Immunohematology, Blood Groups
K Fayyaz and CM Westhoff, New York Blood Center, New York, NY, USA
Ó 2014 Elsevier Inc. All rights reserved.
Glossary
Acute hemolytic transfusion reaction (AHTR) A type of
transfusion reaction that is associated with hemolysis
within 24 h of transfusion either due to recipient antibody
against donor red blood cells (RBCs) or donor antibody
against recipient RBCs.
Alloantibody An antibody made against foreign tissues.
Antibody A protein produced by B cells in response to an
antigenic stimulus.
Antigen Any foreign substance that causes the immune
system to produce antibodies against it.
Antithetical antigens The alternative products of a blood
group gene.
Autoantibody An antibody made against one’s own
components.
Blood type (or group) Variations in molecules on the
surface of RBCs that differ between individuals.
Genotype The genotype of an organism is the inherited
instructions it carries within its genetic code. When applied
to blood group testing, the genotype is determined by
testing DNA for the specific nucleotide changes that encode
the blood group antigens.
Human blood groups were discovered in 1900 at the University
of Vienna by Karl Landsteiner in the process of trying to learn why
blood transfusions sometimes cause death and at other times
revives and benefits a patient. He observed that when mixing
blood samples from himself and his students, some caused
clumping (known as agglutination) of the blood cells and others
did not. This simple test was ignored by surgeons who continued
to transfuse blood from individuals without testing, resulting in
hemolytic transfusion reactions (HTRs). It was not until the
discovery of anticoagulants and sterility methods that blood
could be stored as a liquid and refrigerated in glass bottles, which
moved blood collection, processing, and testing from the surgical
arena into the laboratory. This allowed testing for agglutination
(compatibility) in the laboratory prior to blood transfusion.
Blood groups are determined by the presence of inherited
substances on the surface of red blood cells (RBCs) that differ
between individuals. These are called blood group antigens and
may be proteins, carbohydrates, glycoproteins, or glycolipids.
Most of these antigens are also present on the surface of other
types of cells of various tissues.
In 1980, the International Society of Blood Transfusion
(ISBT) established a Working Party to devise a numerical
terminology for RBC antigens. Blood group antigens are
defined by a specific antibody. A blood group system consists
of one or more antigens controlled at a single gene locus, or by
two or more very closely linked homologous genes with little
or no observable recombination between them (ISBT, Blood
Group Terminology, 2012). There are approximately 30
Reference Module in Biomedical Research, 3rd edition http://dx.doi.org/10.1016/B978-0-12-801238-3.00076-3
Hemolytic disease of the fetus and newborn (HDFN) An
immune condition that develops in a fetus/newborn when
antibodies are produced by the mother against the fetal
RBCs antigens. The antibodies pass through the placenta
and destroy the fetal RBCs.
Hydrops fetalis Characterized by an accumulation of
excessive fluid, or edema, in at least two fetal compartments.
It can be immune or nonimmune mediated.
Lyonization Also called X-inactivation, lyonization is
a process by which one of two copies of the X-chromosome
present in female mammals is inactivated.
Phenotype The composite of an organism’s observable
characteristics or traits, such as its morphology,
development, biochemical, or physiological properties.
When applied to blood groups, the phenotype is
determined by testing the RBCs with antibodies that react
with specific blood group antigens.
Rh immune globulin (RhIG) Product used to prevent an
immune response to Rh-positive blood in people with an
Rh-negative blood type. It may also be used in the
treatment of immune thrombocytopenic purpura (ITP).
human blood group systems, and antigens of 23 of these are
defined by variations in the amino acid sequence of RBC
membrane proteins. The carriers of blood group antigens
contribute to essential RBC functions: as membrane trans-
porters, receptors, or enzymes, and by providing linkage to the
underlying RBC skeleton or by facilitating the membrane
assembly of the protein complexes involved in these processes.
The proteins expressing antigens of the remaining 17 blood
group systems are much less abundant and their functional
importance for the circulating RBC is as yet largely unknown.
Human Blood Group Antigens and Antibodies
There are over 300 blood group antigens, most of which are
included in 30 different blood group systems, Table 1 (HGNC,
HUGO Gene Nomenclature Committee, 2012). Many of the
proteins carrying blood group antigens reside in the erythrocyte
membrane as complexes with other proteins (Figure 1).
Terminology
A variety of different terminologies have been used to denote
blood groups. Some systems bear the family surname in which
the antibody was first discovered (Kell, Kidd, Duffy, etc.), with
abbreviations to indicate antigens (K/k, Jka/Jkb, Fya/Fyb, etc.).
Others were given letter designations (A, B, D, M, N, etc.).
