Blood Groups

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Terminology for Blood Group System Genes
and Gene Products
• ABO Genotypes and Phenotypes • ABO Genotypes and Phenotypes
• Genotype • Phenotype
• A1A1 • A1
• A1A2 • A1
• A1O • A1
• A2A2 • A2
• A2O • A2
• A1B • A1B
• A2B • A2B
• OO • O
• BB • B
• BO • B

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Formation of A, B, and H Red Cell Antigens
• A, B, and H antigens are formed from the same basic precursor
material (called a paragloboside or glycan) to which sugars are
attached in responseto specific enzyme transferases elicited by an
inherited gene.
• H antigen is actually the precursor structure on which A and B
antigens are made.
• Inheritance of the H gene results in the formation of the H antigen.
• The H and Se genes are closely linked and located on chromosome 19
• ABO genes, which are located on chromosome 9.
• The H and Se genes are not part of the ABO system; however, their
inheritance does influence A and B antigen expression

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ISBT Blood Group System Assignments
BLOOD SYSTEM NAME ISBT GENE NAME ISBT NUMBER
ABO ABO 001
MNS MNS 002
P1PK P1 003
Rh RH 004
Lutheran LU 005
Kell KEL 006
Lewis LE 007
Duffy FY 008
Kidd JK 009
Diego DI 010
Cartwright (Yt) YT 011
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ISBT Blood
BLOOD SYSTEM NAME
Group System
ISBT GENE NAME
Assignments
ISBT NUMBER
Xg XG 012
Scianna SC 013
Dombrock DO 014
Colton CO 015
Landsteiner-Weiner LW 016
Chido/Rodgers CH/RG 017
Hh H 018
Kx XK 019
Gerbich GE 020
Cromer CROM 021
Knops KN 022
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ISBT Blood Group System Assignments
BLOOD SYSTEM NAME ISBT GENE NAME ISBT NUMBER

Indian IN 023

Ok OK 024

Raph RAPH 025

JMH JMH 026

I IGNT 027

Globoside GLOB 028

Gil GIL 029

Rh-associated glycoprotein RHAG 030

International Society of Blood Transfusion

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Summary of Forward and Reverse Groupings

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Landsteiner’s Law
• 1.The RBC Antigen determines the ABO Blood Groups of an individuals
• Ex.Blood Type A= antigen A
• 2. The corresponding antibody in the serum is never found in an individual.
• 3.The Opposite antibody in the serum is always found in an individual
• Ex.Blood Type A= Anti B in serum

• Landsteiner’s Rule :Rule stating that normal ,healthy individuals possess

ABO antibodies to the ABO blood group antigens absent from their red
cells

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Inheritance
• ABO genes –found in the Long arm of chromosome 9
• H genes-found in the chromosome 19 (secretor of
Locus) Lu-Lutheran,Le-Lewis genes
• O genes- Silent genes, called amorph, it is a gene that
is unable to formed in detectable antigens

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ABO Subgroups
• ABO phenotypes can be divided into categories termed subgroups.
• Subgroups differ in the amount of antigen expressed on the red cell
membrane, representing a quantitative difference in antigen
expression.
• Most H antigens Fewest H Antigens

HH HHH
H H H
HHHHHH
H H H
HHHHH

Group O red cells posses the most H antigens, Group A,B Red cells Possess the fewest H antigens
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ABO Subgroups
Red cells classified as subgroups of A posses fewer A antigens
than the A1 phenotype

A1 Most A
Antigens

A el
Fewest A Antigens

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Group A phenotype
• Two Subgroups
• A1- exists in 80% of group a individuals. Antigens are highly
concentrated on branched and linear oligosaccharide chains
• A2-20% of Group A individuals,A antigen copies are fewer than the
A1.
• Reactivity of anti-H anti-sera or anti H lectin with ABO Blood Groups

•O > A2 > B > A2B > A1 > A1B

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• Lectin- Seed extracts that can agglutinate red cells with some degree
of specificity

LECTIN SOURCE ANTIBODY

Ulex europaeus Anti-H

Dolichos biflorus Anti-A1

Bandeirea simplificifolia II Anti-B

Iberis amara Anti-M

Vicia graminea, Bauhinia variegate; Bauhinia purpura Anti-N

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Additional subgroups
• Subgroups of A
• Subgroups of B
• A int
•A3
•B
•Ax •B 3
•Am •B x
• A end •B m
• A el
• B el
• A bantu
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Weak B Subgroups
• B3-characterized by a mixed field • Bx-demonstrate weak
pattern of agglutination with
anti-B and Anti A,B.Presence of
agglutination with anti-B
B glycosyltransferase in serum and Anti A,B antisera.No
but not in RBC membrane.Anti-B B glycosyltransferase
is absent in serum but B enzyme in RNC and
substance is present in
secretions.This is the most secretions.Readily and
common weak B subgroup easily adsorbs and elutes
anti-B
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Weak B Subgroups
• Bm-unagglutinated by • Bel- unagglutinated by
anti-B and anti- anti B or Anti A,B.No
A,B.Easily and rapidly glycosyltransferase on
elutes and adsorbs RBC and serum. Weak
anti-B.B anti-B might be present
glycosyltransferase is on serum.Only H
usually present in substance is seen on
serum secretions
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ABO Phenotypes and Possible Genotypes
Phenotype Possible Genotypes
Group A1 A1A1
A1A2
A1O
Group A2 A2A2
A2O
Group B BB
BO
Group A1B A1B
Group A2B A2B
Group O OO
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A,B,H Soluble Substances
• Present in all body fluids except: CSF
• Depends on the inheritance of the secretor gene( Se gene)
• Product of Se gene is same with the product of H gene(fucosyl
transferase/FUT)
• FUT2 transfers and adds L-Fucose to a Type 1 precursor
substance/paragloboside/oligosaccharide
• Chain(B1-----3 Linkage) to produce H Soluble Antigen/H Soluble
Substance
• Secretor (80%)- A,B,H soluble substances in the body fluids
• Non secretor(20%)-Does not express A,B,H soluble antigens
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GENOTYPE Antigen/s on Soluble antigens in
RBC secretions
Hh AB Sese H Ag, A Ag, B Ag H soluble Ag, Asoluble Ag, B
soluble Antigens

