C H A P T E R 110 
HUMAN BLOOD GROUP ANTIGENS AND ANTIBODIES
Connie M. Westhoff, Jill R. Storry, and Beth H. Shaz
Pretransfusion testing includes ABO and Rhesus (Rh) type and anti-
body screening to determine whether a patient has an unexpected red
blood cell (RBC) antibody. If the antibody screen is positive, an
identification panel is performed to identify the specificity of the
antibody. Unexpected antibodies can be clinically significant causing
hemolysis (i.e., acute or delayed hemolytic reaction) after transfusion
of RBCs carrying the reciprocal antigen, or can be insignificant. The
clinical significance of an antibody is assessed by correlating the sero-
logic information with clinical experiences reported in the literature
and with the patient’s medical history. Notably, the majority of clini-
cally significant antibodies (outside the ABO system) are in response
to RBC antigen exposure either through transfusion or pregnancy.
Other antibody characteristics that are used to predict clinical signifi-
cance include immunoglobulin (Ig) class and in vitro characteristics
such as strength of reactivity and titer; however, no foolproof method
exists to predict the clinical significance. For antibodies with well-
known clinical significance, antigen-negative blood is selected for
transfusion. Predicting clinical significance is more difficult when a
patient has an antibody to a novel or rare high-prevalence antigen and
requires a transfusion but antigen-negative blood is not available.
ERYTHROCYTE BLOOD GROUP ANTIGENS
Erythrocyte blood group antigens are polymorphic, inherited, carbohy-
drate, or protein structures located on the surface of the RBC membrane.
There are more than 300 blood group antigens, most of which are
included in 36 different blood group systems (Table 110.1). The protein
antigens are primarily located on integral transmembrane proteins, but
a few are on glycosylphosphatidylinositol (GPI)–linked proteins (Fig.
110.1). Some antigens are carbohydrates attached to proteins or lipids,
some require a combination of a specific portion of protein and carbo-
hydrate, and a few antigens are carried on proteins that are adsorbed
from the plasma. Many of the proteins carrying blood group antigens
reside in the erythrocyte membrane as complexes with other proteins.
Recognition of a new blood group antigen begins with discovery
of an antibody. When an individual whose RBCs lack an antigen is
exposed to RBCs that possess the antigen, he or she may mount an
immune response and produce antibodies that react with the antigen.
Depending on the characteristics of the antibody and the number
and topology of antigens in the RBC membrane, the interaction in
vivo between antibody and antigen may result in removal of antibody-
coated RBCs by the reticuloendothelial system or in hemolysis if
complement is activated.
In blood group testing, most assays are designed to detect
antibody-antigen binding with clumping of the RBCs (“agglutina-
tion”) as the detectable endpoint. The ability to detect and identify
blood group antigens and antibodies has contributed significantly to
current safe supportive blood transfusion practice, to the appropriate
management of pregnancies at risk for hemolytic disease of the fetus
and newborn (HDFN), and to management of hematopoietic pro-
genitor cell and solid organ transplantation.
Terminology
Some blood group systems bear the family surname in which the
antibody was first discovered (Kell, Kidd, Duffy, etc.), with abbrevia-
tions to indicate antigens (K/k, Jka/Jkb, Fya/Fyb, etc.). Others have
been given letter designations (A, B, D, M, N, etc.). A committee
for terminology of RBC surface antigens and alleles, organized by the
International Society of Blood Transfusion (ISBT), works to stan-
dardize terminology of new blood group antigens and the coding
alleles.
DNA-Based Typing for Blood Group Antigens
The majority of genes encoding blood group antigens have been identi-
fied and cloned, and the molecular basis of most blood group antigens
has been determined.1,2 Details concerning the alleles associated with
blood group antigens are found on the ISBT nomenclature and the
Blood Group Antigen Gene Mutation Database (BGMUT) websites
(www.ncbi.nlm.nih.gov/gv/mhc/xslcgi.cgi?cmd=bgmut/home;
www.isbtweb.org/working-parties/red-cell-immunogenetics-and-
blood-group-terminology/). Knowledge of the genes has advanced
understanding of the structure and function of the components
carrying antigens and resulted in an appreciation of diseases associated
with loss of expression of some blood groups, for example, null phe-
notypes (Table 110.1). Of importance, knowledge of the gene has
made it possible to perform DNA analyses to predict the serologic
phenotype, to determine gene dosage (zygosity), to perform noninva-
sive fetal typing, and to type for numerous blood group antigens in a
single assay.
Although the simple hemagglutination test remains the principal
assay for RBC antigen typing for ABO and Rh, antibody screen, and
compatibility testing; genotyping for minor blood group antigens has
become commonplace in several clinical situations (Table 110.2).
These include determination of the extended blood group phenotype
in patients who are multiply transfused, which avoids false typing
because of contaminating donor RBCs and aids determination of
antibody specificity. This approach is also preferred in patients with
strongly direct antiglobulin test (DAT)-positive RBCs, as well as for
typing for antigens when no serologic reagents are available and for
fetal typing from amniocytes or from free DNA present in the
maternal plasma. In these instances2a and others (Table 110.2),
hemagglutination is not helpful and genomic analysis is a useful
adjunct to routine testing. More recently, genotyping is useful in
patients treated with daratumumab (anti-CD38) because treatment
results in panreactivity on antibody screening (all cells being reactive).
High-throughput genotyping systems have enabled blood centers to
screen donors for a large number of antigens in a single assay.
Blood Group Antibodies
The common causes of immunization against blood group antigens
are transfusion, pregnancy, transplantation, or occasionally, practices
such as sharing needles. “Naturally occurring” antibodies are not a
result of RBC exposure; rather, a response to microbes encountered
by way of the digestive tract and other mucosal surfaces regularly
(e.g., anti-A, anti-B,) or sometimes (e.g., anti-M, -P, -Pk, -P1, -Lea,
-Leb, -I, -IH) which result in production of antibodies with these
specificities. These are the most common antibodies present in chil-
dren and nontransfused male patients, and are primarily IgM. These
multivalent IgM antibodies directed to carbohydrate antigens
optimally bind and directly agglutinate to RBCs at temperatures
below 37°C. Most are not clinically significant (outside of ABO).
1687
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TABLE
Blood Group Systems, Antigens, Expression, and Disease Associations
110.1
Predicted Topology Principal Associated Blood
ISBT System (Number of Amino Group Antigens (null
Name (Number) Gene Name Acids [AA]) Component Name phenotype) Present in Other Tissue Disease Association Function
ABO (001) ABO Glycosyl-transferases Carbohydrate A, B, AB, A1 Secretions, platelets, broad tissue Altered in some hematologic Glycosylation
Type IIa (354 AA) (group O) distribution disorders, leukemia
MNS (002) GYPA (MN) Type I (131 AA) GPA M, N, S, s, U, Vw; Mk Mk Renal endothelium and epithelium Decreased Plasmodium falciparum Negative charge on sialic
GYPB (Ss) Type Ia (72 AA) GPB lack GPA and GPB; invasion acid; receptor for
En(a−) lack GPA; May be receptor for Escherichia coli microbes
S−s−U− lack GPB
Part XI  Transfusion Medicine