1
2 Immunohematology, Blood Groups

Table 1 Human blood group systems

No. System name System symbol Gene name(s)a Chromosomal location CD numbers

001 ABO ABO ABO 9q34.2

002 MNS MNS GYPA, GYPB, GYPE 4q31.21 CD235
003 P1PK P1PK A4GALT 22q13.2
004 Rh RH RHD, RHCE 1p36.11 CD240
005 Lutheran LU LU 19q13.32 CD239
006 Kell KEL KEL 7q34 CD238
007 Lewis LE FUT3 19p13.3
008 Duffy FY DARC 1q23.2 CD234
009 Kidd JK SLC14A1 18q12.3
010 Diego DI SLC4A1 17q21.31 CD233
011 Yt YT ACHE 7q22.1
012 Xg XG XG, MIC2 Xp22.33 CD99þ
013 Scianna SC ERAMP 1p34.2
014 Dombrock Do ART4 12p12.3 CD97
015 Colton CO AQP1 7p14.3
016 Landsteiner–Wiener LW ICAM4 19p13.2 CD242
017 Chido/Rodgers CH/RG C4A, C4B 6p21.3
018 H H FUT1 19q13.33 CD173
019 Kx XK XK Xp21.1
020 Gerbich GE GYPC 2q14.3 CD236
021 Cromer CROM CD55 1q32.2 CD55
022 Knops KN CR1 1q32.2 CD35
023 Indian IN CD44 11p13 CD44
024 Ok OK GSG 19p13.3 CD147
025 Raph RAPH CD151 11p15.5 CD151
026 John Milton Hagen JMH SEMA7A 15q24.1 CD108
027 I I GCNT2 6p24.2
028 Globoside GLOB B3GALT3 3q26.1
029 Gill GIL AQP3 9p13.3
030 Rh-associated glycoprotein RHAG RHAG 6p21-qter CD241
031 FORS FORS GBGT1 9q34.13
032 JR JR ABCG2 4q22
033 LAN LAN ABCB6 2q36
a
As recognized by the HUGO Gene Nomenclature Committee http://www.genenames.org/.

Figure 1 Graphic representation of the structures that carry different blood group antigens in the red blood cell membrane. Adapted from Reid,
M.E., Mohandas, N., 2004. Red blood cell group antigens; structure and function. Sem. Hematol. 41, 93–117.

Blood Group Systems
Presented here is a brief description of the more clinically
relevant blood group systems, defined as antibodies to these
blood groups causing acute hemolytic or delayed hemolytic
transfusion reactions (AHTRs or DHTRs) following an incom-
patible blood transfusion, or hemolytic disease of the fetus and
newborn (HDFN) during pregnancy. For further information,
the interested reader is referred to specialized texts.
Transfusion Reactions
For the majority of routine RBC transfusions, the patient and
blood donor are matched for ABO and RhD type, and the
transfusion is uneventful. However, because there are many
other blood group antigens that will not be identical between
patient and donor, the immune system of some patients,
particularly those who require multiple transfusions, may
recognize one or more of the nonidentical blood group antigens
as foreign. These patients make antibodies directed to the foreign
protein or carbohydrate antigens on the donor RBCs, which can
result in immediate or delayed removal by the spleen or lytic
destruction of the transfused RBCs. All future transfusions must
lack the blood group antigen that stimulated the immune
response (i.e., the corresponding antigen to the patient’s anti-
body), in addition to being ABO compatible (see Transfusion-
Related Adverse Events).
Hemolytic Disease of the Fetus and Newborn
HDFN can occur when the fetal RBCs express an RBC antigen
inherited from the father that is not present on the RBCs of the
mother. The maternal immune system can recognize fetal RBCs
as foreign and make an antibody directed to the paternally
inherited antigen. If the maternal antibody is IgG subclass, it
may cross the placenta and bind to the fetal RBCs, causing RBC
destruction and resulting in fetal anemia. The severity of
disease in the fetus depends on the specific antigen target, the
maternal antibody titer and subclass (IgM does not cross the
placenta), and if the antigen is also expressed on the placenta or
other fetal tissues in addition to the fetal RBCs (these can also
bind the antibodies and reduce the severity of disease). As
maternal exposure to fetal RBCs is usually limited during
pregnancy and occurs primarily during delivery, HDFN is
generally more severe in subsequent pregnancies. HDFN due to
RhD incompatibility (Rh blood system) and K (Kell blood
system) incompatibility are the most clinically significant.