HH OO SeSe H Ag H soluble Ag

hh AB Sese None H soluble Ag, A soluble Ag,

B soluble Ag
Hh OO sese H Ag none
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Comparison of ABH Antigens and ABH Soluble
Antigens/substances
ABH Antigens ABH Soluble
substances
Found in RBC Membrane Found in secretions
Synthesized on Type 2 PS Synthesized in
Type 1 PS
Glycolipids, Glycoproteins
Glycoproteins,
Glycosphingolipids
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Bombay Phenotype(O h)
• Inherited the hh genotype
• No H,A,B antigens or red cells
• Has anti A and Anti B and anti H on serum and Anti AB
• Reaction with Ulex europaeus: negative

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Oh Phenotype
• The term Oh or Bombay phenotype has been used for the very rare
individuals whose red cells and secretions lack H, A, and B antigens
and whose plasma contains potent anti-H, anti-A, and anti-B.
• This phenotype was first discovered in Bombay, India. The phenotype
initially mimics normal group O but becomes apparent when serum
from the Oh individual is tested against group O red cells, and strong
immediate-spin agglutination and/or hemolysis occurs
Para-Bombay Phenotype
• The para-Bombay phenotype designation, Ah, Bh, and ABh, is classically
used for individuals who are H-deficient secretors, ie, those who have an
inactive H-transferase but have active Se-transferase.
• The red cells lack serologically detectable H antigen but carry small
amounts of A and/or B antigen (sometimes detectable only by
adsorption/elution tests), depending on the individual’s alleles at the ABO
locus.
• Tests with anti-A or anti-B reagents may or may not give weak reactions,
but the cells are nonreactive with anti-H lectin or with anti-H serum from
Oh persons
• Individuals with the para-Bombay phenotype have a functional Se allele
and thus will express A, B, and H antigens in their plasma and secretions.
 3 categories
•1.H deficient,Non Secretor:
• Classic Bombay phenotype
•2.H partially Deficient;Non Secretor:
• weaker forms of A and B ag
•3.H deficient secretor:
• Parabombay phenotype

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ABO Discrepancies
• Occurs when results of Forward grouping does not match
with the result of the reverse grouping or vice versa
• It occurs when unexpected reactions occur in the forward
and reverse grouping

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 Overview
Problems with Red Cell Testing Problems with Serum /Plasma Testing
Extra Antigens Extra antibodies
Group A with acquired B antigen A subgroups with anti-A1
B (A) phenotype Cold alloantibodies
Polyagglutination Cold autoantibodies
Rouleaux Rouleaux
Hematopoietic progenitor cell transplants Intravenous Immunoglobulin

Missing or weak antigens Missing or weak antibodies

ABO subgroup Newborn
pathologic etiology Elderly
Transplantation Pathologic etiology
Immunosuppressive therapy for transplantation
Mixed-field reactions
Transfusion of group O to group A,B, or AB
Hematopoietic progenitor stem cell
transplants
A3 phenotype
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General Rules to Resolve Discrepancies
• 1.Always re test first
• 2.Check for clerical/technical error
• 3.Weakest reaction is usually the one in doubt
• 4.Check results of the screening cells
• 5. Check the patient’s age
• 6.Check diagnosis
• 7.Check the transfusion history

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Causes
• 1.Technical errors • Reagent or equipment problems
• Clerical Errors I. Using expired Reagents
I. Mislabeled tubes II. Using uncalibrated centrifuge
II. Patient misidentification III. Contaminated or hemolyzed
III. Inaccurate interpretations reagents
recorded IV. Incorrect storage
IV. Transcription Error temperatures
V. Compute entry Error

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Causes
• 1.Technical Errors
• Procedural Errors
I. Reagents not added
II. Manufacturer’s directions not followed
III. RBC suspensions incorrect concentration
IV. Cell buttons not resuspended before grading agglutination

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Causes
• Group 1 Discrepancies
• Can cause unexpected reactions in reverse typing due to antibodies
• Most common cause of ABO discrepancy
• Populations which can exhibit Group 1 discrepancy:
• 1.Newborns
• 2.Elderlies
• 3.Leukemic patients
• 4.Patients taking immunosuppressive drugs
• 5.Patients with BM Transplantation
• 6.Patient with congenital agammaglobulinemia
• 7.Patient’s whose ABO antibodies are diluted with plasma transfusion or
exchange
• 8.ABO subgroups
• 9.Chimerism-presence of two cell populations in a single individual like
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Group 1 Discrepancies
• RESOLUTION
• 1. Obtain the patient’s diagnosis, historical blood group, and history of
previous transfusions, transplantation, and medications.
• 2. Review the results of the antibodydetection test against group O red
cells and autologous red cells to detect possible interference from allo- or
autoantibodies.
• 3. Obtain a new blood specimen and test the new sample if a discrepancy
due to a contaminated specimen is suspected.
• 4. Incubating patient’s serum for 15-30 minutes at 4 C
• 5. Autocontrol (should be negative) and O control must always be tested
alongside with the patient’s sample

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Group 2 Discrepancies
• Can cause unexpected reactions in the Forward grouping due to Antigens
• Least frequently encountered
• Causes
1.Subgroups of A may be present
2.Weakened A or B antigen as a result of leukemia
3.Hodgkin’s Disease
4.Acquired B phenomenon
5.B (A ) phenotype
6.Chimerism
Resolution
Same with Group 1
Treat patient’s red cell with acetic anhydride
Incubating patient’s serum for 15-30mins at 4 C
Autocontrol and O control must always be tested alongside with the patient’s
sample(RBC and serum of the patient with plasma)
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Group 3 Discrepancies
• Cause problems in forward and reverse grouping and are due to
which can result to rouleaux formation and pseudoagglutination
• Causes:
• 1.Elevated levels of globulin due to multiple myeloma ,Waldenstrom’s
macroglobulinemia, plasma cell dyscrasias, some forms of Hodgkin’s Disease
• 2. High Fibrinogen levels
• 3.Plasma expanders like dextran and polyvinylpyrrolidone
• 4.Wharton’s jelly mucopolysaccharide
• Resolution
• Perform saline dilution or saline replacement technique
• Washing cord cells six-eight times with saline to remove Wharton’s Jelly
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Group 4 Discrepancies
• Due to Miscellaneous causes
• Causes
• 1.Presence of cold-reactive autoantibodies
• 2.Patient has circulating RBC with more than one blood type
• 3.Unexpected ABO isoagglutinins
• 4.Unexpected non ABO isoagglutinins
• 5.CIS- AB (refers to inheritance of both AB genes from one parent carried on
one chromosome and an O gene inherited from another parent
• Resolution
• For cold autoantibodies incubate RBCs of patient at 37 C ,treatment with
dithioreitol