P (003) A4GALT Galactosyl- Carbohydrate P1, Pk (P1−, PP1Pk−) Lymphocytes, granulocytes, Receptor E. coli and Glycosylation
transferase monocytes, platelets Parvovirus-B19
Type II (353 AA) Miscarriage
Rh (004) RHD Multipass—12 RhD D, C, E, c, e, G, V/VS RBC-specific Hemolytic anemia; stomatocytosis Structural link to
RHCE spans (417 AA) RhCE (Rhnull syndrome) Reduced expression and mosaicism underlying cytoskeleton
in hematologic malignancies
Lutheran LU Type I IgSF (597 Lutheran Lua, Lub, Lu3, Aua, Aub Broad tissue distribution Increased expression possibly Possibly adhesion; may
(005) AA) (557 AA) glycoprotein (recessive Lu(a−b−)) Not on lymphocytes, granulocytes, involved in vasoocclusion in mediate intracellular
B-CAM monocytes or platelets sickle cell disease signaling
Binds to laminin
Kell (006) KEL Type II (732 AA) Kell glycoprotein K, k, Kpa, Kpb, Ku, Jsa, Jsb Broad tissue distribution Depressed in McLeod syndrome Cleaves big endothelin
(K0 or Knull) Bone marrow, fetal liver, testes, (see XK) 3 to ET-3 (a potent
brain, heart, skeletal muscle vasoconstrictor)
Lewis (007) FUT3 (LE) Not endogenous to Carbohydrate Lea, Leb, Leab, Lebh, ALeb, Saliva and body fluids, Increased expression in fucosidosis Fucosyl transferase
RBCs Adsorbed from BLeb (Le(a−b−)) Blood cells, GI, skeletal muscle,
Type II (361 AA) plasma kidney, adrenal
Duffy (008) ACKR1 Multipass—7 spans Fy glycoprotein Fya, Fyb, Fy3, Fy6 Broad tissue distribution Plasmodium vivax receptor Chemokine receptor
(FY) (338 AA) (Fy(a−b−)) Endothelial and epithelial cells, RBC null-resistant to P. vivax
Purkinje cells, colon, lung,
spleen, thyroid, thymus, kidney
Kidd (009) SLC14A1 Multipass—10 Kidd glycoprotein Jka, Jkb, Jk3 (Jk(a−b−) or Kidney: vasa recta endothelium Urine concentrating defect Urea transport
(JK) spans (389 AA) Jknull) Renal medulla
Diego (010) SLC4A1 Multipass—14 Band 3, AE1 Dia, Dib, Wra, Wrb, (1 Kidney: intercalated cells of distal Southeast Asian ovalocytosis, Anion transport
(DI) spans (911 AA) reported—transfusion and collecting tubules hereditary spherocytosis, renal CO2/HCO3−
dependent; predicted to tubular acidosis exchange
be incompatible with
life)
Yt (011) ACHE (YT) GPI-linked (557 AA) Acetyl-cholinesterase Yta, Ytb Brain, muscle, nerves Absent from PNH III RBCs Enzymatic
Xg (012) MIC2 (XG1) Type I (180 AA) Xga glycoprotein Xga The antigen may be restricted to Adhesion molecule
(163 AA) RBC, but CD99 has broad tissue
distribution
 Predicted Topology Principal Associated Blood
ISBT System (Number of Amino Group Antigens (null
Name (Number) Gene Name Acids [AA]) Component Name phenotype) Present in Other Tissue Disease Association Function
Scianna (013) ERMAP Type I (475 AA) ERMAP Sc1, Sc2, Sc3, Rd (Sc Possible adhesion
(SC) −1, −2, −3)
Dombrock ART4 (DO) GPI-linked (314 AA) Do glycoprotein; Doa, Dob, Gya, Hy, Joa Lymphocytes, spleen, lymph nodes, Absent from PNH III RBCs Enzymatic
(014) ART 4 (Gy(a−)) GI, ovary, testes, heart, liver
Colton (015) AQP1 (CO) Multipass—6 spans Aquaporin Coa, Cob, Co3 (Co(a−b−)) Broad tissue distribution Monosomy 7, congenital Water transport
(269 AA) Kidney, liver, gallbladder, eye, dyserythropoietic anemia
capillary endothelium
Landsteiner- ICAM4 (LW) Type I IgSF (241 LW glycoprotein LWa, LWb, LWab Depressed in some malignant Ligand for integrins
Wiener AA) ICAM-4 (LW(a−b−)) diseases; decreased in Rhnull
(016) syndrome
Chido/ C4A, C4B Not endogenous to C4A; C4B Ch1, Ch2, Rg1 Adsorbed from plasma Certain phenotypes increased Part of the complement
Rodgers (CH/RG) RBC (1191 AA) susceptibility to autoimmune cascade
(017) conditions and infections
C4-deficient
predisposes for SLE
H (018) FUT1(H) Fucosyl-transferase Carbohydrate H (Bombay Oh) Broad distribution Soluble—all Decreased in some tumor cells Glycosylation
Type II (365 AA) fluids except CSF in secretors Increased in hematopoietic stress
Kx (019) XK (XK) Multipass—10 XK glycoprotein Kx (McLeod) Fetal liver, adult skeletal muscle, X-linked midlife onset neuropathy, Transport; possible
spans (444 AA) brain, pancreas, heart elevated CPK, muscular neuro-transmitter
dystrophy, acanthocytosis;
sometimes associated with CGD
Gerbich (020) GYPC (GE) Type I (128 AA) GPC GPD Ge2, Ge3, Ge4 (Leach Fetal liver, renal endothelium Hereditary elliptocytosis, hemolytic Structural Interacts with
(107 AA) phenotype) anemia, receptor P. falciparum protein 4.1 and p55
Cromer (021) CD55 GPI-linked (347 AA) DAF Cra, Tca, Tcb, Tcc, Dra, Esa, Vascular endothelium Absent from PNH III RBCs Complement regulation;
(CROM) IFC (Inab) Epithelial GI, GU, CNS Dra is receptor for uropathogenic E. binds C3b;
Soluble form in plasma and urine coli disassembles C3/C5
convertase
Knops (022) CR1 (KN) Type I (1998 AA) CR1 Kna, Knb, McCa, Sla, Yka, Blood cells, glomerular podocytes, Antigens depressed in certain Complement regulation;
KCAM (no nulls follicular dendritic cells autoimmune and malignant binds C3b and C4b;
reported) conditions mediates phagocytosis
Indian (023) CD44 (IN) Type I (341 AA) Hermes antigen Ina, Inb Wide tissue distribution 1 case—congenital Binds hyaluronic acid;
dyserythropoietic anemia mediates adhesion of
leukocytes
Ok (024) BSG (OK) Type I IgSF (248 Basigin Oka All cells tested Receptor P. falciparum Possible adhesion
AA)
RAPH (025) MER2 Multipass—4 spans CD151 MER2 (Raph−) Fibroblasts Absence associated with renal
(253 AA) disease and kidney failure

Continued
Chapter 110  Human Blood Group Antigens and Antibodies
1689
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TABLE
Blood Group Systems, Antigens, Expression, and Disease Associations—cont’d
110.1
Predicted Topology Principal Associated Blood
ISBT System (Number of Amino Group Antigens (null
Name (Number) Gene Name Acids [AA]) Component Name phenotype) Present in Other Tissue Disease Association Function
JMH (026) SEMA-L GPI-linked (656 AA) Semaphorin 7A JMH Absent from PNHIII RBCs Adhesion molecule
(JMH)
I (027) GCNT2 N-acetyl- Carbohydrate I (I− or i adult) Broad tissue distribution Cataracts in Asians Glycosylation
glucosaminyl-
transferase type
Part XI  Transfusion Medicine

II (400 AA)
Globoside B3GALT1 N-acetyl- Carbohydrate (Gb4, P (P−) Broad tissue distribution Receptor E. coli and Glycosylation
(028) galactosaminyl- globoside) Pk and p Placenta (trophoblasts and Parvovirus-B19
transferase type interstitial cells) Spontaneous abortion
II (331 AA)
GIL (029) AQP3 (GIL) Multipass—6 spans AQP3 GIL (GIL−) Board tissue distribution Glycerol/ water/ urea
(292 AA) Kidney, prostate, GI tract, spleen, transport
skin, eye
RHAG (030) RHAG Multipass—12 Rh-associated RHAG1 or Duclos, RHAG2 RBC-specific but Hereditary overhydrated Ammonia transport
spans (409 AA) glycoprotein or Ola, RHAG3 or DL, homologs RhBG, RhCG in kidney, stomatocytosis
RHAG4 (Rhnull regulator) liver, skin, GI tract
FORS (031) GBGT1 Type II (347 AA) Carbohydrate FORS1 Broad tissue distribution Glycosyltransferase
JR (032) ABCG2 Type III – 6 spans ATP-binding Jra (Jr(a−)) Broad tissue distribution. High in Gout; multidrug resistance in Urate exporter; porphyrin
(655 AA) cassette placenta, seminal vesicles. cancer hemostasis
sub-family G
member 2
LAN (033) ABCB6 Type III – 6 spans ATP-binding Lan (Lan−) Broad tissue distribution Dyschromatosis universalis Binds heme and
(842 AA) cassette hereditaria; Microphthalmia porphyrins. Important in
sub-family B heme synthesis
member 6,
mitochondrial
VEL (034) SMIM1 Type 1 (78 AA) SMIM1 Vel (Vel−) RBCs, salivary glands, testis Not known
CD59 (035) CD59 GPI-linked (128 AA) CD59 glycoprotein CD59.1 (CD59.1−) Broad tissue distribution; Soluble Hemolytic anemia, with or without Complement regulation;
form in plasma polyneuropathy inhibits MAC complex
AUG SLC29A1 Type III – 11 spans Equilibrative Ata (At(a−) Broad tissue distribution Pseudo gout in the null phenotype Nucleoside transmembrane
(456 AA) nucleoside transporter
transporter 1
Type I, protein with a single pass through the RBC lipid bilayer with its amino terminus to the outside of the cell; type II, protein with a single pass through the RBC lipid bilayer with its amino terminus to the inside of the cell.
AE1, Anion exchanger 1; AQP, aquaporin; C4, fourth component of complement; CGD, chronic granulomatous disease; CR1, complement receptor 1; CSF, colony-stimulating factor; CNS, central nervous system;
DAF, decay-accelerating factor; ERMAP, erythrocyte membrane-associated protein; GPA, glycophorin A; GPB, glycophorin B; GPC, glycophorin C; GPD, glycophorin D; GI, gastrointestinal; GPI, glycosylphosphatidylinositol;
GU, genitourinary; ICAM4, intercellular adhesion molecule 4; IgSF, immunoglobulin super family; ISBT, International Society of Blood Transfusion; PNH, paroxysmal nocturnal hemoglobinuria; RBC, red blood cell; SLE, systemic
lupus erythematosus.
 Chapter 110  Human Blood Group Antigens and Antibodies 1691

Single-pass proteins
MNSs (GPA/GPB)
Gerbich (GPC/GPD)
Indian (CD44) GPI-linked proteins
Knops (CR1)
Cromer (DAF)
Lutheran (B-CAM)
Yt (AChE)
LW (ICAM-4)
Dombrock (ART4)
Xg
JMH
Sc (ERMAP)
Kell Multipass proteins NH2
Carbohydrate NH2 COOH Rh (12 pass)
ABO RhAg (12 pass)
Hh Kx (10 pass)
Lewis Diego (Band 3, 14 pass)
I Colton (AQP-1, 10 pass)
NH2 Duffy (7 pass) Kidd (10 pass)
P1
P Outside

COOH NH2 COOH NH2 COOH

N-glycan O-glycan GPI-linker

Fig. 110.1  MODEL OF BLOOD GROUP PROTEINS IN THE RED BLOOD CELL MEMBRANE.
Schematic representation of the red blood cell (RBC) molecules that carry blood group antigens and the
predicted structure. These include carbohydrates, single and multipass proteins, and GPI-linked proteins
in the RBC membrane. AQP-1 (aquaporin-1), COOH (carboxyl group), CR1 (complement receptor 1),
DAF (decay-accelerating factor), ERMAP (erythrocyte membrane-associated protein), GPA (Glycophorin
A), GPB (glycophorin B), GPC (glycophorin C), GPD (glycophorin D), GPI (glycosylphosphatidylinositol),
ICAM-4 (intercellular adhesion molecule 1), LW (landsteiner-wiener), Rh (rhesus), RhAG (Rh-associated
glycoprotein).