Generally, maternal antibody titers and amniotic bilirubin
levels are good predictors of the severity of the disease (Shaz
et al., 2013). Historically, the severity of HDFN was monitored
by amniocentesis, typically performed with ultrasound guid-
ance, to follow the level of bilirubin pigment found in amniotic
fluid. Because fetal anemia due to HDFN results in increased
cardiac output, noninvasive color Doppler ultrasonography
can also be used to monitor the severity of HDFN. The current
trend has emphasized this approach over amniotic bilirubin
sampling because it is noninvasive. The fetal middle cerebral
artery (MCA) peak flow velocity has been shown to correlate
with severity of the anemia and to be diagnostically equivalent
to amniocentesis, without the risk (Roback et al., 2008).
Immunohematology, Blood Groups 3
RhD HDFN is now uncommon in developed countries due
to the introduction of Rh immune globulin (RhIG) prophylaxis
in the 1960s. RhIG is a human plasma-derived hyper-
immunoglobulin product consisting of human IgG antibodies
to the RhD antigen that is administered to RhD-negative preg-
nant women who are at risk for RhD sensitization from an RhD-
positive fetus. RhIG is administered at 28 weeks gestational age,
or when there is a risk of fetomaternal hemorrhage (FMH)
through amniocentesis, trauma, or other procedures, and after
delivery of an RhD-positive newborn or fetus (see Perinatal
Alloantibody Disorders – Neonatal Alloimmune Thrombocy-
topenia/Hemolytic Disease of the Fetus and Newborn).
Carbohydrate Blood Group Systems
ABO Blood Group System
The ABO system, initially described by Karl Landsteiner in 1900
(Landsteiner, 1900), remains the most important blood group
system in transfusion and organ transplantation medicine
(Stussi et al., 2006). Transfusion of ABO-incompatible blood
can be associated with acute intravascular hemolysis, resulting
in renal failure and death. Likewise, transplantation of
ABO-incompatible organs is associated with acute rejection.
Because of the clinical consequences of ABO-incompatible
transfusion and transplantation, ABO typing and compati-
bility testing is the cornerstone of transfusion practice.
Antigens
There are four major blood groups, A, B, AB, and O, determined
by the presence or absence of A and B antigens on the surface of
RBCs. Group A has only A antigen, group B carries B antigen,
and group AB has both A and B antigens on the RBCs. Group O
has neither A nor B antigen, but group O individuals have H
antigen, which is the precursor substrate for A and B antigens.
The A and B antigens are synthesized by transferase enzymes
and differ only by the nature of the terminal carbohydrate to
a D-galactose (Gal) residue that also has L-fucose (Fuc) in a 1-2
linkage of the N-linked oligosaccharides chain. N-acetyl-D-
galactosamine is added by A-transferase, and D-galactose by
B-transferase. Group O individuals have defective A or B
transferases; therefore, no terminal carbohydrate is added,
leaving H antigen, the terminal sugar of which is fucose, on the
RBC. Some H antigen precursor remains on A and B RBCs in
this order: A2 > B > A2B > A1 > A1B. In clinical practice, four
ABO phenotypes (A, B, O, and AB) are discriminated. In
addition, two common variations of group A, A1, and A2, can
be distinguished. A1 and A2 phenotypes differ in the amount of
A antigen on the RBCs (A2 has less than A1) and differ in
carbohydrate branching structure. Approximately 80% of
group A individuals are A1 and 20% are A2. In addition, there
are other inherited phenotypes that have weaker expression of
the specified antigen, e.g., A3, Ax, Ael, B3, B(A), and cisAB.
Rare are ‘Bombay’ (Oh) phenotype RBCs (first reported in
Bombay, India), which lack the H antigen, and consequently,
also lack A and B antigens. Of clinical relevance, potent anti-
H with the same hemolytic potential as anti-A and anti-B can
be produced by Bombay individuals, and they can only
receive RBC transfusions from other people with the same
Bombay type.
4 Immunohematology, Blood Groups
A or B antigen expression can weaken in patients with acute
leukemia or stress hematopoiesis or occasionally during preg-
nancy. Chromosomal deletions or lesions that involve the ABO
locus can result in the loss of transferase expression in the
leukemic cell population.
ABO Antibodies
Anti-A and anti-B are found in the sera of individuals who lack
the corresponding antigen on their RBCs. For example, anti-A is
produced by individuals who lack A antigen (i.e., group B and
group O). They are produced in response to similar environ-
mental carbohydrate structures, such as those found in plants
and bacteria (Springer et al., 1959). These antibodies are
produced after birth, reaching a peak level at 5–10 years of age,
and declining after the fifth decade. ABO blood group is
determined by testing the person’s RBCs with anti-A and anti-B
and observing for agglutination (known as forward or front
type) and testing the plasma with group A1 and group B RBCs
(known as reverse or back type).
