Other Blood Group

Sytems
Blood Group
Antigens
• Antigens found on the red cells which may be peripheral or integral
proteins, glycoproteins or glycolipids (ABO)
• Red cell antigens belong to any of the four ISBT designation
• Blood group system (001-043)
• Blood group collection (200)
• High incidence series (901)
• Low incidence series (700)
Blood Group
System
• Composed of antigens produced by alleles at a single gene locus or at
loci so closely linked that crossing over does not occur or is very rare
• Most blood group genes are located on the autosomal chromosomes
except
• Xg Blood group system (ISBT 012) Xp22.33
• Kx Blood group system (ISBT 019) Xp21.1
Blood Group
System
• Most blood group alleles are codominant and express
a corresponding antigen
• E.g. a person who inherits alleles K and k expresses both K and k antigens on
his or her RBCs.)
• Some genes code for complex structures that carry more than one
antigen
• E.g Glycophorin B which carries S or s and U antigens (U- are also S- and s-)
Blood Group
System
• Silent or amorphic alleles: rare alleles that do
not encode for any antigen.
• Homozygous inheritance of silent alleles leads
to
null phenotype.
• h (Bombay), se (nonsecretor), O, Lu, le
• Some blood group systems have regulator
or modifying genes, which alter antigen expression
• E.g. RBCs with the dominant type of Lu(a–b–) have
suppressed expression of all the antigens in the Lutheran
blood group system as well as many other antigens,
including P1 and i
 Nomenclature
• Genes: written in italics or underlined when italics are
not
available and their allele number or letter is always superscript
• Antigen: written in regular type without italics or
underlining;
some antigens have numbers or superscript letters
• D, K, Jka
• A phenotype is a description of which antigens are present on an
individual’s RBCs and simply indicates the results of serologic
tests on those RBCs
• A1 antigen
• A1 phenotype
• A1 allele
 ISBT
Terminology
• In 1980, the International Society of Blood Transfusion
(ISBT) formed the Working Party on Terminology for Red
Cell Surface Antigens
• Each antigen is given a six-digit identification number. The
first three digits represent the system, collection, or series,
and the second three digits identify the antigen
• The anti gens within the system are numbered
sequentially in order of discovery
• For example, using the ISBT terminology, the K antigen is
006001: 006 - system; 001 - antigen
ISBT Terminology

•For example, using the ISBT terminology, the

K antigen

006001
SYSTEM/
ANTIGEN
COLLECTION/
SERIES
ISBT Terminology

•For example, using the ISBT terminology, the

PX2 antigen

209004
SYSTEM/
ANTIGEN
COLLECTION/
SERIES
ISBT Terminology

•For example, using the ISBT terminology, the

Emm antigen

901016
SYSTEM/
ANTIGEN
COLLECTION/
SERIES
Blood Group
Collection
• Antigens that have a biochemical, serologic, or genetic relationship
but do not meet the criteria for a system.
• Antigens classified as a collection are assigned a 200 number
 Low (700 Series) and
High (901 Series)
•Prevalence
All remaining RBC antigens that are not associated with a system or
a collection are catalogued into
• 700 series of low-prevalence antigens. Antigens with prevalence of less than
1% in the general population
• 901 series of high-prevalence antigens. Antigens with prevalence of more
than 90% in the general population
ell adhesion Transport
LW DI
R
H
OK CO
JK
XG
IN
GI
SC LU L XK
RAP
H
KE YT
L GE MN
DO Structural
S
Fy
AB
CH/ O
o RG P
LE H
r
CRO
P1
M
KN
IGN
T

omplement Carbohydra
control te
On ISBT
Terminology...
• 001-035 (<100) series for BGS
• 200 series for BGC
• 700 series for low prevalence antigens
• 901 series for high prevalence antigens
Obsolete Numbers

• Once a number has been allocated to a specificity, that number cannot

be subsequently used for any other specificity. Consequently, if the
number of a specificity becomes inappropriate, then that number
becomes obsolete.
Obsolete Numbers