TABLE Uses of DNA-Based Genotyping Assays
110.2 for Transfusion Medicine
Type patients who have been recently transfused
Type patients who are being treated with monoclonal antibody therapy,
for example anti-CD38
Type RBCs coated with immunoglobulin
Type patients with AIHA (to select antigen-negative RBCs for
transfusion and absorption of autoantibodies when searching for
underlying alloantibodies)
Type RBCs when commercial antisera are not available
Type for numerous blood group antigens in a single assay
Identify weak D and partial D (to determine candidate for Rh immune
globulin or avoid use of limited Rh-negative donor supply)
Resolve blood group typing discrepancies
Determine paternal zygosity for RHD and HPA
Type fetus to determine risk for HDFN or NAIT
AIHA, Autoimmune hemolytic anemia; HDFN, hemolytic disease of the fetus
and newborn; HPA, human platelet antigen; NAIT, neonatal alloimmune
thrombocytopenia; RBC, red blood cell.
group systems are primarily of the IgG isotype that react at 37°C and
are detected by the indirect antiglobulin test (IAT). These bivalent
antibodies optimally bind to, but do not directly agglutinate, RBCs
at 37°C. The addition of an antiglobulin reagent (i.e., antihuman
IgG (AHG), also known as Coombs serum) is required to induce
RBC agglutination. Most of these are clinically significant antibodies,
with the exception of antibodies to Knops (Kn), Chido/Rodgers (Ch/
Rg) and JMH systems (Table 110.3 summarizes the Ig class and
clinical significance associated with alloantibodies; see also box on
Indirect Antiglobulin Test and Direct Antiglobulin Test).
Antibodies recognizing antigens in the ABO system are by far the
most clinically significant and are present in nearly all individuals
who lack the antigen (they typically appear by 4 months of age).
Other clinically significant antibodies occur in the following approxi-
mate order, from the most to the least commonly encountered in
transfusion practice: anti-D, anti-K, anti-E, anti-c, anti-Fya, anti-C,
anti-Jka, anti-S, and anti-Jkb. Clinically significant antibodies occur in
approximately 3% of transfused patients3 but have a higher incidence
of 35% to 55% in patients undergoing chronic transfusion.4–8 The
frequency of antibody production depends on the antigen immuno-
genicity and prevalence of the antigen in a population.

Exceptions occur if the antibody is reactive at 37°C and/or has an

IgG component. Antibodies that are considered not to be clinically Compatibility Procedures and Location of
significant unless the antibody reacts in tests performed at 37°C Antigen-Negative Blood
include those to A1, P1, M, N, Lua, Lea, Leb, I, IH, and Sda
antigens. Manual tube, solid phase, or gel-column methods based on agglutina-
In contrast, antibodies occurring following immunization to tion of RBCs are the most common serologic assays performed in
protein antigens such as those in the Rh, Kell, Kidd, and Duffy blood transfusion medicine laboratories.
 1692 Part XI  Transfusion Medicine

TABLE
Characteristics of Some Blood Group Alloantibodies (Listed in Approximate Order of Clinical Significance)
110.3
Clinical
Antibody
Specificity IgM IgG Transfusion Reaction HDFN
ABO Most Some Immediate; mild to severe Common; mild to moderate
H in Bombay Most Some Immediate; mild to severe Rare; mild
Rh Some Most Immediate/delayed; mild to severe Common; mild to severe
RhAG Rare Most Immediate/delayed; mild to severe Mild to severe
Kell Some Most Immediate/delayed; mild to severe Mild to severe
Kidd Few Most Immediate/delayed; mild to severe Rare; mild
Duffy Rare Most Immediate/delayed; mild to severe Rare; mild
S Some Most Delayed/mild Rare; mild to severe
s Rare Most Delayed/mild Rare; mild to severe
U Rare Most Immediate/delayed; mild to severe Rare; severe
PP1Pk Most* Most* Immediate; mild to severe Mild to severe†
Vel Most* Most* Immediate/delayed; mild to severe Mild to severe
Diego Some Most Delayed; none to severe Mild to severe
Colton Rare Most Delayed; mild Rare; mild to severe
Lutheran Some Most Delayed Rare; mild
Dombrock Rare Most Immediate/delayed; mild to severe Rare; mild
M Some Most Delayed (rare) Rare; mild to severe
N Most Rare None None
LWa Rare Most Delayed; none to mild Rare; mild
a
Yt Rare Most Delayed (rare); none to mild None
Ch/Rg Rare Most Anaphylactic (rare) None
JMH Rare Most Delayed (rare in genetic variants); none to mild None
P1 Most Rare None (rare) None
Lea Most Few Immediate (rare) None
Leb Most Few None None
I Most Rare None None
None to mild in I adults
Knops Rare Most None None
Xga Rare Most None None
*Most examples of these antibodies are both IgM and IgG.
†Seldom hemolysis of fetal cells but high incidence of recurrent spontaneous abortions.
IgG, Immunoglobulin G; IgM, immunoglobulin M; HDFN, Hemolytic disease of the fetus and newborn; Rh, rhesus; RhAG, Rh-associated glycoprotein.

ABO Antibody Screening

Commercially available mouse monoclonal anti-A and anti-B are
used to determine ABO type, and these reagents directly agglutinate
RBCs at room temperature. To confirm the RBC ABO reactivity, the
plasma is tested for the presence of the corresponding agglutinins by
testing with commercially available group A1 and group B RBCs. In
both tests, agglutination is macroscopically visible.
Rhesus
Patient and donor RBCs are routinely tested for the presence of the
D antigen in the Rh system. Reagents containing monoclonal anti-D
that directly agglutinate D-positive (Rh-positive) RBCs suspended in
saline at room temperature are commonly used for testing. Testing
by a method that detects expression of a weak D antigen on RBCs
is required for donors, but additional testing for weak D is optional
when testing patient samples. Exceptions include typing the RBCs
of a newborn when the mother is D-negative to determine whether
she is a candidate for Rh immune globulin (RhIG) (see box on Rh
Immune Globulin).
Patient plasma is incubated at 37°C with commercially available
reagent RBCs of known antigen type. After incubation, unbound
antibodies are removed by washing with saline, and an antiglobulin
reagent containing either AHG, or a mixture of AHG and antihuman
complement is added. Column agglutination technology is now
widely used and eliminates the requirement to wash unbound IgG.
If the antibody screen is positive, the specificity of the antibody is
determined by testing the plasma against a panel of different group
O reagent RBCs (usually 10) varying in antigen phenotype (termed
antibody identification).
Compatibility Testing
Once a patient is actively immunized to an RBC antigen and pro-
duces a clinically significant alloantibody, the patient is considered
immunized for life and should be transfused with antigen-negative
RBCs, even if the antibody is no longer detectable. Patients with
passively acquired antibody (e.g., neonates with maternal antibody;
recipients of plasma and platelet products or RhIG) need to be