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 RH Blood Group System

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HISTORICAL Overview of the Discovery of the
D antigen
• The Terms Rh-positive and Rh-negative refer to the presence or
absence of the D red cell antigen.
• More correct terms are D positive and D negative.
• 1940- the cause of Hemolytic Disease of the Fetus and Newborn
(HDFN) was linked to the Rh group system by LEVINE and STRETSON.
• Rh was given because of the similarity of this antibody to one made
from stimulating guinea pigs and rabbits with Rhesus monkey cells.
• RH antibody was described by Landsteiner and Wiener .The rhesus
antibody specificity was actually directed toward another red cell
antigen.

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Common Antigens in the RH blood group
system : Equivalent Notations
Numeric Fisher-Race Other Names ISBT NO.
Rh1 D Rh+ 004001
Rh2 C 004002
Rh3 E 004003
Rh4 c 004004
Rh5 e 004005
Rh6 ce cis-ce or f 004006
Rh7 Ce cis- Ce 004007
Rh8 Cw 004008
Rh9 Cx 004009
Rh10 ce s V 004010
Rh12 G 004012
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FISHER-RACE –CDE Terminology
• Fisher and Race postulated that the RH blood group system antigens
were inherited as a gene complex or haplotype that codes for three
closely linked sets of alleles.
• D gene is inherited at one locus
• C or c genes are inherited at the second locus
• And E or e genes are inherited
at the third locus
The order of genes on the chromosomes is DCE
however it is often written alphabetically as
CDE
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WIENER- RH-HR terminology
• Wiener postulated that alleles at one gene locus were responsible for expression
of the RH blood group system antigens on red cells.Each parent contributes one
RH gene. Inherited gene may be Homozygous or Heterozygous
• The gene encodes a structure on the red cell called AGGLUTINOGEN
• Gene Locus are Ro ,R1 ,R2 , r, r’ , r’’, ry
Wiener Theory :Genes and Antigens
Gene (Wiener) Antigens (Fisher-Race)
Ro cDE
R1 CDe
R2 cDE
Rz CDE
r ce
r’ Ce
r’’ cE
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r CElenizarae 40
• Numbers are used with R
• Symbols ‘and ‘’ are used with r
• Z and y are used to refer when both C and E are present
• Genes are italicized or underlined while agglutinogen ,antigen or a blood
factors are written in standard form.
• Immunogenecity of RH ANTIGENS
• D>c>E>C>e
• Genetics of RH System
• RHD and RHE genes: located on chromosome no 1
• RHAg /X1r gene: located on chromosome no 6.(30th blood group)
• Abnormal genes:
• Xor:Regulator gene
• Xqr:Rh mod phenotype
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Rh-Hr Terminology of Wiener

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Weiner Haplotype Terminology

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RH antigens
• Characterized as nonglycosylated proteins on red cell membrane
• D antigen-is the most clinically significant of all non-ABO antigens
• It is so highly immunogenic
• The only Rh antigen that undergoes routine testing,except in the case
of investigation of unexpected antibodies

• Variations of the Rho (D) Antigen

• Du phenotype-weakened expression of the D antigen

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Biochemistry of RH Antigens
• Non glycosylated proteins
• Integral part of RBC Membrane
• Functions:
• 1.Cations transport
• 2.Maintaining Stability of RBC

• Weak D/D’’ variant

• D antigen that is present in very low level in the RBC,or D antigen with
missing parts

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Causes/Mechanism:
• 1.Genetic Weak D: refers to the weak form of D gene products fewer
D antigen
• 2.C Trans: Genes interaction effect or position effects
• 3.Partial D or D mosaic: Missing fragments of the D Ag
• 4. Del phenotype: 10-30%, resulting due to mutation of the D genes
leading to the less production of D Ag

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RH ANTIBODIES
• Immune or Acquired Antibodies
• Predominantly IgG ( IgG1 and IgG 3 rbc stimulated)
• Reaction is enhanced by the use of enzyme treated
• RBCs
• Do not usually bind complement
• Crosses placenta and causes HDN

• Clinically significant
• Causes extravascular hemolysis of RBCs
• Produced 120 days after primary exposure (IgM)
• Produced 2-7 days after secondary exposure (IgG)

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Unusual Phenotypes and Rare alleles of the
RH System
• 1. Cw • 7.Rh 23,30,40
• 2.f • 8.Rh 33 (Har)
• 3.rhi---+Ce • 9.Rh 32
• 4.G---DC • 10. Rh 43 (Crawford)
• 5.Rh 13,14,15,16 • 11. e variants
• 6.Rh 17 (Hro) • 12.V and VS

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Rh NULL Phenotype/syndrome/disease
• 2 types
• 1.Silent type: due to inheritance of silent gene
• 2.Regulator type: due to inheritance of Xor , Xor
• Signs and Symptoms:
Decrease Hemoglobin and Hematocrit
Decrease Haptoglobin
Increase Bilirubin
Increase Hemoglobin F
Reticulocytosis
Stomatocytosis
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RH NULL syndrome
• It expresses no Rh antigen on red cell and the phenotype is expressed
as --/--.
• RH Null system
• 2 mechanism
• 1.Regulation
• -RHO and RHCE are present
• RHAG-absent /mutated/deleted
• 2.Amorphic type
• RHAG-present
• RHD/RHCE are absent /mutated/deleted

