Immunohematology, more commonly known as blood banking is a branch of hematology which studies

antigen-antibody reactions and analogous phenomena as they relate to the pathogenesis and clinical
manifestations of blood disorders. A person employed in this field is referred to as an
immunohematologist. Their day-to-day duties include blood typing, cross-matching and antibody
identification.[1][citation needed]

Immunohematology and Transfusion Medicine is a medical post graduate specialty in many countries.
The specialist Immunohematology and Transfusion Physician provides expert opinion for difficult
transfusions, massive transfusions, incompatibility work up, therapeutic plasmapheresis, cellular
therapy, irradiated blood therapy, leukoreduced and washed blood products, stem cell procedures,
platelet rich plasma therapies, HLA and cord blood banking. Other research avenues are in the field of
stem cell researches, regenerative medicine and cellular therapy.[1]

Basics of Immunohematology
Immunohematology is the study of RBC antigens and antibodies associated with blood transfusions.
There are more than 230 types of antigens present on the surface of RBCs that, based on their chemical
structure, can be grouped into two major categories—carbohydrates and polypeptides. The RBC antigen
formation is encoded by specific genes inherited from parents and categorized in blood group systems if
genes are known and found on closely located loci and in blood group collections if the genes
responsible for their formation have not yet been discovered.
The ABO blood group system was the first one discovered at the beginning of the 20th century, and it is
still considered the most important antigenic system mostly because the ABO mismatch is potentially
fatal. Other major blood group systems are Rh, Kell, Kidd, Duffy, Lutheran, and MNS. The presence or
absence on the RBC surface of specific antigens gives an individual antigenic profile or RBC phenotype.
For routine transfusions, blood is typed only for ABO and Rh blood group systems. “Rh typing” is a
misnomer because it does not involve phenotyping for all major antigens belonging to the Rh system
but, rather, only for the D antigen, the most immunogenic of all. Therefore, Rh-positive or Rh-negative
should read as D-positive or D-negative, respectively. Determination of the full RBC antigenic profile
(RBC phenotype) is not routinely performed, but it is required for correct selection of blood products in
certain situations in which antibodies are identified in recipient’s plasma.
Transfusion of ABO-compatible blood is required at all times because the ABO blood group system has
preformed antibodies capable of causing hemolysis with release of free hemoglobin and other
intracellular components into the circulating plasma, leading to renal failure, activation of the
coagulation system, and potentially death. Other preformed antibodies, also called “naturally occurring”
or non-RBC stimulated, are formed against RBC antigens belonging to the carbohydrate group. These
antibodies are not considered clinically significant because they do not usually react at body
temperature. Unlike antibodies against RBC antigens belonging to the carbohydrate group, the
antibodies against polypeptide RBC antigens are not preformed but require prior RBC exposure
(sensitization) via prior transfusion or pregnancy for their formation. A second exposure to the same
RBC antigen results in RBC coating with antibody and/or complement fractions, shortened RBC life span
with hemolysis.
The principle of most immunohematology tests is the antigen–antibody reaction leading to RBC
agglutination or hemolysis. If any of these occur, the reaction should be interpreted as positive.
Hemolysis is considered the strongest positive reaction that can occur and indicates the presence of a
potent, complement-fixing antibody, but it is not commonly seen. The RBC agglutination is most
commonly seen as a sign of a positive reaction in transfusion medicine tests. RBC agglutination occurs in
two phases. In the first phase, also known as RBC sensitization, a reversible reaction occurs between the
paratope and the epitope held together by noncovalent attraction, whereas in the second phase, RBCs
with bound antibodies form a stable lattice via antigen–antibody bridges bound to different RBCs. The
formation of this lattice is naturally prevented by the net negative charge of the RBC membrane created
by sialic acid. If suspended in an ionic medium, a charge difference or electrical potential forms between
cations closest to the RBC membrane and the outer cations that move more freely in the solution. This is
called the ζ potential, and it is responsible for keeping the RBCs in solution approximately 25 nm apart.
Factors affecting the RBC agglutination include the inherent characteristics of the specific antigens and
antibodies involved, the density and accessibility of specific antigens on the RBC membrane, the
antibody isotype and concentration, as well as physical and/or chemical parameters of the reaction
environment (temperature, incubation time, and ionic strength of the solution). The impact of the RBC
antigen density is illustrated by the ease with which a reaction occurs with A or B antigens, which are
present in hundreds of thousands to millions of molecules per RBC. Another example is illustrated by the
so-called “dosage effect,” meaning stronger antibody reaction with RBCs that are homozygous than with
heterozygous RBCs for a particular antigen because homozygous RBCs express twice the number of
antigen molecules per cell. The impact of the antibody isotype is mostly due to the difference in size of
various classes of immunoglobulins. For example, because they are large molecules (35 nm), the IgM
antibodies can easily reach two adjacent RBCs in solution; therefore, they have an intrinsic agglutinin
ability and are thus referred to as direct agglutinins. In contrast, most IgG antibodies are smaller (14 nm)
and unable to induce agglutination without an enhancement of the reaction, which is why they are
referred to as indirect agglutinins [1–4]. In case of a negative immunohematology reaction, an extra
quality control step is performed using reagent RBCs known to give a positive reaction (also called
“check cells”). Check cells are commercially available reagent RBCs known to give a positive reaction and
tested exactly as the patient’s RBCs. A positive test result with check cells validates the patient’s
negative test result. If the check cells do not give a positive reaction, as expected, the patient’s results
cannot be considered truly negative, and the test should be repeated.

Clinical Apheresis
In many blood centers, the physicians make all determinations about the clinical service (therapeutic
apheresis, HCT/P and other cellular therapies apheresis collections) including procedure medical
appropriateness and technical aspects (replacement fluids, volume processed, etc.), and provide
consultation to ordering physicians (the ordering physician is directly responsible for patient care). In
many locations, clinical apheresis is performed by registered nurses or specially qualified medical
technologists, and the procedures occur outside the confines of the blood center. It is important to
define the exact role of the blood center physician and where his or her hegemony stops relative to the
hospital ordering and/or attending physician responsible for the ongoing care of the patient. In some
cases when the physician is credentialed at the patient’s hospital, the blood center physician will
accompany apheresis staff to the patient’s bedside and participate in direct patient care. It is important
for blood center physicians to know whether senior management also expect the physician to be
directly responsible for apheresis staff and, if indicated, to be given direct authority over this aspect of
the center’s operations.
IRL, Platelet, HLA and HCT/P Laboratories
In the IRL, the blood center physician may play a highly medical and technical role providing input,
interpretation and decision making regarding immunohematology and RBC genomics testing, including
blood typing (both phenotyping and genotyping), complex Rh determinations, testing for unexpected
antibodies in donor and patient samples sent to the blood center IRL, and panel and eluate data
interpretation. It is important for blood center physicians to know if senior management expects the
physician to be directly responsible for IRL staff, and to have this authority so designated if required. In
addition, blood center physicians provide clinical consultation to hospital transfusion medicine and
transfusing clinicians regarding complicated donor–recipient matching, as often relates to the
transfusion of patients with sickle cell disease, and adverse outcomes post-transfusion. Finally, the
blood center physician is intimately involved with policy, procedural, technical, regulatory and medical
aspects of automation, device, computer and technology decisions and other aspects of the IRL and RBC
genomics. These duties parallel the functional activities of the physician who serves as the platelet, HLA
or HCT/P laboratory medical director.