Indirect Antiglobulin Test and Direct Antiglobulin Test
The indirect antiglobulin test (IAT) is used to detect alloantibodies in
patient sera in vitro following incubation at 37°C and includes antibody
screening and identification and crossmatching with donor red blood
cells (RBCs). IAT is also sometimes used for antigen typing to detect
RBCs coated with antibody following incubation with reagent antisera.
After incubation, unbound antibodies are removed by washing with
saline and an antiglobulin reagent containing either antihuman IgG
(AHG) or a mixture of AHG and monoclonal antihuman complement
is added. Differential agglutination suggests the presence of antibodies
to one or more specific RBC antigens while agglutination of all cells
suggests the presence of an antibody to a high-prevalence antigen or
the presence of an autoantibody.
The direct antiglobulin test (DAT) is used to detect the presence of
antibody or complement (or both) on the surface of RBCs in vivo such
as autoantibodies coating the patient’s cells in warm autoimmune
hemolytic anemia, cold hemagglutinin disease, or alloantibodies coating
the patient’s cells in immediate or delayed transfusion reactions, or
hemolytic disease of the fetus and newborn. Patient RBCs obtained
in ethylenediaminetetraacetic acid, to prevent in vitro complement
deposition on the RBCs, are washed with saline and then incubated
with a commercial antiglobulin reagent containing AHG or antihuman
complement or a mixture of the two. Antiglobulin reagents contain-
ing anti-IgM or anti-IgA are available in specialized centers to detect
coating of RBCs by antibodies of these isotypes.
Rh Immune Globulin
Rh immune globulin (RhIG) is a human plasma-derived hyperim-
munoglobulin product consisting of IgG antibodies to D antigen that
is administered to D-negative pregnant women who are at risk for
D sensitization. RhIG is administered (1) at 28 weeks gestational
age, (2) when there is a risk for fetal maternal hemorrhage through
amniocentesis, trauma, or other procedures, and (3) postpartum in the
case of a known or potential D-positive newborn or fetus. If the Rh(D)
typing of a pregnant woman is discrepant with prior results, or typing
reactions are weaker than expected, or if variable reactivity is seen,
RHD genotyping should be considered to guide RhIG prophylaxis and
selection of blood for transfusion.
RhIG is sometimes administered outside of pregnancy to D-negative
patients who receive D-positive blood products, most commonly whole
blood derived platelet products. This is primarily considered for females
of childbearing potential when the formation of anti-D has serious
consequences. Because the risk for D alloimmunization from whole
blood derived platelet transfusion is less than 4%, and even less for
apheresis platelets, the majority of D-incompatible platelets are given
without RhIG administration. RhIG in significantly higher doses is used
to treat immune thrombocytopenic purpura (ITP) in patients who are
D-positive and have not been splenectomized.
For prevention of D-sensitization in the United States, 300 µg are
routinely administered, but dosing is increased if there is evidence
of large fetal-maternal hemorrhage (300 µg for every 15 mL of RBC
exposure or 30 mL of whole blood exposure). The dose is calculated
based on the estimated volume of D-positive fetal RBCs from Kleihauer-
Betke or flow cytometry, which is more precise. RhIG dosing calculators
are available. RhIG should be given within 72 hours, which was the
time period for the original studies, but should not be withheld if not
administered within this time period. Adverse events to low doses
used to prevent D immunization include fever, chills, and pain at the
injection site. Rarely, hypersensitivity reactions are noted. RhIG doses
used to treat ITP are substantial: 50 µg/kg for hemoglobin values
≥10 g/dL and 25–40 µg/kg when hemoglobin is 8–10 g/dL. Adverse
events include possible anemia, hemolysis, disseminated intravascular
coagulopathy, and rarely, death (Chapter 131).
transfused with antigen-negative RBCs only while the passive anti-
body is present. Selection of blood for transfusion to patients with
alloantibodies requires typing of donor units for the corresponding
antigen to identify antigen-negative units and crossmatch of the
selected units with the patient’s plasma. Antigen-negative units are
provided by, or can be located by, most donor centers. Provision of
Chapter 110  Human Blood Group Antigens and Antibodies 1693
Approaches to Supplying Red Blood Cell Products to
TABLE
Prevent Alloimmunization in Patients With Sickle Cell
110.4
Disease or Other Transfusion-Dependent Anemia
Phenotype or genotype for clinically significant antigens before
transfusion
Provide antigen-matched blood for C, E, and K prophylactically
Provide blood negative for the major antigens that the patient lacks
after the patient makes an antibody
antigen-negative blood will to some extent depend on the prevalence
of the target antigen(s) in the donor population. Transfusion service
staff are vital for communication between the patient’s physician and/
or consultant transfusion medicine specialist to determine the imme-
diate and ongoing transfusion needs of the patient and to ensure that
antigen-negative blood is available. Understanding the risks and
benefits of transfusion are important, as well as understanding the
potential clinical significance of the antibody and the urgency of
transfusion. When a patient’s antibody is directed at a high-prevalence
antigen, it is important to test siblings in the quest for compatible
blood and to urge the patient to donate blood for long-term storage
when clinical status permits. In hemolytic anemia because of warm-
reactive autoantibodies, compatibility may be difficult to demonstrate.
In this scenario, the important issue is to be sure that there are no
clinically significant alloantibodies underlying the warm reactive
autoantibodies. Donor RBCs antigen-matched with the patient for
clinically significant blood group antigens should be considered in
lieu of transfusion with “least incompatible” blood to minimize
alloimmunization.
Prevention of Alloimmunization
Transfusion management of patients who require chronic trans-
fusion therapy, in particular patients with sickle cell disease can
be challenging.9–11 Many programs attempt to reduce or prevent
alloimmunization by transfusion of RBCs that are prophylactically
antigen-matched, typically for C, E, and K,12 and some match for
additional antigens. Some centers match for extended antigens once
the patient makes an antibody (Table 110.4). The goal is to prevent
hemolytic or delayed transfusion reactions, which are known to be
underreported because they can manifest as a sickle cell crisis and
may result in decreasing the transfusion interval.
Blood Group Disease Association
The absence of some blood group antigens and their carrier molecules
can result in disease. For example, an absence of the Rh and
Rh-associated glycoprotein (RhAG) proteins causes stomatocytosis13
and anemia, termed Rhnull syndrome. The absence of Xk protein is
associated with the McLeod syndrome, which is associated with
myopathy and neurodegeneration. RBCs and white blood cells from
patients with leukocyte adhesion deficiency II (also known as con-
genital disorder of glycosylation type II) lack antigens that are dependent
on fucose. The RBCs have the Le(a−b−) Bombay phenotype and the
white blood cells lack sialyl-Lex, which explains the high white blood
cell count and infections in these patients. Hemagglutination is a
simple test that can be used to diagnose these syndromes. In patients
with paroxysmal nocturnal hemoglobinuria, a proportion of the
RBCs will lack antigens carried on GPI-linked proteins. Other
associations between blood group antigens and diseases are summa-
rized in Table 110.1.
Diseases associated with antibodies to blood group antigens
include hemolytic disease of the newborn, warm autoimmune hemo-
lytic anemia, cold hemagglutinin disease, and paroxysmal cold
hemoglobinuria. Hemagglutination is a valuable aid in diagnosis of
these conditions.
 1694 Part XI  Transfusion Medicine

Blood Group Systems
Presented here is a brief description of the most clinically relevant
blood group systems in approximate order of clinical significance. For
further information and prevalence of blood group antigens in dif-
ferent populations, refer to specialized texts such as Human Blood
Groups, The Blood Group Antigen Facts Book, and the AABB Technical
Manual.2,3,14
Carbohydrate Blood Groups
ABO and H
The ABO blood group system is by far the most clinically significant,
because of the presence of naturally occurring IgM antibodies (and
sometimes IgG). The original observation by Landsteiner that certain
human erythrocyte suspensions were agglutinated by other human
sera led to the recognition of ABO polymorphism.14a This initial
observation is still the cornerstone of modern transfusion practice
more than a century later.
Antigens and Their Synthesis
ABH antigens occur on glycoproteins and glycolipids and are synthe-
sized in a stepwise fashion by glycosyltransferases that sequentially
add specific monosaccharides in specific linkages to a growing oligo-
saccharide precursor chain (reviewed in Clausen and Hakomori15).
The terminal sugar determines antigen specificity (Fig. 110.2). Group
O individuals have H antigen only, the terminal sugar of which is
fucose, and this is the precursor substrate for A and B antigens. Group
O individuals have defective A or B transferases. The A and B
transferase enzymes differ only by the nature of the monosaccharide
added to the chain. N-acetyl-D-galactosamine is added by A-transferase,
and D-galactose is added by B-transferase. 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.
The differences between A1 and A2 phenotypes are quantitative and
qualitative. Not only is the A1 transferase more efficient in converting
H to A antigen (approximately five times more A sites per RBC on
A1 RBCs than on A2 RBCs), it also has the capacity to make A1
antigen on the repetitive A epitope. Quantitatively normal ABH
expression also requires the branching of carbohydrate chains, which
is performed by the blood group I enzyme. Some H antigen precursor
remains on A and B RBCs in this order: A2 > B > A2B > A1 > A1B.
Inherited and Acquired ABH Variation  In addition to the main
ABO types, there are many other inherited phenotypes with a weaker
expression of the specified antigen, for example, A3, Ax, Ael, B3, B(A),
and cis-AB. This can cause problems in determining the ABO blood
group, but for patients needing immediate transfusion, the selection

Gal GlcNAc R
Precursor: β1 → 4
Gal GlcNAc
β1 → 4 β1 → 3

Fucosyltransferase H (FUTI)
Gene

Gal GlcNAc R
β1 → 4
H Gal GlcNAc
β1 → 4 β1 → 3

α1 → 2

Fuc

A transferase B transferase

A B
Gal GlcNAc R Gal GlcNAc R
β1 → 4 β1 → 4
GalNAc Gal GlcNAc Gal Gal GlcNAc
α1 → 4 β1 → 4 β1 → 3 β1 → 4 β1 → 3

α1 → 2 α1 → 2

Fuc Fuc

Gal = Galactose
Fuc = Fucose
GalNAc = N-acetylgalactosamine
GlcNAc = N-acetylglucosamine

Fig. 110.2  BIOCHEMICAL STRUCTURES OF ABH ANTIGENS. Schematic representation of the ter-
minal portions of the carbohydrate structures carrying the H, A, and B antigens on red blood cells.