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False Reaction with RH Typing
• False Positive reactions may be caused by:decreased specificity
• 1. Positive DAT- most common cause of Rh typing ( Du Typing)
discrepancies
• 2. Rolueax
• 3.Cold Autoagglutinins
• False Negative Reactions may be cause by:
• 1.incorrect cell suspension (cell suspension too heavy or too light)
• POST ZONE Effect-antigen excess
• PROZONE Effect-antibody excess
• 2.Improper Procedure
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Wiener Fisher Race Rosenfield
Rho D Rh1
rh’ C Rh2

rh’’ E Rh3

hr’ c Rh4

hr’’ e Rh5

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RH Blood Group
• 1.With genetic basis
• A.Fisher-Race
• B.Wiener

• 2. Without Genetic Basis

• A.Rosenfield (alpha-numeric)
• B. ISBT –International Society of Blood Transfusion

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Rh-Hr Terminology of Wiener

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Common Rh Types by Three Nomenclatures

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False Reactions With Rh Typing Reagents

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False Reactions With Rh Typing Reagents

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• Rh was a primary cause of HDFN, erythroblastosis fetalis, and a
significant cause of hemolytic transfusion reactions.
• Fisher-Race DCE terminology is based on the theory that antigens of
the system are produced by three closely linked sets of alleles and
that each gene is responsible for producing a product (or antigen) on
the RBC surface.
• In the Wiener Rh-Hr nomenclature, it is postulated that the gene
responsible for defining Rh actually produces an agglutinogen that
contains a series of blood factors in which each factor is an antigen
recognized by an antibody

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• In the Rosenfield alpha/numeric terminology, a number is assigned to
each antigen of the Rh system in order of its discovery (Rh1 = D, Rh2 =
C, Rh3 = E, Rh4 = c, Rh5 = e).
• The most common phenotype in whites is R1r (31%); the most
common phenotype in blacks is R0r (23%), followed by R0R0 at 19%.
• A partial-D individual is characterized as lacking one or more pieces or
epitopes of the total D antigen and may produce alloantibody to the
missing fraction if exposed to RBCs with the complete D antigen
• Most Rh antibodies are IgG immunoglobulin and react optimally at
37°C or following antiglobulin testing; exposure to less than 0.1 mL of
Rh-positive RBCs can stimulate antibody production in an Rh-negative
person

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Erythroblastosis fetalis.
• (a) The condition occurs with an RH+ father and RH– mother. (b) First
pregnancy with an RH+ fetus stimulates the mother’s blood to form
antibodies against the fetal blood. (c) As the placenta separates
during birth, the mother is further exposed to the RH+ blood,
increasing her blood’s reaction against it. (d) The mother carries
antibodies against the RH+ blood. (e) In a subsequent pregnancy with
an RH+ fetus, the mother’s antibodies attack the RH+ blood of the
fetus, causing hemolysis of the fetal red blood cells resulting in the
disease that can kill the child.

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OTHER BLOOD GROUP
SYSTEM

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Hemolytic Disease of the Fetal/Newborn
• HDFN is prevented, monitored, and treated with the help of tests
performed in the laboratory. Understanding the physiology of HDFN is
important in choosing the correct tests to perform and detecting
early indicators of hemolytic disease. Important points to remember
when performing these tests are outlined.
• HDFN occurs when:
• Fetal red cells, carrying antigens inherited from the father, stimulate the
mother to produce IgG antibodies.
• Maternal IgG antibodies destroy fetal red cells

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Hemolytic Disease of the Fetal/Newborn
• Hemolytic processes can cause the following:

• In utero, this destruction can cause severe anemia, which can result in heart
failure and possibly death.
• After delivery, red cell destruction continues with the increase of bilirubin,
causing jaundice and possible damage to the CNS (kernicterus).

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Hemolytic Disease of the Fetal/Newborn
• HDFN can be caused by ABO, Rh, or other IgG antibodies:

• ABO HDFN is the most common type of HDFN and occurs most commonly in
group O mothers who deliver group A or B babies.
• HDFN caused by anti-D is the most severe type of HDFN; it occurs in D-
negative women with anti-D who deliver D-positive infants.
• Any IgG antibody can cause HDFN if the child inherits the antigen from the
father and the red cell antigen is well developed on the fetal red cells. Anti-c
and anti-K are most frequently reported after anti-D.

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Hemolytic Disease of the Fetal/Newborn
• Laboratory tests to predict, prevent, or monitor HDFN before delivery
include:

• ABO/D phenotype and antibody screen are performed on the mother.

• D-negative mothers should receive prenatal RhIG.

• Titration of the maternal antibody can be helpful in deciding when to perform
diagnostic and invasive procedures.
• Spectrophotometric analysis of the amniotic fluid and use of the Liley graph
can aid in predicting the severity of HDFN.

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Chromosomal Assignment of Genes for
common Blood Group System
• BLOOD GROUP SYSTEM CHROMOSOME
• Rh , Duffy 1
• MNS 4
• Chido/Rodgers 6
• Kell 7
• ABO 9
• Kidd 18
• Lewis,Landsteiner,Wiener,Lutheran,Hh 19
•P 22

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• At the present time, the International Society of Blood
Transfusion (ISBT) has defined 30 blood group systems.
• The antigens of the ABO and Rh blood group systems are of
primary importance in transfusion. The antibodies to ABO
and Rh blood group system antigens are capable of effecting
a decreased survival of transfused red cells and playing a role
in the pathogenesis of hemolytic disease of the fetus and
newborn (HDFN).
• Knowledge of the blood group systems provides the
foundation for solving complex antibody problems in a
logical and efficient manner.

