Al-abdulmalek6
Mohamed A Yassin1,7- 1Hamad Medical Corporation, Doha, Qatar
- 2Sultan Qaboos University College of Education, Muscat, Oman
- 3Salmaniya Medical Complex, Manama, Bahrain
- 4Bahrain Salmania Hospital, Manama, Bahrain
- 5Qatif Central Hospital, Al Qatif, Saudi Arabia
- 6McGill University Department of Hematology, Montréal, Canada
- 7National Center for Cancer Care & Research, Doha, Qatar
Select one of your emails
You have multiple emails registered with Frontiers:
Notify me on publication
Please enter your email address:
If you already have an account, please login
You don't have a Frontiers account ? You can register here
Hyperhemolysis Syndrome (HHS) is a rare but severe complication of red blood cell transfusion, characterized by the destruction of both the patient's and donor's red blood cells. This condition results in post-transfusion hemoglobin levels lower than pre-transfusion levels, often leading to profound anemia, tissue ischemia, and multiorgan failure. HHS predominantly affects individuals with hemoglobinopathies, particularly sickle cell disease. While the pathophysiology remains poorly understood, proposed mechanisms include bystander hemolysis via complement activation, suppression of erythropoiesis, macrophage-mediated RBC destruction. Refractory cases of HHS are managed with Eculizumab and Tocilizumab, targeting the complement pathway and macrophage activation, respectively. This review analyzed 22 reported cases of HHS identified through PubMed, Embase, and Google Scholar. Of these, 11 patients received Eculizumab, 10 received Tocilizumab, and 1 received both. The cohort had an mean age of 29.5 years, with 36.4% male and 63.6% female. Most patients had underlying hemoglobinopathies. Outcomes showed improvement in 18 patients without major side effects, while 1 patient showed no improvement, and 3 patients passed away. Despite promising results, concurrent use of other immune-modulating agents during treatment complicates attributing the observed efficacy to specific medications alone. Further studies are required to further evaluate the pathophysiology of HHS and assess the safety and effectiveness of these novel therapies.
Keywords: Eculizumab, HHS, Hyperhemolysis syndrome, monoclonal antibodies, tocilizumab, Transfusion reaction
Received: 22 Jun 2025; Accepted: 03 Sep 2025.
Copyright: © 2025 AQEL, Al-Asa'd, Alkindi, Altouk, Al Zayed, Al-abdulmalek and Yassin. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
* Correspondence: Yousef Al-Asa'd, Hamad Medical Corporation, Doha, Qatar
Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.