of group O red cells and AB plasma products is an option. In blood
donors, if very weak expression of A or B antigens on the RBCs is
not detected, the major risk is that they may be transfused to a patient
whose antibodies may cause accelerated destruction of the transfused
cells.
Rare Bombay (Oh) phenotype RBCs, first reported in Bombay
(Mumbai), India, lack H antigen and, consequently, A and B anti-
gens. Other variants with weak H expression on RBCs, with or
without H in secretions, also occur (para-Bombay) and have been
reviewed.16 Of clinical relevance, potent anti-H with the same hemo-
lytic potential as anti-A and anti-B can be produced by Bombay
individuals. Anti-H is often found in para-Bombay individuals but
is generally not a potent antibody. HDFN caused by anti-H has not
been reported.
Acquired B antigen is a rare phenomenon that results from the
action of bacterial deacetylase, an enzyme that can remove an acetyl
group from the A-terminal sugar, N-acetylgalactosamine. Galactos-
amine is similar to galactose, the B-specific terminal residue, and
anti-B reagents can cross-react with the deacetylated structure.
Acquired B can occur in individuals suffering from gram-negative
infections of gastrointestinal origin or carcinoma and can be clinically
significant if a patient’s blood group is misinterpreted and group AB
blood is transfused. Other polyagglutinable states (e.g., T, Tn, Tk)
are detected by naturally occurring antibodies found in the serum of
most people; these can be identified by a panel of lectins.
A or B antigen expression can weaken in patients with acute
leukemia or stress hematopoiesis or, occasionally, during pregnancy.
Chromosomal deletions or lesions that involve the ABO locus can
result in the loss of transferase expression in the leukemic cell popula-
tion. A decrease in A or B antigen expression, when found without
a hematologic disorder, can be prognostic of a preleukemic state.
Genes and Enzymes  The ABO gene was cloned in 1990 following
purification of A transferase; since then, over 200 different alleles have
been described.17 There are only four amino acid differences between
A and B transferases in the catalytic domain, two of which (Leu-
266Met and Gly268Ala) are primarily responsible for the substrate
specificity. The group O phenotype results from mutations in ABO
that cause a loss of glycosyltransferase activity. The most common
group O allele (ABO*O1) results from a single nucleotide deletion
near the 5′ end of the gene that causes a frameshift and early termina-
tion with no active enzyme production. The rare B(A) and cis-AB
phenotypes have both A and B enzyme activity from a single allele
caused by variant glycosyltransferases that have a combination of
A-specific and B-specific residues.
The fucosyltransferases required for H synthesis are encoded by
two closely linked genes on chromosome 19, FUT1 (or H) and FUT2
(or Se for secretor), which have different substrate specificity and
expression in tissues. Homozygosity for defective FUT2 alleles is
responsible for the common nonsecretor phenotype in which A, B,
and/or H antigen are not present in secretions. Individuals homozy-
gous for null alleles at both the FUT1 and FUT2 loci have the
Bombay phenotype (see earlier section).
ABO and Transplantation  As tissue antigens, ABO antigens are
important in solid organ transplantation. 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. However, successful transplan-
tation across ABO barriers is possible, particularly with blood group
A2 to O and with current immunosuppressive and pretreatment regi-
ments including removal of ABO antibodies.18 Allogeneic hemato-
poietic stem cell transplantations are routinely performed regardless
of ABO compatibility, but occasionally initial hemolysis or pure red
cell anemia because of persisting anti-A or anti-B titers in the recipi-
ent can result.
Antibodies  Anti-A and anti-B are found in the sera of individuals
who lack the corresponding antigens. They are produced in response
to environmental stimulants, such as bacteria. These antibodies are
Chapter 110  Human Blood Group Antigens and Antibodies 1695
produced after birth, reaching a peak at 5–10 years of age, and
declining with increasing age. The antibodies are mostly IgM and can
activate complement, which in conjunction with the high density of
ABO antigen sites on RBCs, are responsible for the severe, life-
threatening transfusion reactions that may result following ABO-
incompatible transfusions. In contrast, HDFN caused by ABO
antibodies is usually mild because (1) placental transfer is limited to
the fraction of IgG anti-A and anti-B found in maternal serum, (2)
ABH antigens are not fully developed on fetal RBCs because of a lack
of fully branched carbohydrate chains, and (3) tissue ABH antigens
provide additional targets for the antibodies.
Platelets have intrinsic A, B, and H antigens; thus ABO incompat-
ibility can decrease the posttransfusion platelet increment, but this is
often not of clinical significance.19 However, platelets from donors
with an A2 phenotype lack both A and H antigens. Approximately
20% of group A platelets would be from A2 donors and would be
appropriate for “universal” use. Platelets from A2 donors may also be
a superior product for patients undergoing A/O major mismatch
allogeneic progenitor cell transplantation.20
Potent anti-H (along with anti-A and anti-B) found in Oh
(Bombay) individuals will destroy transfused RBCs of any ABO
group, so these individuals must be transfused only with H− RBCs.
In contrast, anti-H identified in individuals with low expression of
H antigen, notably A1B and A1, is usually IgM, reacts only at lower
temperatures, and is thus clinically insignificant.
Other Carbohydrate Blood Group Systems
As for all glycoconjugate structures, sequential enzymatic action is
required to build other carbohydrate antigenic epitopes, and the
genetic background of all these involves different glycosyltransferase
loci.
The null p phenotype, P2k and P1k, are of clinical interest because
of potent naturally occurring antibodies that are present in plasma of
individuals whose RBCs lack the glycolipid-based antigens P1/P/Pk,
P1/P/PX2, or P/PX2, respectively. In analogy with the ABO blood
group system, antibodies of IgM and IgG class (anti-PP1Pk, anti-
P1PPX2, or anti-PPX2) are made against the missing antigens.
Although the incidence of the null phenotypes is only 5–10 per
million, they have attracted considerable interest because of 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 caused by destruction of the placenta by
anti-P. In addition, anti-P and anti-Pk cause hemolytic transfusion
reactions if antigen-positive RBCs are transfused. Transient autoanti-P,
produced following a viral infection, causes paroxysmal cold hemo-
globinuria and lysis of autologous P-positive RBC. P antigen (also
known as globoside) is the cellular receptor for the parvo-B19 virus
that causes erythema infectiosum (fifth disease) in children, some-
times complicated by severe aplastic anemia because of lysis of early
erythroid precursors. P-fimbriated Escherichia coli expresses both
P-binding and Pk-binding molecules at the tips of their pili, a finding
with implications for uropathogenicity. Individuals lacking P, or Pk
and P, appear to be naturally resistant to these bacterial and viral
infections. In contrast to anti-P and anti-Pk, it should be noted that
anti-P1 is a cold-reactive agglutinin that seldom has clinical impor-
tance. The clinical importance of anti-PX2 made by Pk individuals is
unclear.
Lewis antigens are fucosylated glycolipids that are synthesized by
nonerythroid cells, circulate in plasma, and are passively adsorbed
onto RBC. Antibodies to Lewis can be made by individuals with the
Le(a−b−) phenotype. These antibodies are of IgM class and seldom
cause any clinical problems. Lewis antibodies are commonly found
in pregnant women.
The i and I antigens are nonterminal epitopes on linear and
branched carbohydrate structures, respectively, carrying ABH anti-
gens at their terminal ends. During the first years of life, linear chains
are modified into branched chains, resulting in the appearance of I
antigens. The i phenotype is very rare among adults, but it is the
 1696 Part XI  Transfusion Medicine

normal state on RBCs from fetuses and infants. The gene encoding
the I-branching β-1,6-N-acetylglucosaminyltransferase (GCNT2) has
three alternative forms of exon 1 with common exons 2 and 3.
Mutations in exon 2 or exon 3 silence GCNT2 and give rise to the
form of the i phenotype that is associated with cataracts in Asians.
Mutations in exon 1C silence the gene in erythrocytes (but not in
other tissues) and lead to the i phenotype without cataracts.
Alloanti-I made by a person with the rare i adult phenotype can
be clinically significant and cause destruction of transfused I-positive
RBCs. However, the sera of all I-positive individuals contain autoanti-I
that is clinically benign and reactive only at or below room tempera-
ture. In contrast, cold hemagglutinin disease is characterized by a high
titer of complement-fixing monoclonal anti-I, which causes in vivo
hemolysis and hemolytic anemia. The titer and thermal range of
autoanti-I is often increased following infection with Mycoplasma
pneumoniae. If transfusion cannot be avoided, donor RBCs should
be transfused through a blood warmer.
The FORS1 blood group antigen is a rare low prevalence antigen
that is A-like in that it is defined by a terminal N-acetylgalactosamine
and was first recognized as a weak A subgroup. The antigen has been
defined as Forssman antigen, commonly found on the RBCs of
nonprimate mammals, and arises from a gain-of-function mutation
in the GBGT1 pseudogene. The clinical relevance of anti-FORS1
found naturally occurring in the plasma of most individuals is not
known.
Protein Blood Groups
Rhe, Rhe-associated glycoprotein, and
LW Blood Group Systems
The Rh system is second only to the ABO system in importance in
transfusion medicine. Rh antigens, especially D, are highly immuno-
genic; thus in most countries, blood for transfusion is tested and
labeled with the D antigen type (Rh-positive or Rh-negative) and
D−recipients are transfused with D−RBC products.
Three systems for naming Rh antigens have been used. Two are
shown in Table 110.5, which indicates the incidence of the common
Rh haplotypes present in different ethnic groups. The Fisher-Race
nomenclature was based on the premise that there were three closely
linked genes (D, C/c, and E/e), whereas the Wiener nomenclature
(Rh-Hr) was based on the belief that a single gene encoded multiple
factors (antigens). Although it is now well established that two genes,
RHD and RHCE, encode the Rh proteins, the Fisher-Race (D, C/c,
and E/e) terminology is often preferred for written communication;
for spoken communication, a modified version of the Wiener nomen-
clature is preferred. Uppercase R indicates that D antigen is present
and use of a lowercase r (or “little r”) indicates that it is absent. The
C or c and E or e antigens carried with D are represented by sub-
scripts: 1 for Ce (R1), 2 for cE (R2), 0 for ce (R0), and Z for CE (Rz).
The presence of these antigens without D is represented by a super-
script: prime for Ce (r′), double-prime for cE (r″), and y for CE (ry).
This terminology allows one to convey the common Rh antigens (the
phenotype) with a single term. The third system of numeric designa-
tions is not widely used in the laboratory, with a few exceptions
(Rh17, Rh32, Rh33).
Genes, Proteins, Antigens, and Phenotypes  The Rh proteins are
designated RhD (encoded by RHD), which carries the D antigen,
and RhCE (encoded by RHCE), which carries the CE antigens
(either ce, cE, Ce, or CE). RhD differs from the various forms of
RhCE by 32–35 amino acids. RhD and RhCE are not glycosylated
but form a complex in the RBC membrane with RhAG (Rh-associated
glycoprotein). Other proteins present in the Rh-complex are CD47
(an integrin-associated protein), LW, and glycophorin B. The
Rh-complex also associates with band 3 (the anion exchanger) as a
macrocomplex in the membrane.
The D-negative (Rh-negative) phenotype is prevalent in whites
(15%–17%), less common in African blacks (3%–5%), and rare in
Asians (<0.1%). The absence of D in Europeans is primarily caused
by a deletion of the RHD gene. African blacks and rare D-negative
whites and Asians carry a RHD gene that is silenced by a variety of
molecular events.3
RBCs with weak D have D antigen but at lower levels than normal
because of one or more amino acid changes that are often predicted to
be in the intracellular or transmembrane regions of RhD. The RBCs
do not lack, or have altered, epitopes of D. Many individuals with a
serologic weak D phenotype have weak D types 1, 2, and 3 by RHD
genotyping, and individuals with these genotypes can safely receive
D-positive blood and do not make clinically significant anti-D.21,22
Partial D antigens (previously called D categories or D mosaics) are
caused either by point mutations in RHD that encode amino acid
changes that alter D epitopes, or by replacement of RHD nucleotides
or exons by the equivalent part of RHCE that result in loss of D
epitopes. RBCs with a partial D antigen may have strong or weak
reactivity with anti-D. Because patients with partial D antigens can
make anti-D directed to the D epitopes that are altered or absent, they
ideally should receive D-negative blood and women of childbearing
potential are candidates for Rh immune globulin. In practice, many
type as D-positive and are recognized only after they make anti-D.
However, in the United States monoclonal D typing reagents licensed
by the Food and Drugs Administration for patient testing classify
partial DVI phenotypes as D-negative in direct testing, and as
D-positive by IAT. RHD genotyping is very useful to distinguish weak
D phenotypes from partial D to guide selection of blood for transfu-
sion and prevent D alloimmunization and to avoid unnecessary Rh
immune globulin injection (see box on Weak or Variable D Typing).