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Functional Roles of the Blood Group Systems
Functions Blood Groups
Glycosyltransferases ABO, P1PK, Lewis, and H blood group systems
Structural Relationship to MNS, Diego, and Gerbich blood group systems
Red Cell
Transport Proteins Rh, Kidd, Diego, Colton, and Kx blood group systems
Complement Pathway Chido/Rodgers, Cromer, and Knops blood group
Molecules systems
Adhesion Molecules Lutheran, Xg, Landsteiner-Wiener, and Indian blood
group systems
Microbial Receptors MNS, Duffy, P, Lewis, and Cromer blood group
systems
Biologic Receptors Duffy, Knops, and Indian blood group systems
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LW BLOOD GROUP SYSTEM
• The LW blood group system is presented in this chapter because of its
phenotypic rela-tionship to the Rh blood group system.
• The antigens and antibodies are similar in sero-logic properties but
are not genetically related. As discussed earlier, the LW antibody,
made by guinea pigs and rabbits that were immunized with red cells
from rhesus monkeys in early experiments, is similar to the anti-D
antibody.
• Anti-LW reacts strongly with D-positive cells and weakly with D-
negative cells. Rhnull cells are negative for LW antigens as well. The
theory suggesting a precursor relationship between the Rh blood
group system and LW antigens has been discounted, although the
membrane biochemistry is still being studied.
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• The LW locus is mapped to chromosome 19. The LW system alleles
are LWa, LWb, and LW. LW(a+b−) is the most common phenotype in
the population because the LWa gene is of high frequency. The LW
gene is an amorph, and inheriting two LW genes produces the rare
LW(a−b−) phenotype. Antibodies to the LW system are clinically sig-
nificant and rare.
• LW Blood Group System
GENOTYPE PHENOTYPE CHARACTERISTICS
LWaLWa or LWaLW LW(a+b−) Most common (97%) LW phenotype
LWaLWb LW(a+b+) 3%

LWbLWb or LWbLW LW(a−b+) Rare

Rare; can make anti-LW, which reacts more
LWLW LW(a−b−) strongly with D+ cells
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KELL BLOOD GROUP SYSTEM
• ISBT SYSTEM = KEL
• ISBT Number=006
• Antibody Class= IgG
• Temperature= 37 C
• Reaction Phase=AHG
1946=detected this new blood grp. (Coombs) it was named under the
patient’s name Kelleher .
Anti-Kell, defined a red cell antigen that was designated the Kell
antigen; the Kell blood group system was established

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Summary of Antigens: Kell Blood Group System
• Antithetical Antigens: High Frequency and Low Frequency
• K (KEL1) and k (KEL2)
• Kpa (KEL3), Kpb (KEL4), and Kpc (KEL21)
• Jsa (KEL6) and Jsb (KEL7)
• Cote (KEL11) and Wka (K17)
• KEL14 and KEL24
• Antithetical Antigens: Low Frequency
• VLAN (KEL25) and VONG (KEL28)

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 Summary of Antigens: Kell Blood Group System
High-Frequency Antigens Low-Frequency Antigens
Ku (KEL5) Ula (KEL10)
KEL19
KEL12 KEL23
KEL20
KEL13 KYO
KEL22
KEL16
KEL26 (TOU)
KEL18
KEL27 (RAZ)
KALT
KTIM
KUCI
KASH
KANT
KELP

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• Kell blood group antigens are found only on RBCs. They have not been
found on platelets or on lymphocytes, granulocytes, or monocytes.
The associated Xk protein is found in erythroid tissues and in other
tissues, such as brain, lymphoid organs, heart, and skeletal muscle
• The K antigen can be detected on fetal RBCs as early as 10 weeks and
is well developed at birth. The k antigen has been detected at 7
weeks
• K is very immunogenic.
• The antigens are not denatured by the routine blood bank enzymes
ficin and papain but are destroyed by trypsin and chymotrypsin when
used in combination.
• Thiol-reducing agents destroy Kell antigens but not Kx.
• Glycine-acid EDTA (an IgG-removal agent) also destroys Kell antigens

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K0 or Kellnull Phenotype
• A red cell phenotype lacking expression of the Kell glycoprotein, and
consequently the Kell antigens, was identified by Chown in 1957.
• The inheritance of two recessive K0 genes in a homozygote (K0K0)
results in the null phenotype
• Anti-Ku is produced because the Ku antigen is present on all red cells
except K0 cells.

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Common Phenotypes in the Kell Blood Group
System
PHENOTYPE
K−k+
K+k−
K+k+
Kp(a+b−)
Kp(a−b+)
Kp(a+b+)
Js(a+b−)
Js(a−b+)
Js(a+b+)
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• Anti-K is the most commonly observed antibody of the Kell blood
group system
• Most examples of anti-K are IgG and react well in IATs
• The K antigen’s high degree of immunogenicity is responsible for the
occurrence of the antibody in a patient population
• Antibodies to k, Kpb, and Jsb are not commonly detected because
individuals who lack these high-incidence antigens are scarce.
• Anti-k and anti-Kpb production is associated with the white
population, whereas anti-Jsb is associated with the black population
• Antibody production to the Kpa and Jsa antigens is also infrequent in a
patient population because both antigens possess low frequencies

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Kx BLOOD GROUP SYSTEM
• ISBT system symbol: XK
• ISBT system number: 019
Kx ANTIGEN AND ITS RELATIONSHIP TO KELL BLOOD GROUP SYSTEM
Kell glycoprotein is located on chromosome 7.
X chromosome and designated as XK1, encodes a protein that carries the Kx
antigen.
Kx has been assigned to the Kx blood group system.
It possesses a phenotypic relationship to the Kell blood group system. Red
cells with normal Kell phe-notypes carry trace amounts of Kx antigen. Red
cells from K0 individuals possess elevated levels of Kx antigen.

lendg 85
• In 1961, Allen and coworkers described a young male
medical student who initially appeared to be Kell null
but who demonstrated weak expression of k, Kpb, and
Jsb detectable by adsorption-elution methods.
• This unusual phenotype was called McLeod, after the
student.