The antibodies are mostly IgM, and can activate comple-
ment, which in conjunction with the high density of ABO
antigen sites on RBCs, may result in severe, life-threatening
AHTR that may result following ABO-incompatible trans-
fusions. In contrast, HDFN caused by ABO antibodies is usually
mild because (1) placental transfer is limited to the fraction of
IgG anti-A, B, anti-A, and anti-B found in maternal serum, (2)
ABH antigens are not fully developed on fetal RBCs due to lack
of fully branched carbohydrate chains, and (3) tissue ABH
antigens provide additional targets for the antibodies.
ABO Genes
The ABO gene was cloned in 1990 following purification of A
transferase (Hakomori, 1999); since then, over 200 different
alleles have been described. There are four amino acid differ-
ences between A and B transferase enzymes in the catalytic
domain, two of which (Leu266Met and Gly268Ala) are
primarily responsible for the substrate specificity (Yamamoto
and Hakomori, 1990). The group O phenotype results from
mutations in ABO that cause a loss of glycosyltransferase
enzyme activity.
ABO and Transplantation
As tissue antigens, ABO is important in solid-organ trans-
plantation. Recipient antibodies will react with antigens on the
transplanted organ and complement activation at the surface of
endothelial cells can result in rapid destruction and hyperacute
rejection of organs that are not matched for ABO (Platt and
Bach, 1991). However, successful transplantation across ABO
barriers is possible, particularly with blood group A2 to O, and
with current immunosuppressive and pretreatment regimens
including removal of ABO antibodies from the patient (Rydberg,
2001). Allogeneic hematopoietic stem cell transplantations are
routinely performed irrespective of ABO compatibility but
occasionally initial hemolysis or pure RBC aplasia due to per-
sisting anti-A or anti-B titers in the recipient can result.
P1PK Blood Group System
The P system was renamed the P1PK system in 2010, based
on insights gained from study of the galactosyltransferase
enzyme encoded by the gene A4GALT. The high-prevalence
antigens, Pk and P1, are defined by terminal galactosyl (Gal)
sugars added to precursor glycosphingolipids by the action of
the A4GALT product. The absence of antigen is called a ‘null’
phenotype. The p, P2k, and P1k phenotypes are of clinical
interest because of potent naturally occurring antibodies that
are present in the plasma of individuals whose RBCs lack the
glycolipid-based antigens P1/P/Pk, P1/P, or P, respectively.
In analogy with the ABO blood group system, antibodies of
IgM and IgG class are made against the missing antigens.
Although the incidence of the null phenotypes is only 5–10
per million, they have attracted considerable interest due to
their relationship to disease and as receptors for pathogens.
Women with p and Pk phenotypes suffer a high incidence of
spontaneous abortion, a phenomenon most likely due to
destruction of the placenta by anti-P. Transient auto-anti-P
produced following a viral infection causes paroxysmal
cold hemoglobinuria and hemolysis of autologous
P-positive RBCs. P antigen is the cellular receptor for parvo-
virus B19 that causes erythema infectiosum (fifth disease) in
children.
Lewis Blood Group System
Lewis antigens, Lea and Leb, are not intrinsic to the RBC
membrane. They are synthesized by intestinal epithelial cells,
circulate in plasma, and are passively adsorbed onto RBC
(Henry et al., 1995). Lea and Leb are synthesized in a stepwise
fashion by two separate fucosyltransferases: Lewis (FUT3) and
Secretor (FUT2), which add fucose moieties onto type 1
glycoprotein chains to form Lea and type 1 chain H antigen,
respectively. Lewis gene can also add a second fucose to type 1
H antigen to form Leb antigen. Antibodies to Lewis antigens can
be made by people with the Le (ab) phenotype. Antibodies
to the Lewis antigens are primarily IgM, can be naturally
occurring, and are not usually clinically significant. Rare cases
of HTRs secondary to Lewis antibodies have been reported, and
are more commonly due to antibodies against Lea. Lewis
antibodies do not cause HDFN because Lewis antigens are not
present on fetal RBCs and most antibodies to Lewis antigens
are IgM and not able to cross the placenta. These antibodies
seldom cause any clinical problems, but are commonly found
in pregnant women (Shaz et al., 2013).