TABLE
Prevalence of the Principal Rhesus Haplotypes
110.5 Weak or Variable D-Typing
Incidence (%)
Fisher-Race Modified Weiner Clinically significant D-sensitization potentially results in a pregnancy
Haplotype Haplotype White African Black Asian with a fetus at risk for hemolytic disease of the fetus and newborn and
Rh-Positive hemolytic transfusion reactions if transfused with D-positive red blood
cells (RBCs). Individuals with RBCs that express a partial D antigen
DCe R1 42 17 70
are at risk for D-sensitization, whereas those with weak D antigen are
DcE R2 14 11 21 usually not at risk. These cannot be distinguished by serologic reactiv-
ity, because either may present as weak or moderately positive or give
Dce R0 4 44 3
variable results with anti-D reagents. Particularly in the prenatal setting,
DCE RZ <0.01 <0.01 1 RHD genotyping should be done to distinguish weak D from partial D.
Rh-Negative Women with weak D expression, particularly weak D types 1, 2, and 3,
ce r 37 26 3 are not at risk for clinically significant D-sensitization and therefore are
not candidates for RhIG prophylaxis. In contrast, individuals with partial
Ce r′ 2 2 2 D, lack D epitopes and have produced clinically significant anti-D and
cE r″ 1 <0.01 <0.01 should receive RhIG prophylaxis. RHD genotyping avoids unnecessary
treatment with RhIG and excess use of Rh-negative blood in patients
CE r y
<0.01 <0.01 <0.01 with weak D antigen.

Several phenotypes, including D− −, Dc−, and DCw−, have an
enhanced expression of D antigen and no, or variant, CE antigens.
They are caused by replacement of portions of RHCE by RHD. The
RhD sequences in RhCE, along with a normal RhD, explain the
enhanced D and account for the lack, or reduced expression, of CE
antigens. Immunized individuals with these CE-depleted phenotypes
can make antibodies to high-prevalence Rh antigens.
C and c antigens differ by four amino acids, but only residue
Ser103Pro is predicted to be extracellular. E and e differ by one amino
acid, Pro226Ala. The RhD and various combinations of RhCE
proteins (ce, Ce, cE, and CE) are typical for the majority of white
transfusion recipients. However, Rh proteins in other ethnic groups
often carry additional polymorphisms, particularly in individuals of
African descent, and this fact often complicates transfusion in patients
with sickle cell disease. For example, the RBCs of more than 30% of
blacks are VS+ because of a Leu245Val substitution in Rhce, and
expression of this antigen is associated with variant expression of e
antigen. Many other amino acid changes in Rhce, as well as in RhD,
are associated with production of Rh antibodies in patients with
sickle cell disease. RH genotyping by DNA methods allows enhanced
Rh antigen matching of patients and donors and is particularly
important in patients who present with Rh antibodies reacting with
all, or the majority, of cells tested.
The Rhnull phenotype is very rare and occurs on two genetic
backgrounds: the “regulator” type, caused by mutations in RHAG,
which encodes an Rh-associated glycoprotein, and the “amorph” type,
caused by mutations in RHCE on a D− (deleted RHD) background.
Rhnull RBCs are stomatocytic, fragile, and associated with anemia.
RhAG is involved in maintenance of cation balance in RBCs.13
Antibodies  Most Rh antibodies are IgG and do not activate comple-
ment. As a result, primarily extravascular hemolysis, rather than
intravascular hemolysis, occurs in transfusion reactions involving Rh
antibodies. The antibodies are almost always caused by RBC immu-
nization from pregnancy or transfusion and usually persist for years.
Anti-D can cause severe hemolytic transfusion reactions and HDFN,
but the incidence of anti-D has decreased with the prophylactic use
of Rh immune globulin. Most Rh antibodies should be considered
as having the potential to be clinically significant for HDFN and
hemolytic transfusion reactions. If serum antibody levels fall below
detectable levels, subsequent exposure to the antigen characteristically
produces a rapid secondary immune response. Autoantibodies in the
sera of patients with warm autoimmune hemolytic anemia, as well as
in some cases of drug-induced autoimmune hemolytic anemia,
appear to demonstrate relative specificity to high-prevalence Rh
antigens, although specificity for other members of the Rh complex
have not been ruled out (see box on Transfusion Management of
Patients With Warm Autoimmune Hemolytic Anemia).
RHAG Blood Group System
RhAG glycoprotein, encoded by RHAG, is highly similar to the RhD
and RhCE proteins. It carries four blood group antigens: two of high
prevalence (RHAG1 and 3) and two of low prevalence (RHAG 2 and
4). Antibodies to RHAG4 cause HDFN. RhAG is important for
erythrocyte ion balance in RBCs and is required for the expression
of RhD and RhCE proteins forming the core of the Rh-complex.
LW Blood Group System
Rh and LW are independent blood group systems but have a pheno-
typic relationship. In adults, D-positive RBCs have a stronger expres-
sion of LW antigen than D-negative RBCs, and anti-LW can be
confused with anti-D. Transient loss of LW antigens from RBCs has
been described in pregnancy and in patients with diseases, particularly
Hodgkin disease, lymphoma, leukemia, sarcoma, and other forms of
malignancy. Loss of LW antigens is usually associated with the pro-
duction of antibodies that appear to be alloanti-LW.
Kell and Kx Systems
The Kell glycoprotein is highly folded through multiple intrachain
disulfide bonds and is covalently linked to the XK protein in the RBC
Chapter 110  Human Blood Group Antigens and Antibodies 1697
Transfusion Management of Patients With Warm Autoimmune Hemolytic
Anemia
Patients with warm autoimmune hemolytic anemia may present with
jaundice, fatigue, and anemia, or they may show no overt clinical
manifestations. The antibody screen and antibody identification panel
will show all red blood cells (RBCs) positive (panagglutinin) with anti-
IgG in the indirect antiglobulin test. The autocontrol (patient’s own
plasma and RBCs) will also be positive.
History: A transfusion history should be obtained to differentiate
these results from a hemolytic transfusion reaction or hemolysis
because of an alloantibody.
DAT: A direct antiglobulin test should be performed with anti-IgG
and anti-C3. In clinically significant hemolysis, the DAT is usually
strongly positive.
Eluate: If patient has been recently transfused (3–4 months), an
eluate should be prepared from the patient cells to remove the
antibody(ies); the eluate should be tested to determine specificity.
The eluate is usually reactive with all cells when tested by the IAT
with anti-IgG.
Phenotype or genotype: Type the patient’s RBCs for minor blood
group antigens (Cc, Ee, K, Jka/b, Fya/b, Ss) if the patient has not
been recently transfused. When possible, IgM typing reagents are
used because the patient’s own antibody-coated RBCs may result
in false-positive typing. Some laboratories are able to remove the
IgG from the RBCs and perform a phenotype, but alternatively,
genotyping for minor blood group antigens including Doa/b
antigens (there is no serologic reagent) can be performed.
Adsorption: Adsorb the serum autoantibody onto the patient’s own
RBCs to test for underlying alloantibody if the patient has not
been recently transfused (3–4 months). If the patient has been
recently transfused or if the low hematocrit results in insufficient
autologous RBCs, perform alloadsorption with well-characterized
RBCs (usually three with known antigen profiles). Test the
adsorbed serum for underlying alloantibodies.
Crossmatch: Perform with neat and with adsorbed plasma.
Crossmatch performed with neat plasma will usually be
incompatible.
Communication: Inform ordering physician of reactivity and of delay
in receiving crossmatched RBCs. Provide emergency-release
RBCs if patient’s clinical situation warrants. Inform the physician
that the patient may hemolyze transfused RBCs similar to
hemolysis of his or her own RBCs.
Transfusion: Consider providing RBC units negative for minor
antigens that the patient also lacks. Consider matching for Cc,
Ee, K, Jka/b, Fya/b, Ss (and Doa/b if possible). This potentially
enables RBC units to be available before completion of the
antibody identification testing. Transfusion with antigen-matched
units potentially allows continued transfusion without need for
autoadsorption or alloadsorption unless signs and symptoms
of RBC destruction occur or there is a change in reactivity in
antibody screening or the DAT.
membrane. Kell is highly polymorphic because of single amino acid
substitutions in the glycoprotein that account for 35 of 36 antigens
described to date. The K antigen is remarkably immunogenic even-
though it differs from wild-type (k, small k) by only one amino acid,
and it appears that loss of an N-glycan exposes the peptide, thereby
rendering it immunogenic.
Inherited weak expression of Kell antigens, termed Kmod pheno-
type, occurs with amino acid changes in the protein, with Kpa in cis,
and in the McLeod phenotype.23 Transient depression of Kell system
antigens may also occur in autoimmune hemolytic anemia, in micro-
bial infections, and was reported in two cases of idiopathic thrombo-
cytopenia purpura. The lack of Kell antigens (the K0 or Knull
phenotype) is caused by multiple different gene defects.
HDFN caused by 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. Kell antigens
are expressed very early during erythropoiesis, and anti-K has been
shown to suppress erythropoiesis in vitro. This may explain the low
level of bilirubin observed in cases of neonatal anemia; thus Doppler
 1698 Part XI  Transfusion Medicine
screening of the fetal middle cerebral artery peak systolic velocity is
used to monitor anemia. Other unusual consequences of Kell anti-
bodies include risk for fetal thrombocytopenia and neutropenia.
McLeod Syndrome  This uncommon syndrome is associated with
the loss of expression of Kx protein caused by mutations and deletions
in the XK gene.23 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 neurologic problems. A minority of patients with
chronic granulomatous disease also have the McLeod phenotype as a
result of X-chromosome deletions encompassing both genes. Carrier
females have two populations of RBCs (one of the McLeod pheno-
type and one of normal phenotype).
Duffy Blood Group System
The Duffy (FY), previously known as DARC now designated ACKR1
for atypical chemokine receptor, glycoprotein is a promiscuous che-
mokine receptor found on RBCs and on endothelial cells in the
kidney and brain that binds a family of chemotactic and proinflam-
matory peptides from the CXC (IL-8, MGSA) and the CC (RANTES,
MCP-1, MIP-1) classes. The physiologic role of FY is clear, but on
RBCs the receptor may allow RBCs to act as scavengers for excess
chemokines. FY is also a receptor to which Plasmodium vivax mero-
zoites can bind to invade RBC and cause malaria.
Antigens  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(a+b−),
Fy(a−b+), and Fy(a+b+) phenotypes. The null Fy(a−b−) phenotype
is rare in most ethnic groups, but it is common in people of African
and Arabian origins. The null phenotype most often results from a
mutation in the promoter region of FY that disrupts a binding site
for the erythroid transcription factor GATA-1 and results in loss of
FY on RBCs.24 Because the erythroid promoter controls expression
only in erythroid cells, FY expression in other tissues is unaffected.
All individuals of African origin with a mutated GATA box to date
have been shown to carry FYB and therefore Fyb is expressed on
nonerythroid tissues. This explains why Fy(a−b−) individuals make
anti-Fya but not anti-Fyb. Fy(a−b−) caused by a mutated GATA box
on an FYA allele has been found in Papua New Guinea, another
malaria-endemic region.
Antibodies  FY antigens are much less immunogenic than Rh and
K. Anti-Fyb is less common than anti-Fya, and both antibodies can
cause delayed hemolytic transfusion reaction (DHTR) and rarely
HDFN. Anti-Fy3 is made by Fy(a−b−) individuals who are excep-
tions to above, and it is speculated they may lack FY protein on all
cells.
Kidd Blood Group System
The Kidd (JK) blood group protein was implicated in urea transport
when RBCs lacking the antigens were shown to resist lysis in 2 M
urea. The protein is present in RBCs and kidney medulla and is a
constitutive urea transporter, but failure to express Kidd does not
result in an overt clinical syndrome; the only observed manifestation
is a reduced capacity to concentrate urine.25
Antigens  The Jka and Jkb antigens differ by a single amino acid
(Asp280Asn) and are responsible for the common Jk(a+b−), Jk(a−b+),
and Jk(a+b+) phenotypes. The Jk(a−b−) or Jknull phenotype is
uncommon and occurs with greater incidence in Polynesians, Asians,
and Finns. Many different molecular changes in both JKA and JKB
alleles have been shown to abolish expression of the Kidd blood group
protein. Weakly expressed variants of Jka and Jkb antigens are also not
uncommon.
Antibodies  JK antibodies are responsible for at least one-third of
cases of DHTR. The antibodies often drop to undetectable levels or
react only with cells that are homozygous for the antigen and escape
detection in the sensitized patient’s serum before transfusion. JK
antibodies only rarely cause HDFN, and if they do, it is typically not
severe. Anti-Jk3, sometimes referred to as anti-Jkab, is produced by
Jk(a−b−) individuals, and rare donors must be located for
transfusion.
MNS System
M and N antigens are carried on alternative forms of glycophorin
A (GPA), whereas S and s antigens are carried on alternative forms
of glycophorin B (GPB). M/N and S/s are homologous proteins
encoded by adjacent genes and consequently show linkage disequi-
librium in inheritance of the antigens. The MNS system is highly
polymorphic and most of the 49 antigens are the result of amino acid
substitutions or rearrangements between GYPA and GYPB. Persons
who are S−s− are usually of African origin. They either also lack
the high-prevalence U antigen arising from a deletion of GYPB
or express variant weak U antigen as a result of an altered form
of GYPB.
Antibodies  Anti-S, anti-s, and anti-U are usually IgG and can be
clinically significant antibodies. Anti-M and anti-N can be naturally
occurring, may be reactive at room temperature or below, and are
often clinically insignificant.
Other Protein Antigens
Antibodies to antigens in the following systems are less common than
those described earlier in this chapter, and information regarding
their general clinical significance is summarized in Table 110.3.
Lutheran System
Lutheran (Lu), along with Secretor, provided the first example of
autosomal linkage in humans, the first example of autosomal crossing
over, and the first indication that crossing over in humans is more
common in females than in males. The Lu system consists of four
antithetical pairs of antigens and 16 independent high-prevalence
antigens. The Lu(a−b−) phenotype is rare, but in the majority of
individuals, it is caused by heterozygosity for silencing mutations in
the EKLF/KLF1 gene.26 KLF1 is a transcription factor that regulates
many erythroid-specific genes, and the expression of antigens in other
blood group systems (e.g., Kn, In) is also affected. In one family,
heterozygosity for a mutation in the GATA1 gene was shown to be
responsible for the Lu(a−b−) phenotype.
Antibodies  Antibodies in this system are rarely encountered because
the antigens are not highly immunogenic. They are usually IgG and
give characteristic agglutinates surrounded by unagglutinated RBCs.
They can cause mild transfusion reactions, but do not typically cause
HDFN. Anti-Lu3 is found in the serum of immunized people of
the rare recessive Lu(a−b−) phenotype, and the antibody is usually
IgG and may cause DHTR or HDFN. Blood with the Lu(a−b−)
phenotype should be used for transfusion of patients with these
antibodies.
Diego System
The Diego (Di) blood group antigens are on Band 3 anion transport
protein (AE1), one of the most abundant erythrocyte glycoproteins.
AE1 forms complexes with many other proteins in the cell membrane
and is important for RBC stability. The Diego blood group system
contains three antithetical pairs of antigens and 16 low-prevalence
antigens. Dib antigen has a prevalence of greater than 99.9%, but Dia
is rare in most populations. Exceptions include South American
Indians (Dia occurs in 54% of this population) and North American
Indians, approximately 12% of whom are Di(a+).
Antibodies  Di antibodies are usually IgG and do not bind comple-
ment. These antibodies have caused DHTR (usually delayed) and
HDFN. Autoantibodies to band 3 are common in patients with
warm autoimmune hemolytic anemia.