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McLEOD PHENOTYPE
• When the XK1 gene is not inherited, Kx antigen is not expressed on the red
cells.
• . The absence of Kx antigen from red cells and a concurrent reduced
expression of the Kell blood group system antigens are characteristically
associated with a red cell abnormality known as the McLeod phenotype.
• Individuals with the McLeod phenotype have red cell morphologic and
functional abnormalities characterized by decreased red cell survival.
• The McLeod phenotype is very rare and is seen almost exclusively in males
as a result of the X chromosome–borne gene
• Increased Acanthocytosis and Reticulocytosis
• The X-linked disorder of chronic granulomatous disease is occasionally
associated with McLeod syndrome. In this disorder, the normal functional
properties of phagocytic white blood cells are impaired
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Summary of Kell Blood Group System
Phenotypes
Kx Antibodies
PHENOTYPE KELL
Normal Weak Kell alloantibodies
Common
K0 ------- Increased Anti-Ku

McLeod Decreased None

Anti-KL (anti-Kx
and anti-Km)
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DUFFY BLOOD GROUP SYSTEM
• ISBT System Symbol= FY
• ISBT System Number= 008
• Antibody Class=IgG
• Temperature= 37 C
• Reaction Phase= AHG

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Duffy Antigens Facts
• The Duffy blood group system was first described in 1950 when a
previously unrecog-nized antibody was discovered in the serum of a
hemophiliac who received multiple transfusions.
• Mr. Duffy.The antigen that defined this antibody was called Fya(FY1)
• Its antithetical antigen, Fyb(FY2), was described the following year.
• Sanger reported in 1955 that most blacks lacked both Fya and Fyb antigens
and had the phenotype Fy(a−b−). The Fy(a−b−) phenotype is rare among
white.
• The Fya, Fyb, and Fy6 antigens are suscep-tible to proteolytic degradation
by the enzymes papain and ficin. When red cells are treated with papain or
ficin, these antigens are destroyed.
• In 1993, Horuk identified the Duffy glycoprotein as an erythrocyte receptor
for numerous proinflammatory chemokines
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Common Phenotypes of Duffy Blood Group
System
ANTI-Fya ANTI-Fyb
INTERPRETATION
+ 0 Fy(a+b−)
0 + Fy(a−b+)

+ + Fy(a+b+)

0 0 Fy(a−b−)
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Duffy Blood Group System -Antigens
Fya and Fyb
Antithetical antigens

Expressed on cord blood cells

Sensitive to ficin or papain treatment

Receptors for Plasmodium vivax and Plasmodium

knowlesi

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Duffy Blood Group System -Antigens
• Fy3 =

Expressed on cord blood cells

Resistant to ficin or papain treatment

Red cells that are Fy(a−b−) are also
Fy:-3
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Duffy Blood Group System -Antigens
• Fy5 =
Expressed on cord blood cells
Resistant to ficin or papain treatment
Common in whites
Altered expression in Rhnull phenotype
Possible antigen interaction between Duffy
and Rh proteins
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Duffy Blood Group System -Antigens
• Fy6 =
Expressed on cord blood cells

Red cells that are Fy(a−b−) are also Fy:-6

Sensitive to ficin or papain treatment
Antigen has been defined by murine
monoclonal antibodies; no human
anti-Fy6 has been described
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CHARACTERISTICS OF DUFFY ANTIBODIES
• The antibodies are stimulated by antigen exposure through transfusion or
pregnancy.
• Agglutination reactions are best observed in IATs.
• Immunoglobulin class is IgG.
• The antibodies usually do not bind complement.
• The antibodies possess clinical significance in transfusion and are an uncommon
cause of HDFN.
• Anti-Fya and anti-Fyb are nonreactive with enzyme-treated cells because the
antigens are degraded by these enzymes.
• Weaker examples of Duffy antibodies demonstrate stronger agglutination
reactions with the homozygous expression of antigen [Fy(a−b+) or Fy(a+b−)]
versus the hetero-zygous expression of antigen [Fy(a+b+)]; antibodies are
detecting dosage of antigen expression.
• Anti-Fya is more commonly observed than anti-Fyb.
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DUFFY SYSTEM AND MALARIA

• Most African and American blacks are resistant to infection from

certain forms of malarial parasites.
• Miller first made the connection between malaria and the Duffy
blood group system in 1975

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KIDD BLOOD GROUP SYSTEM
• ISBT SYSTEM SYMBOL= JK
• ISBT SYSTEM NUMBER= 009
• Antibody= IgG
• Temperature= 37C
• Reaction Phase= AHG

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Kidd Antigens Facts

• The unique characteristic of the Kidd blood group system arises from the
challenge for the transfusion service personnel to detect Kidd
alloantibodies in vitro. The Kidd antibodies are often linked to extravascular
hemolysis in delayed hemolytic transfusion reactions, where removal of
antibody-sensitized red cells is facilitated by the reticuloendothelial system.
• Three antigens—Jka, Jkb, and Jk3—define the Kidd blood group system.
• The Jk3 antigen is present whenever Jka or Jkb antigens are also produced
• The Kidd antigens do not rank high in terms of red cell immunogenicity. The
Kidd antigens are not denatured after exposure to routine proteolytic
enzyme reagents.

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• Heaton and McLoughlin reported the first evidence clarifying the
biochemical structure of the Kidd antigens in 1982.
• Mrs. Kidd, whose infant had HDFN. The antibody, named anti-Jka,
reacted with 77% of Bostonians. Its antithetical partner, Jkb, was
found 2 years later. The null phenotype Jk(a–b–) was described in
1959. The propositus made an antibody to a high-prevalence antigen
called Jk3, which is present on any RBC positive for Jka or Jkb.
• The Kidd blood group system has been assigned to a genetic locus, JK,
located on chromosome 18.
• . Delayed hemolytic transfusion reactions and extravascular hemolysis
are commonly associated with the antibodies of this blood group
system. In addition, rare examples of Kidd antibodies capable of the
activation and binding of complement proteins may cause
intravascular red cell destruction in a transfusion reaction.