Protein Blood Group Systems
Rh Blood Group System
The Rh system is the second most clinically important blood
group system, the first being ABO. Rh antigens, especially RhD,
are highly immunogenic. The Rh system was discovered
40 years after ABO. Over the past 50 years, we have learned far
more about Rh. This blood group may be the most complex
genetically since it involves more than 50 different antigens on
the surface of RBCs controlled by two closely linked genes
(RHD, RHCE) on chromosome 1. One encodes the D antigen;
the other encodes CE antigens (ce, Ce, Ce, or CE). Despite its
genetic complexity, the inheritance of the most important Rh
antigen, D, is straightforward and it is inherited in a dominant
fashion. Individuals who are homozygous dominant (DD)

or heterozygous (D/) are ‘RhD positive.’ Those who are
homozygous recessive are ‘RhD negative.’ The RhD-negative
type is prevalent in Caucasians (15–17%), less prevalent in
African blacks (3–5%), and rare in Asians (<0.1%). RhD
negative in Caucasians is primarily due to a deletion of the
RHD gene. African blacks and rare RhD-negative Caucasians
and Asians carry an RHD gene that is silenced due to a variety of
mutation events.
RBCs with weak D have D antigen but at lower levels than
normal due to one or more amino acid changes in RhD
(Wagner et al., 1999). The majority of individuals with a weak
D phenotype can safely receive RhD-positive blood and do not
make anti-D (Flegel, 2005).
Other Rh antigens include C and c, and E and e. These are
allelic; C/c differs by six nucleotide substitutions causing four
amino acids changes and E/e differs by one amino acid. Rh
proteins in diverse ethnic groups often carry additional poly-
morphisms, particularly individuals of African black descent;
this complicates transfusion in patients who need multiple
transfusions like sickle-cell disease, which is more common in
individuals of African black descent. For example, V and VS are
Rh antigens expressed primarily in African blacks and expres-
sion of these antigens is associated with variant expression of e
antigen (Westhoff, 2007). RH genotyping by DNA methods
allows enhanced Rh antigen matching of patients and donors.
The Rhnull phenotype is very rare and these individuals lack
expression of Rh blood groups. Rhnull RBCs are stomatocyte
shaped, fragile, and are associated with mild anemia.
Rh Antibodies
Rh antibodies are due to RBC immunization from pregnancy or
transfusion, and usually persist for years. Anti-D can cause
severe HTR and HDFN. Anti-D generally results from FMH
occurring in D-negative women who carry D-positive fetus, or
following transfusion of RhD-positive blood products to RhD-
negative patients.
Kell and Kx Blood Group Systems
The Kell blood group systems contain over 34 antigens, but the
major antigens are K and k. The Kell glycoprotein is highly
folded through multiple intrachain disulfide bonds and is
covalently linked to Kx protein in the RBC membrane (Lee
et al., 2000). The K antigen is the second most immunogenic
antigen; particularly notable since K and k differ by a single
amino acid, which results in the loss of an N-glycan and
exposes the peptide.
HDFN due to anti-K can result in severe neonatal anemia,
and unlike anti-D, maternal antibody titers and amniotic
bilirubin levels are not good predictors of the severity of the
disease; however, fetal MCA peak flow velocity is. Kell anti-
gens appear on erythroid progenitor cells early in erythro-
poiesis, after glycophorin C, but before glycophorin A and
band 3, and much earlier than the Rh proteins (Daniels et al.,
2003). Anti-K has been shown to suppress erythropoiesis in
vitro (Vaughan et al., 1994; Wagner, et al., 2000a,b). This may
explain the low level of bilirubin observed in the face of
neonatal anemia. Other unusual consequences of Kell anti-
bodies include risk of fetal thrombocytopenia and neu-
tropenia (Wagner et al., 2000a).
Immunohematology, Blood Groups 5
McLeod Syndrome
This uncommon (0.5–1% per 100 000 population) syndrome
is associated with the loss of expression of Kx protein due to
mutations and deletions in the XK gene (Danek et al., 2001).
The syndrome, which is X-linked and manifests only in males,
may be underdiagnosed. The physical characteristics, which
often develop only after the fourth decade of life, include
muscular and neurological problems. A minority of patients
with chronic granulomatous disease also have the McLeod
phenotype due to X-chromosome deletions encompassing
both genes. Carrier females have two populations of RBCs (one
of the McLeod phenotype and one of normal phenotype) due
to lyonization.
Duffy Blood Group System
The Duffy (FY) glycoprotein is a chemokine receptor found on
RBCs and on endothelial cells in the kidney and brain. The Fya
and Fyb antigens differ by a single amino acid (Gly42Asp)
located on the N-terminal extracellular domain of the FY
glycoprotein and is responsible for the common Fy(aþb),
Fy(abþ), and Fy(aþbþ) phenotypes. The FY chemokine
receptor binds a family of chemotactic and proinflammatory
peptides from the CXC (IL-8, MGSA) and the CC (RANTES,
MCP-1, MIP-1) classes. This receptor may allow the RBCs to act
as scavengers of excess chemokine in the circulation.