• Obsolete collections:
 201 Gerbich ---> 020
 202 Cromer --> 021
 203 Indian --> 023
 204 Auberger --> 005
 206 Gregory --> 014
 211 Wright --> 010
 212 Vel --> 035
Clinically Significant
Antibodies
• Antibodies reactive at 37ºC (warm reactive); usually IgG;
causes
transfusion reactions.
• Anti-H (Bombay), anti-A, anti-B, Anti-Fya, anti-Fyb, anti-Jka, anti-Jkb, anti-
S, anti-s, anti-U, anti-PP1Pk, anti-Lub
Clinically Nonsignificant
Antibodies
• Cold reacti ng (RT) anti bodies; usually IgM; rarely causes
complications in blood transfusion; sometimes referred to as
“nuisance antibodies”.
• Anti-I, anti-i, anti-P1, anti-H (A1, A1B), anti-M, anti-N, anti-Lea, anti-
Leb, anti-Lua
Lewis Blood Group
System (ISBT 007) and
ISBT 210
• Named after the first antibody producer (anti-Lea)
reported by Mourant in 1946.
• The Lewis blood group system is unique because the
Lewis antigens are not intrinsic to RBCs but are on
type 1 paragloboside that are passively adsorbed
onto the RBC membrane from the plasma.
• Lea and Leb were NOT antithetical antigens but rather
a result of interaction between Se (FUT2) and Le
(FUT3) genes.
Lewis Blood Group
System
• Abbreviation: LE
• Clinically significant: NO
• Antibody Class: IgM
• Optimal reaction temperature: 37ºC and 4ºC
• Reactive phase: 37ºC and AHG
•E n zym e t re at m e nt e n h a n c e d( i n c r e a s
: ed
agglutination
• Alleles: Le and le (amorph)
Lewis Blood Group
System
• The Le gene must be present for a precursor substance
to be converted to Lea, but the Se gene must also be
present for conversion to Leb.
• Le (a+b-): LeLe/Lele, sese
• Le (a-b+): LeLe/Lele, SeSe/Sese
• Le (a-b-): lele, regardless of secretor status
• The Lewis gene (FUT3) is linked to Se (FUT2) and H
(FUT1), all located on chromosome 19
• Lewis antigens are not expressed on cord RBCs and are
often diminished on the mother’s RBCs during
pregnancy
Lewis
Phenotypes
• Le(a+b-) LeLe/Lele, sese
• ABH nonsecretor
• secrete Lea
• Le(a-b+) LeLe/Lele, SeSe/Sese
• ABH secretors
• secrete Lea and Leb
• Le(a-b-) lele
• Frequent among Africans
• Cord blood cell phenotype
• Le(a+b+)
• Frequent among Asians
Lewis Phenotype
Frequencies

Phenotype Whites (%) Blacks (%)

Le (a+ b–) 22 23

Le (a– b+) 72 55

Le (a– b–) 6 22

Le (a+ b+) rare rare

 Type 1 Chain:
#1 carbon of Gal is attached
to the #3 carbon of
GlcNAc.
Lewis transferase enzyme
adds Fucose in an (14)
linkage to make Lea antigen. It
can add this fucose ONLY to
the Type 1 chain. Why?

Type 2 Chain:
#1 carbon of Gal is attached
to the #4 carbon of
 Lea Lea
What Le antigens Lea
would be present in Lea Lea
the secretions and on
the RBC if you Lea Lea Lea Lea
inherit the following
Lea
genes?
Lele and sese Lea
Lea
Lea

The Lewis red cell Lea Lea Lea

phenotype is: Le (a+ b–)
Have Lea in secretions. Lea Lea
Lea Lea
 Leb
What Le antigens Leb Leb
Leb
would be present in
Leb Leb
the secretions and Le a

on the RBC if you Leb Leb

inherit the following Leb
genes? Leb

Lele and Sese

Leb
Leb
Lea
The Lewis red cell
phenotype would be Leb
Lea Le Leb
Le (a– b+). Have Lea b

and Leb in secretions. Leb

Leb
Lewis Antibodies (Anti-Lea, Anti-LebL,Anti-
LebH)
1. Non-RBC Immune (present in the plasma without any
known RBC stimulus)
 Good complement activators: can cause both in vivo and in
vitro hemolysis
 Made by Le(a–b–) persons
 Generally IgM and do not cross placenta
2. Enhanced by enzyme treatement
3. Neutralized by soluble lewis substances in the saliva.
4. Causes weak, dirty looking agglutination
5. Occur frequently in the sera of pregnant women who
transiently exhibit the Le(a–b–) phenotype.
Lewis
Antibodies
1. Anti-Lea
• Most common Lewis antibody encountered
2. Anti-Leb
• Anti-LebH: Reacts best with Leb positive red cells
with highest amount of H. Group O or A2 Leb
positive red blood cells. More common of the two.
• Anti-LebL: Reacts equally will with the Leb antigen on
red cells of all ABO phenotypes.
 Lewis Antibodies