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Common Phenotypes of Kidd Blood Group
System
ANTI-Jka ANTI-Jkb
INTERPRETATION
+ 0 Jk(a+b−)
0 + Jk(a−b+)

+ + Jk(a+b+)

0 0 Jk(a−b−)

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 Common characteristics of anti-Jka and anti-
b
Jk include the following:
• The immunoglobulin class is IgG.
• Agglutination reactions are best observed by the IAT.
• The antibodies show dosage of Kidd antigens on red cells; weak examples of
antibodies demonstrate stronger agglutination reactions with the homozygous
expression of antigen [Jk(a−b+) or Jk(a+b−)] versus the heterozygous expression of
antigen [Jk(a+b+)].
• Some antibodies may bind complement.
• The antibodies are produced in response to antigen exposure through transfusion
or pregnancy.
• The antibodies usually appear in combination with multiple antibodies in the sera
of individuals who have formed other red cell antibodies.
• Antibody detection is aided with enzyme reagents, LISS, and polyethylene glycol
(PEG).
• The antibodies do not store well; antibody
lendg
reactivity quickly declines in vitro. 102
LUTHERAN BLOOD GROUP SYSTEM
• ISBT System Symbol = LU
• ISBT System Number = 005
• Antibody Class = IgG and IgM
• Lub =Temp 37C
• Lua= Room Temp
• Reaction Phase
• Lub = Room Temp
• Lua = AHG
• In biochemical studies using monoclonal antibodies, the Lutheran antigens
were located on a membrane glycoprotein.
• The LU locus has been assigned to chromosome 19 and is linked to the Se
(secretor) locus. The H, Le, and LW genetic loci are also located on
chromosome 19
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Lutheran Antigens Facts
• The Lutheran blood group system comprises 20 antigens. The
Auberger antigens, Aua and Aub, first reported in 1961 and 1989,
respectively, were added more recently to the Lutheran system and
assigned to LU18 and LU19.
• Lutheran antigens have not been found on lymphocytes,
granulocytes, monocytes, or platelets. In addition, Lutheran anti-gens
are weakly expressed on cord blood cells.
• The two primary antigens of this system include the antithetical
antigens, Lua (LU1) and Lub (LU2). Antibodies to these antigens are
occasionally observed in patient samples. Lua (LU1) and Lub (LU2)
antigens are resistant to ficin and papain treatment of red cells.
Individuals in most populations have the Lu(a−b+) phenotype
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• In 1945, anti-Lua was found (and described in detail a year later) in
the serum of a patient with lupus erythematosus, following the
transfusion of a unit of blood carrying the corresponding low-
prevalence antigen. The new antibody was named Lutheran for the
donor; the donor’s last name was Lutteran but the donor blood
sample was incorrectly labeled.
• In 1956, Cutbush and Chanarin described anti-Lub, which defined the
antithetical partner to Lua.

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Common Phenotypes of Lutheran Blood
Group System
ANTI-Lua ANTI-Lub
INTERPRETATION
+ 0 Lu(a+b−)
0 + Lu(a−b+)

+ + Lu(a+b+)

0 0 Lu(a−b−)

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Lunull phenotype
• Lu(a−b−), rarely occurs and may manifest itself in any of the following
three unique genetic mechanisms:
• Recessive: only true Lunull phenotype; homozygosity for a rare
recessive amorph, Lu, at the LU locus
• Dominant inhibitor or In(Lu) phenotype: heterozygosity for a rare
dominant inhibitor gene, In(Lu), that is not located at the LU locus
• X-linked suppressor gene: inherited in a recessive manner

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CHARACTERISTICS OF LUTHERAN ANTIBODIES
• Anti-Lua
• Anti-Lua may be present without immune red cell stimulation.
• Immunoglobulin classes are IgM and IgG.
• Optimal in vitro agglutination reactions are observed at room
temperature.
• Anti-Lua has a characteristic mixed-field pattern of agglutination;
small agglutinates are surrounded by unagglutinated free red cells.
• It has no clinical significance in transfusion; mild cases of HDFN have
been reported.

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Anti-Lub

• Anti-Lub is a rare antibody because of the antigen’s high incidence.

• Immunoglobulin class is IgG
• Most examples of anti-Lub agglutinate at the antiglobulin phase.
• Some examples of anti-Lub show a mixed-field agglutination pattern.
• Anti-Lub has been associated with transfusion reactions and mild
cases of HDFN.

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LEWIS BLOOD GROUP SYSTEM
• ISBT System Symbol = LE
• ISBT System Number = 007
• Antibody Class= IgM
• Temperature= 37C, Room Temp
• The product of the Lewis gene is L-fucosyltransferase, which adds L-
fucose to the number 4 carbon of N-acetylglucosamine of type 1
precursor structures

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Common Phenotypes of Lewis Blood Group
System
ANTI-Lea ANTI-Leb
INTERPRETATION
+ 0 Le(a+b−)
0 + Le(a−b+)

+ + Le(a+b+)

0 0 Le(a−b−)

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Antigens and Phenotypes Resulting From
Interaction of Lewis, Secretor, and ABO Genes

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CHARACTERISTICS OF LEWIS ANTIBODIES
• Lewis antibodies occur almost exclusively in the serum of
Le(a−b−) individuals, usually without known red cell
stimulus.
• Le(a−b+) individuals do not produce anti-Lea, and it is rare to
find anti-Leb in an Le(a+b−) individual.
• Anti-Lea or anti-Leb can be found in an Le(a−b−) individual.
Lewis antibodies are IgM and have no clinical significance

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• Lewis system antibodies can be challenging to identify because
the reactions can have a wide temperature range.
• The challenges include the following:
• Agglutination is observed at immediate spin, 37° C, and the
antiglobulin phase.
• Agglutination is often fragile and easily dispersed.
• Enzymes enhance anti-Leb antibody reactivity.
• Hemolysis is sometimes seen in vitro, especially if fresh serum is
used, because anti-Lea efficiently binds complement.
• Neutralization techniques using commercially prepared Lewis
substance may be helpful to confirm the presence of a Lewis
antibody or eliminate the reactions to identify other antibodies
mixed in the serum lendg 114
I BLOOD GROUP SYSTEM AND i ANTIGEN

• ISBT System Symbol= I

• ISBT Sytem Number = 027
• Antibody Class =IgM
• Temperature=Antibodies bind at room temperature or lower
• Reaction Phase = AHG Phase

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I BLOOD GROUP SYSTEM AND i ANTIGEN
• The I antigen is not well developed at birth; linear chains of the
oligosaccharide pre-cursor chain are found predominantly in
newborns.
• As the straight chains develop into branched chains through the
action of the branching transferase, the i antigen converts to the I-
antigen structure over a 2-year period. Adult red cells possess a
strong expression of I antigen and trace amounts of i antigen.
Conversely, cord cells possess a strong expres-sion of i antigen and a
weak expression of I antigen.