FY is important as a receptor to which Plasmodium vivax
merozoites can bind to invade RBC and cause malaria. The null
Fy(ab) phenotype is rare in most ethnic groups, but is
common in people of African and Arabian origins, occurring in
over two-thirds of the African black population. The racial
variation in the distribution of Duffy antigens is a result of
a positive selection pressure. The absence of Duffy antigens on
RBCs makes the RBCs more resistant to invasion by the
malarial parasite. Worldwide, of the four Plasmodium species
that routinely cause malaria in humans, Plasmodium falciparum
is responsible for the majority of fatal cases. But in Asia and the
Americas, P. vivax is a more common cause of malaria. To cause
disease, P. vivax must enter the human RBC by binding to the
Duffy binding protein. Individuals with the Duffy null
phenotype do not express the Duffy protein on their RBCs and
therefore are resistant to P. vivax infection.
The Fy(ab) phenotype most often results from a muta-
tion in the promoter region of FYB that disrupts a binding site
for the erythroid transcription factor GATA-1 and results in loss
of FY on RBCs (Tournamille et al., 1995). Because the erythroid
promoter controls expression only in erythroid cells, FY
expression in other tissues is unaffected. Fy(ab) due to
a mutated GATA box on an FYA allele has been found in Papua
New Guinea, another malaria-endemic region.
FY antigens are much less immunogenic than Rh and K for
blood transfusion. FY antibodies can cause DHTR but very
rarely HDFN.
Kidd Blood Group System
The Kidd (JK) blood group protein is present in RBCs and in
the kidney medulla and is a constitutive urea transporter. The
Jka and Jkb antigens differ by a single amino acid (Asp280Asn)
and are responsible for the common Jk(aþb), Jk(a–bþ), and
6 Immunohematology, Blood Groups
Jk(aþbþ) phenotypes. The Jk(ab) or Jknull phenotype is
uncommon and occurs with greater incidence in Polynesians,
Asians, and Finns. JK is important in blood transfusion and
antibodies are responsible for at least one-third of cases of
DHTR. The antibodies often drop to undetectable levels and
escape detection in the sensitized patient’s plasma prior to
transfusion. JK antibodies only rarely cause HDFN, and if they
do, it is typically not severe. Anti-Jk3 is produced by Jk(ab)
individuals.
MNS Blood Group System
The MNS system is highly polymorphic and most of the 46
antigens are the result of amino acid substitutions or rear-
rangements between GYPA and GYPB. M/N and S/s are
homologous proteins encoded by adjacent genes and conse-
quently show linkage disequilibrium in inheritance of the
antigens. M and N antigens are carried on alternative forms of
glycophorin A (GPA), while S and s antigens are carried on
alternative forms of glycophorin B (GPB). Persons who are
Ss are usually African blacks who also lack the high-
prevalence U antigen due to a deletion of GYPB, or express
variant weak U antigen due to an altered form of GYPB (Storry
et al., 2003).
Minor Protein Blood Systems
Lutheran Blood Group System
In 1951, when the Lutheran (LU) locus was shown to be
genetically linked to secretor (FUT2) locus, blood groups were
involved in the first human autologous linkage and, conse-
quently, the first demonstration of recombination due to
crossing over in humans (Mohr, 1951) and the first indication
that crossing over in humans is more common in females than
in males (Cook, 1965). Antibodies in this system are rarely
encountered because the antigens are not highly immuno-
genic. They can cause mild HTRs, but do not typically cause
HDFN.
Diego Blood Group System
The Diego blood group antigens are on band 3, the RBC anion
exchanger (AE1) that functions as the major chloride–bicar-
bonate exchanger in the RBC membrane. Band 3 forms
complexes with many other proteins in the cell membrane and
is important for RBCs’ stability (Byrne and Byrne, 2004). The
primary antigens in the Diego system are Dia and Dib. Dib
antigen has a prevalence of greater than 99.9%, but Dia is rare
in most populations, with the exception of South American
Indians in whom Dia occurs in 54%, and approximately 12%
of Native Americans are Di(aþ). Diego antibodies are usually
IgG and do not bind complement. These antibodies have
caused HTRs (usually delayed) and HDFN.
Yt Blood Group System
The Yt system was discovered in 1956. Yta occurs with a prev-
alence of more than 99% in random blood samples. Ytb is
found with a prevalence of approximately 8% with the
exception of Israelis, where it has a prevalence of 20% or higher
(Levene et al., 1987).