Yt Blood Group System
The Yt system was named in 1956 when an antibody was found in
the serum of patient whose last name was Cartwright. Yta occurs with
a prevalence of more than 99% in random blood samples, and Ytb is
found with a prevalence of approximately 8%, except in Israelis, in
whom it has a prevalence of 20% or higher.
Antibodies  Yt antibodies usually are IgG and do not bind comple-
ment. These antibodies have caused DHTR but not HDFN.
Scianna Blood Group System
The Scianna (Sc) antigens are expressed by the RBC adhesion protein,
erythrocyte membrane-associated protein. Sc1 is a high-prevalence
antigen (prevalence ≈99.9%), and Sc2 is a low-prevalence antigen
(1%); there are five other Scianna antigens.
Antibodies  Sc antibodies are usually IgG, and some bind comple-
ment. These antibodies have not caused DHTR, and although they
have caused a positive DAT in cord RBCs, they have not caused
HDFN. Several examples of autoanti-Sc1 have been reported, some
reactive in tests using patient serum but not plasma. Autoanti-Sc3–
like antibodies have been described in one patient with lymphoma
and in one patient with Hodgkin disease whose RBCs had suppressed
Sc antigens.2
Dombrock Blood Group System
Dombrock (Do) antigens are carried on a GPI-linked glycoprotein
that is a member of the mono-ADP-ribosyltransferase family, although
Do has no demonstrable enzyme activity on the RBC. The Do blood
group system consists of two antithetical antigens, Doa and Dob,
and eight other antigens of high prevalence. The null phenotype
is Gy(a−).
Antibodies  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 DHTR and a positive DAT but no clinical
HDFN.
Colton Blood Group System
The Colton (Co) antigens are carried on aquaporin-1 (AQP-1), the
first water channel protein characterized in mammals, and are also
found in the kidney. The function of AQP-1 in RBCs may be to
rehydrate rapidly after shrinking in the hypertonic environment of
the renal medulla. Coa has a prevalence of 99.9%, its antithetical
antigen Cob has a prevalence of 10%, and Co3 and Co4 are present
on all RBCs except those of the very rare Co(a−b−) null phenotype.
Co4 is a high prevalence antigen, the absence of which has been seen
in three families only. Apparently healthy propositi with the Co(a−b−)
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.
Antibodies  Antibodies in the Co system are usually IgG and
some bind complement. The antibodies have caused DHTR and
HDFN.
Gerbich Blood Group System
The Gerbich system antigens are carried on glycophorin C (GPC)
and glycophorin D (GPD). There are six high-prevalence antigens
and five low-prevalence antigens. The two glycoproteins are products
of the GYPC gene. The gene consists of four exons, and the smaller
GPD is generated by the use of an alternative translation initiation
site.
Antibodies  The antibodies may be immune or naturally occurring.
Most are IgG and some of these bind complement. Some antibodies
may be IgM. Although some antibodies have caused DHTR, others
Chapter 110  Human Blood Group Antigens and Antibodies 1699
have been benign. Anti-Ge3 has caused HDFN, and similar to Kell
antibodies, the disease is associated with severe anemia. Clinical
HDFN associated with anti-Ge2 has not been reported, but the
antibodies have been eluted from DAT-positive cord RBCs.
Cromer Blood Group System
The Cromer (Cr) antigens are carried on decay-accelerating factor
(DAF, CD55), a complement control protein attached to the RBC
membrane through GPI-linkage. Cr is a system of two sets of anti-
thetical antigens (Tca/Tcb/Tcc and WESa/ WESb), 16 high-prevalence
antigens, and three low-prevalence 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
black. Most of the other phenotypes are exceedingly rare.
Antibodies  Antibodies in the Cr system are usually IgG and do not
bind complement. The antibodies have caused mild DHTR but not
HDFN.
Knops Blood Group System
The Kn 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 African
Americans. Typing for Kn system antigens can be challenging because
the low level of expression on the RBCs in some disease processes
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 SLE, cold agglutinin
disease, paroxysmal nocturnal hemoglobinuria (PNH), hemolytic
anemia, insulin-dependent diabetes mellitus, acquired immunodefi-
ciency syndrome, some malignant tumors, and any condition associ-
ated with increased clearance of immune complexes. CR1 (the Sla
antigen in particular) may act as a receptor for the malarial parasite
Plasmodium falciparum; thus the Sl(a−) phenotype may provide selec-
tive advantage.
Antibodies  Antibodies in the Kn system are usually IgG, and they
do not bind complement. The antibodies do not cause DHTR 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 Kn system, anti-Kna is the most
common antibody in whites, and anti-Sla is the most common in
African Americans.
Indian Blood Group System
The antigens of the In system are carried on CD44. CD44 has a
diverse range of biologic functions involving cell-cell and cell-matrix
interactions in cells other than RBCs. It is an adhesion molecule in
lymphocytes, monocytes, and some tumor cells. CD44 binds to
hyaluronate and other components of the extracellular matrix and is
also involved in immune stimulation, as well as signaling between
cells. 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.
Antibodies  Antibodies in the Indian system are usually IgG and do
not bind complement. Some antibodies may directly agglutinate
RBCs, but the reactivity is greatly enhanced by the IAT. These
antibodies have caused decreased RBC survival and a positive DAT
in the neonate but not HDFN. A severe DHTR caused by anti-Inb
has been reported.
Chido/Rodgers Blood Group System
Although the Ch and Rg antigens are readily detected on RBCs, they
are located on the fourth component of complement (C4), which
becomes bound to RBCs from the plasma. In complement activation
through the classic pathway, C4 becomes bound to the RBC mem-
brane and undergoes further cleavage; ultimately, a tryptic fragment,
 1700 Part XI  Transfusion Medicine
C4d, remains on the RBC. This C4d glycoprotein carries the Ch/
Rg blood group antigens. The antigens are stable in stored serum or
plasma, and the phenotypes of this system are most accurately defined
in plasma by agglutination inhibition tests.
Antibodies  Antibodies in the Ch/Rg system are usually IgG, do not
activate complement, and are considered benign. Considerable varia-
tion may be common in the reaction strength obtained with different
RBC samples. Although these antibodies do not generally cause
DHTR, they have caused anaphylactic reactions. The antibodies have
not caused HDFN.
JR Blood Group System
The Jra antigen is carried on ABCG2, a member of the ATP-binding
cassette family of multipass membrane proteins. The protein is
broadly distributed and is a high-affinity urate transporter. It is also
involved in porphyrin transport and in multidrug resistance in some
cancers. The Jr(a−) phenotype is the null phenotype and Jr(a−)
individuals lack the protein. Many different mutations have been
identified for this phenotype although it is more common among the
Japanese (where it is associated with gout) and the Roma population
in Europe.
Antibodies  Anti-Jra are usually IgG, do not activate complement
and do not generally cause DHTR or HDFN, however two cases of
severe HDFN have been reported.
Lan Blood Group System
Lan too, is carried by an ATP-binding cassette protein, in this case
ABCB6, a protein that is widely expressed. It is highly expressed in
fetal liver and upregulated during erythropoiesis. ABCB6 is important
in heme synthesis and transports heme and porphyrins into the
mitochondria. The Lan− phenotype is the null phenotype and it
arises from many different molecular backgrounds but is not associ-
ated with a disease phenotype. Lan antigen expression is variable on
erythrocytes.
Antibodies  Anti-Lan are generally IgG and do not bind complement
but have caused mild to severe DHTR and mild HDFN.
Vel Blood Group System
The Vel blood group antigen is dependent on the SMIM1 protein
for expression and a 17-bp mutation in the SMIM1 gene accounts
for the vast majority of Vel− individuals and absence of SMIM1. The
protein is widely expressed but more highly expressed on erythrocytes,
salivary glands, and testes, although its function is unknown. Vel
antigen expression is variable on RBCs.
Antibodies  Anti-Vel are often a mixture of IgM and IgG and readily
bind complement. While HDFN caused by anti-Vel is rare, the
antibodies can cause severe hemolytic transfusion reactions.
CD59 Blood Group System
An antibody in the plasma of a young patient with CD59 deficiency
qualified CD59 as a blood group antigen. CD59 is a GPI-linked
protein on the erythrocyte and is important in complement regula-
tion. It inhibits the formation of the membrane attack complex
(MAC) by specifically binding to C8 and C9. Like other GPI-linked
proteins, it is absent from the erythrocytes of PNH patients and its
absence is the underlying cause of hemolysis.
Antibodies  Only one example of the antibody has been reported. It
was clinically benign although a positive DAT was observed following
one of the transfusions.
Augustine Blood Group System
The blood group system Augustine (symbol AUG; number 036) was
recently assigned to the equilibrative nucleoside transporter 1 protein
(SLC29A1; ENT1) after it was identified as the carrier of the Ata
antigen. The At(a−) phenotype in individuals of African origin is
defined by an amino acid polymorphism on SLC29A1 (p.Glu391Lys),
while the At(a−) members of a rare family affected by bone malforma-
tion lacked the protein due to an inactivating mutation in the
SLC29A1 gene: c.589+1G>C. The antigen defined by the antibody
produced by the null phenotype was named AUG1, and the antigen
defined by the amino acid Glu391 (Ata) was named AUG2.27
Antibodies.  Anti-Ata are mostly IgG although may contain IgM.
While HDFN due to anti-Ata is rare, the antibodies can cause severe
hemolytic transfusion reactions.
REFERENCES
1. Reid ME, Lomas-Francis C, Olsson ML: Blood group antigen facts book,
ed 3, San Diego, 2012, Academic Press.
2. Daniels G: Human blood groups, ed 3, Oxford, 2013, Wiley-Blackwell.
2a.  Association Bulletin #16-02: Mitigating the anti-CD38 interference
with serologic testing, 2016, AABB. <https://www.aabb.org/programs/
publications/bulletins/Documents/ab16->.
3. Heddle NM, Soutar RL, O’Hoski PL, et al: A prospective study to
determine the frequency and clinical significance of alloimmunization
post-transfusion. Br J Haematol 91:1000, 1995.
4. Rosse WF, Gallagher D, Kinney TR, et al: Transfusion and alloimmuni-
zation in sickle cell disease. Blood 76:1431, 1990.
5. Aygun B, Padmanabhan S, Paley C, et al: Clinical significance of RBC
alloantibodies and autoantibodies in sickle cell patients who received
transfusions. Transfusion 42:37, 2002.
6. Vichinsky EP, Earles A, Johnson RA, et al: Alloimmunization in sickle
cell anemia and transfusion of racially unmatched blood. N Engl J Med
322:1617, 1990.
7. Cox JV, Steane E, Cunningham G, et al: Risk of alloimmunization
and delayed hemolytic transfusion reactions in patients with sickle cell
disease. Arch Intern Med 148:2485, 1988.
8. Chou ST, Jackson T, Vege S, et al: High prevalence of red blood cell allo-
immunization in sickle cell disease despite transfusion from Rh-matched
minority donors. Blood 122:1062, 2013.
9. Chou ST, Westhoff CM: The role of molecular immunohematology in
sickle cell disease. Transfus Apher Sci 44:73, 2011.
10. Yazdanbakhsh K, Ware RE, Noizat-Pirenne F: Red blood cell alloim-
munization in sickle cell disease: pathophysiology, risk factors, and
transfusion management. Blood 120:528, 2012.
11. Matteocci A, Pierelli L: Red blood cell alloimmunization in sickle cell
disease and in thalassaemia: current status, future perspectives and
potential role of molecular typing. Vox Sang 106:197, 2014.
12. Osby M, Shulman IA: Phenotype matching of donor red blood cell units
for nonalloimmunized sickle cell disease patients: a survey of 1182 North
American laboratories. Arch Path Lab Med 129:190, 2005.
13. Bruce LJ, Guizouarn H, Burton NM, et al: The monovalent cation
leak in overhydrated stomatocytic red blood cells results from amino
acid substitutions in the Rh-associated glycoprotein. Blood 113:1350,
2009.
14. Fung MK, Grossman BJ, Westhoff CM, et al, editors: Technical manual,
ed 18, Bethesda, Md, 2014, American Association of Blood Banks.
14a.  Schwarz HP, Dorner F: Karl Landsteiner and his major contributions
to haematology. Br J Haematol 121:556–565, 2003.
15. Clausen H, Hakomori S: ABH and related histo-blood group antigens;
immunochemical differences in carrier isotypes and their distribution.
Vox Sang 56:1, 1989.
16. Oriol R, Candelier JJ, Mollicone R: Molecular genetics of H. Vox Sang
78:105, 2000.
17. Storry JR, Olsson ML: The ABO blood group system revisited: A review
and update. Immunohematology 25:48, 2009.
18. Rydberg L: ABO-incompatibility in solid organ transplantation. Transfus
Med 11:325, 2001.
19. Curtis BR, Edwards JT, Hessner MJ, et al: Blood group A and B antigens
are strongly expressed on platelets of some individuals. Blood 96:1574,
2000.
20. Cooling LL, Kelly K, Barton J, et al: Determinants of ABH expression
on human blood platelets. Blood 105:3356, 2005.