lendg 116
I BLOOD GROUP SYSTEM AND i ANTIGEN
• Anti-I is usually found as a cold-reacting, clinically insignificant IgM
autoantibody. Most individuals possess an autoanti-I detectable at 4° C.
Anti-I is often detected when samples are tested at room temperature.
• Anti-I also reacts as a compound antibody. It is often found as an anti-IH
and exhibits stronger agglutination, with red cells having greater numbers
of H antigens, such as group O and group A2 cells.
• Autoanti-i is an uncommon cold agglutinin that reacts strongly with cord
blood cells or adult red cells
• Strong autoanti-I is associated with Mycoplasma pneumoniae infections
and cold hemag-glutinin disease. Anti-i is associated with infectious
mononucleosis, lymphoproliferative disease, and occasionally cold
hemagglutinin disease lendg 117
Antibodies
• Autoanti-P
• Autoanti-P is associated with an immune hemolytic anemia called
paroxysmal cold hemo-globinuria (PCH). Autoanti-P is an IgG
antibody known as the Donath-Landsteiner antibody
• Anti-P1 is frequently encountered in the serum of P2 individuals and
does not require red cell immune stimulation. This antibody is an IgM
cold-reactive agglutinin enhanced with enzymes. Commercially
available P1 substance can be used to neutralize the antibody to
confirm the antibody presence or eliminate the reactions

lendg 118
Antibodies
• Anti-PP1PK
• Individuals with the null phenotype (p phenotype) can make an
antibody with anti-PP1Pk specificity. This antibody was originally
referred to as anti-Tja before it became associated with the P system.
It can be separated into three antibodies and often exhibits hemolysis
in vitro. Anti-PP1Pk is a clinically significant antibody, and red cells
from donors who are also “p” are required if transfusion becomes
necessary

lendg 119
P1PK BLOOD GROUP SYSTEM, GLOBOSIDE BLOOD
GROUP SYSTEM,
AND GLOBOSIDE BLOOD GROUP COLLECTION
• ISBT SYSTEM SYMBOL= P1PK
• ISBT SYSTEM NUMBER= 003
• Antibody Class= IgM
• P1 antigen- Room Temp or Lower

• P antigen
• ISBT SYSTEM SYMBOL= GLOB
• ISBT SYSTEM NUMBER= 028
• Antibody Class= IgM and IgG
• Temp- 37C ,Room Temp
• Reaction Phase= Room Temp,AHG

lendg 120
Common Phenotypes of P1PK and GLOB
Blood Group System
Phenotype Antigens
P1 P1 P Pk
P2 P Pk
P1k P1 Pk
P2k Pk

p
- lendg 121
P1PK and GLOB Blood Group System
• P1=not well developed at birth
• P2 = lacks P1 but expresses P and Pk antigens
• P1k = Red cell express P1 and Pk antigens
• P2k= Red cell express only Pk antigens
• p= null phenotype
• The Pk antigen serves as the substrate for N
acetylgalactosaminyltransferase 1 which adds N-acetylgalactosamine
to the terminal galactose to make the P antigen
lendg 122
MNS BLOOD GROUP SYSTEM
• ISBT SYSTEM Symbol=MNS
• ISBT Number=002
• Antibody Class=IgM
• Temp= 37C
• Reaction Phase= Room temp,AHG

lendg 123
S AND s ANTIGENS

• ISBT SYSTEM Symbol=MNS

• ISBT Number=002
• Antibody Class=IgG
• Temp= 37C
• Reaction Phase=AHG

lendg 124
• The MNS system includes 46 antigens that are expressed primarily on
red cells.Molecular genetics have provided insight into the genetic
nature of the various MNS system antigens, many of which result
from crossing over, gene recombination, and substitutions. This
section limits the discussion of the MNS antigens and antibodies to M
(MNS1) N (MNS2), S (MNS3), s (MNS4), and U (MNS5).
•

lendg 125
M and N Antigens
• glycophorin A (GPA)
• Characteristics of M and N antigens include the following:
• GPA consists of 131 amino acids, with 72 outside the cell membrane.
• M and N antigens differ at positions 1 and 5; the first and fifth amino
acid residues for the M antigen structure are serine and glycine,
respectively, whereas the N antigen structure has leucine and
glutamic acid at positions 1 and 5, respectively.
• Inheriting M or N in the homozygous state [(M+N−) or (M−N+)]
greatly enhances the strength of the antigen expression

lendg 126
S, s, and U Antigens
• glycophorin B (GPB),
• Characteristics of S, s, and U antigens include the following:
• GPB consists of 72 amino acids, with 43 outside the cell membrane.
• S and s antigens differ at amino acid position 29; S antigen has methionine
at that position, whereas s antigen has threonine.
• The U antigen is located near the membrane and is always present when S
or s is inherited.
• Absence of or altered GPB expression would result in red cells phenotyping
as S−s−U−. GPB carries the same first 26 amino acid sequence as the N
antigen of the GPA structure. Inheriting S or s provides antigenic activity
similar to N called the “N” antigen.

lendg 127
Antibodies
• Anti-M
• Examples of IgM and IgG forms of anti-M have been reported. Anti-M
occurs naturally and Is considered a clinically insignificant antibody.
• Anti-N
• Anti-N is a rarely encountered IgM cold-reacting antibody that is not
usually clinically significant. Examples of an N-like antibody have been
found more frequently in dialysis patients exposed to formaldehyde-
sterilized dialyzer membranes. This anti-N–like anti-body is also not
clinically significant and may be a result of an altered N-antigen structure
on the red cells.
• Anti-S, Anti-s, and Anti-U
• Anti-S, anti-s, and anti-U are clinically significant IgG antibodies that can
cause decreased red cell survival and HDFN. It is not difficult to find
compatible blood for patients who have made anti-S or anti-s
lendg 128
Anti-S, Anti-s, and Anti-U

• The U antigen is a high-incidence antigen,

occurring in more than 99% of the population.
Anti-U is rare but should be considered when
serum from a previously transfused or pregnant
black person contains an antibody to a high-
incidence antigen.

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