Scianna Blood Group System
The Scianna antigens are expressed by the RBC adhesion
protein, erythrocyte membrane-associated protein (Xu et al.,
2001; Wagner et al., 2003). Sc1 is a high-prevalence antigen
(prevalence 99.9%), Sc2 is a low-prevalence antigen (1%), and
there are five other Scianna antigens (Velliquette, 2005).
Scianna antibodies are usually IgG and some bind comple-
ment. These antibodies have not caused transfusion reactions,
and although they have caused a positive direct antiglobulin
test in fetal RBCs, they have not caused HDFN. Autoanti-
Sc3-like antibodies have been described in one patient with
lymphoma and in one patient with Hodgkin’s disease whose
RBCs had suppressed Sc antigens (Westhoff, 2004).
Dombrock Blood Group System
Dombrock antigens are carried on Glycosylphoshatidylinositol
[GPI]-linked proteins that are members of the mono-
ADP-ribosyltransferase family (ART4), although Do has no
demonstrable enzyme activity on the RBC. The Dombrock
blood group system consists of two antithetical antigens, Doa
and Dob, and six other antigens of high prevalence. The absence
of Dombrock protein results in a null phenotype called Gy(a).
Doa and Dob antigens are poor immunogens, and anti-Doa
and anti-Dob are rarely found as single specificities. Antibodies
in the Do system are usually IgG and do not bind complement.
These antibodies have caused delayed transfusion reactions,
but no clinical HDFN (Reid et al., 2000).
Colton Blood Group System
The Colton antigens are carried on aquaporin-1 (AQP-1), the
first water channel protein characterized in mammals, and are
also found in the kidney (Preston and Agre, 1991). The func-
tion of AQP-1 in RBCs may be to rehydrate rapidly after
shrinking in the hypertonic environment of the renal medulla
(Smith et al., 1993). Coa has a prevalence of 99.9%, its anti-
thetical antigen Cob has a prevalence of 10%, and Co3 and Co4
are present on all RBCs except on those of the very rare
Co(ab) null phenotype (Arnaud et al., 2010). Apparently
healthy individuals with the Co(ab) phenotype and AQP-1
deficiency have RBCs with an 80% reduction in the ability to
transport water. The residual water transport in these RBCs may
be through another member of the water channel protein
family, AQP-3, which transports water, glycerol, and urea, and
carries the blood group antigen GIL (Roudier et al., 2002).
Antibodies in the Colton system are usually IgG and some bind
complement. The antibodies have caused DHTRs and HDFN.
Cromer Blood Group System
The Cromer antigens are carried on decay accelerating factor
(CD55), a complement control protein attached to the RBC
membrane through GPI-linkage. Cromer is the receptor for
Escherichia coli, coxackie virus, and echovirus. Erythrocytes of
patients with paroxysmal nocturnal hemoglobinuria (PNH)

exhibit GPI-linked proteins deficiency, which result in a lack of
Cromer, Cartwright, and Dombrock blood group antigens. The
Cr(a) phenotype is the least rare of the negative phenotypes,
and with the exception of one Spanish-American woman, all
people with Cr(a) RBCs are African blacks. Most of the other
phenotypes are exceedingly rare. Antibodies in the Cromer
system are usually IgG and do not bind complement. The
antibodies have caused mild DHTRs but not HDFN.
Knops Blood Group System
The Knops blood group antigens are carried on complement
receptor 1 (CR1). Kna, Sla, and McCa, antigens are fairly
common and have a similar prevalence (>90%) in different
populations; however, Sla is present on RBCs of 98% of whites,
but on only 60% of blacks. Typing for Knops system antigens
can be challenging because of the low level of expression on the
RBCs in some disease processes, which gives false-negative
results. RBC CR1 is important in the processing of immune
complexes, binding them for transport to the liver and spleen for
removal from the circulation. The CR1 copy number per RBC
(and thus antigen strength) is reduced in systemic lupus eryth-
ematosus, cold agglutinin disease, PNH, hemolytic anemia,
insulin-dependent diabetes mellitus, acquired immunodefi-
ciency syndrome, some malignant tumors, and any condition
associated with increased clearance of immune complexes. CR1,
and the Sla antigen in particular, may act as a receptor for the
malarial parasite P. falciparum, and thus, the Sl(a) phenotype
may provide selective advantage (Rowe et al., 1997).
Antibodies in the Knops system are usually IgG and they do
not bind complement. The antibodies do not cause HTRs or
HDFN, and once identified, they can usually be ignored for
clinical purposes. Identification may be complicated by the
fluctuation of antigen expression on RBCs. In the Knops
system, anti-Kna is the most common antibody in Caucasians,
and anti-Sla is the most common in African blacks.