21. Flegel WA: Homing in on D antigen immunogenicity. Transfusion
45:466, 2005.
22. Sandler SG, Flegel WA, Westhoff CM, et al: It’s time to phase in RHD
genotyping for patients with a serologic weak D phenotype. Transfusion
55:680, 2015.
23. Danek A, Rubio JP, Rampoldi L, et al: McLeod neuroacanthocytosis:
Genotype and phenotype. Ann Neurol 50:755, 2001.
24. Tournamille C, Colin Y, Cartron JP, et al: Disruption of a GATA motif
in the Duffy gene promoter abolishes erythroid gene expression in Duffy-
negative individuals. Nat Genet 10:224, 1995.
Chapter 110  Human Blood Group Antigens and Antibodies 1701
25. Sands JM, Gargus JJ, Frohlich O, et al: Urinary concentrating ability
in patients with Jk(a-b-) blood type who lack carrier-mediated urea
transport. J Am Soc Nephrol 2:1689, 1992.
26. Singleton BK, Burton NM, Green C, et al: Mutations in EKLF/KLF1
form the molecular basis of the rare blood group In(Lu) phenotype. Blood
112:2081, 2008.
27. Daniels G, Ballif BA, Helias V, et al: Lack of the nucleoside transporter
ENT1 results in the Augustine-null blood type and ectopic mineraliza-
tion. Blood 125:3651–3654, 2015.