Indian Blood Group System
The antigens of the Indian system are carried on CD44. CD44
has a diverse range of biological functions involving cell–cell and
cell–matrix interactions in cells other than RBCs (Telen and
Ferquson, 1990). It is an adhesion molecule in lymphocytes,
monocytes, and some tumor cells. CD44 binds to hyaluronic
acid and other components of the extracellular matrix and is also
involved in immune stimulation as well as signaling between
cells (Goldstein et al., 1989). It is also the receptor for poliovirus.
Inb is a common antigen, and Ina is rare in white persons but has
a prevalence of 4% in Indians, 10% in Iranians, and nearly 12%
in Arabs.
Vel Blood Group System
The carrier of the Vel blood group protein was recently deter-
mined. The recognition of Vel antigen dates back to 1952,
when a patient had a transfusion reaction due to the presence
of an antibody that was found to agglutinate sera of over
10 000 individuals. Recently, a small integral transmembrane
protein, named SMIM1, has been shown to be the carrier of the
Vel antigen. Vel is a common phenotype worldwide and
Immunohematology, Blood Groups 7
Vel- individuals are rare with a frequency slightly higher in
northern Sweden. Vel-negative individuals show no clinical
manifestations. However, following transfusion with Velþ
blood or an incompatible pregnancy, they usually develop
anti-Vel, which causes hemolysis and may result in acute or
delayed transfusion reactions (Storry et al., 2013).
Blood Groups and Disease Association
The absence of some blood group antigens and their carrier
molecules can result in disease or are diagnostic markers for
disease, as discussed above.
Congenital dyserythropoietic anemia is characterized by
ineffective erythropoiesis and increased numbers of multinu-
cleated RBC precursors in the marrow. This syndrome has been
subclassified on the basis of morphologic differences in the
RBC precursors and type IV is characterized by Co(ab),
In(b), LW(ab), and Lu(bþ) RBC phenotypes (Jaffray et al.,
2013). RBCs of patients with PNH exhibit a deficiency of
GPI-linked proteins. This results in a lack of Cromer, Cart-
wright, and Dombrock blood group antigens as well as John
Milton Hagen antigen.
RBCs and white blood cells from patients with leukocyte
adhesion deficiency II (also known as congenital disorder of
glycosylation type II) lack antigens that are dependent on
fucose. The RBCs have the Bombay, Le(ab) phenotype and
the white blood cells lack sialyl-Lex, which explains the high
white blood cell count and infections in these patients
(Hirschberg, 2001). Hemagglutination is a simple test to
diagnose these syndromes.
DNA-Based Typing for Blood Group Antigens
The majority of genes encoding blood group antigens have
been identified and cloned and the molecular basis of most
blood group antigens has been determined (Lögdberg et al.,
2011). Knowledge of the gene has advanced understanding of
the structure and function of the components carrying antigens,
and an appreciation of diseases associated with loss of
expression of some blood groups, i.e., null phenotypes
(Westhoff, 2006). Importantly, it has made it possible to
perform DNA analyses to predict the serologic phenotype, to
determine gene dosage (zygosity), to perform noninvasive fetal
typing, and to type for numerous blood group antigens in
a single assay. Although the simple agglutination test remains
the principle assay for RBC antigen typing for ABO and Rh,
antibody screen, and compatibility testing, genotyping for
minor blood group antigens has become commonplace.
See also: Autoimmune Hemolytic Disease – Warm Autoimmune
Hemolytic Anemia, Cold Hemagglutinin Disease, Paroxysmal
Cold Hemoglobinuria, and Paroxysmal Nocturnal
Hemoglobinuria; Blood Products; Pathophysiology of Sickle
Cell Disease; Perinatal Alloantibody Disorders – Neonatal
Alloimmune Thrombocytopenia/Hemolytic Disease of the Fetus
and Newborn; Transfusion-Related Adverse Events.
8 Immunohematology, Blood Groups
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Further Reading
Hall, J.E., Gyton, A.C., 2011. Gyton and Hall Textbook of Medical Physiology. Saunders
Elsevier, Philadelphia, PA.
Hoffman, R., Benz, J., Silberstein, L.E., Heslop, H., Weitz, J., Anastasi, J., 2012.
Hematology, Basic Principles and Practice. Elsevier Saunders, Philadelphia, PA.
Quinley, E.D., 2012. Immunohematology Principals and Practice. Lippincott Williams &
Wilkins, New York.
Schenkel-Brunner, H., 2012. Human Blood Groups, Chemical and Biochemical Basis
of Antigen Specificity. Springer, London.