Anti-LebL Anti-LebH
O 4+ 4+

A2 4+ 3+

AB 4+ 1+
Lewis
Antigens
• Lewis antigens are found as glycoproteins in the and
other secretions but primarily as glycolipids (from
gastrointestinal tract) in the plasma
• ONLY GLYCOLIPIDS are adsorbed onto red cells,
therefore:
SALIVA (Lea, Leb)
Le(a-b-)
Le(a-b-) Le(a-b-)

Leb Lea
PLASMA (Lea, Leb)
Le(a-b+)
Le(a-b-) Le(a+b-)
 Lewis
• LeAntigens
a and Le b glycoproteins will be present in the saliva of
newborns, but Lewis glycolipids are not detectable in the
plasma until about 10 days after birth.
• Cord blood and RBCs from newborn infants phenotype as Le(a–
b–).
• In children who inherit both Le and Se genes, the transformation
can be
• Le(a–b–) phenotype at birth
• Le(a+b–) after 10 days
• Le(a+b+)
• Le(a–b+) after 6 years
 Disease
• H,Association
Ley and Leb antigens are receptors for H. pylori
• Increased incidence of ulcers and stomach cancer
among blood group O secretors
• Sialyl- Le a and Sialyl-Lex are l igands for the
endothelial adhesion molecule E-selectin and may
mediate tumor cell–endothelium interactions.
• Sialyl-Lea/Sialyl-Lex is also the epitope for the tumor
marker CA 19-9 found in gastrointestinal and other
malignancies
Kell Blood Group
System (ISBT 006)
• Consists of 38 high-prevalence and low-prevalence antigens
• The first blood group system discovered after the introduction
of antiglobulin testing.
• Anti-K was identified in 1946 in the serum of Mrs. Kelleher
• Anti-k was described in 1949
• Kpa and Kpb discovered in 1957 and 1958 respectively
• Jsa and Jsb described in 1958 and 1963 respectively
• Null phenotype Ko is discovered in 1957
Kell Blood Group
System
• Abbreviation: KEL
• Antibody Class: IgG
• Optimal reaction temperature: 37ºC
• Reactive phase: AHG
• Enzyme treatment: no effect
• Antigens: 38; K (Kell), k (Cellano), Kpa, Kpb, Kpc,
Jsa, Jsb, Cote (K11), Wka,Ku
• Alleles include K and k, Kpa and Kpb, Jsa and Jsb, KEL11
and KEL17
Kell
antigens
• K antigen can be detected on fetal RBCs as early as 10
weeks and is well developed at birth. The k antigen
has been detected at 7 weeks.
• The total number of K antigen sites per RBC is quite
low: only 3,500 up to 18,000 sites per RBC
• Kell antigens have disulfide-bonded regions on the
glycoproteins
• Thiol-reducing agents, such as 100 to 200 mM DTT, 2-
mercaptoethanol (2-ME), AET, and ZZAP (which
contains DTT in addition to enzyme), destroy Kell
antigens but not Kx. Glycine-acid EDTA (an IgG-
removal agent) also destroys Kell antigens.
 Kell
Antigens
• Kell antigens are found on kell glycoprotein which
is covalently linked to XK protein by a single
disulfide bond
• Kell antigen expression is dependent upon the
presence of the XK protein
• K antigen is the second most immunogenic
antigen (after D)
• Absence of XK protein = McLeod phenotype
• Absence of Kell antigens = Ko
 Anti-Ku

Kell Null (Ko)

DTT, 2-ME, AET,
ZZAP, Glycine Acid
EDTA

McLeod Phenotype
Anti-
K
• Outside the ABO and Rh antibodies, anti-K is the
most common antibody seen in the blood bank.
• Anti-K is usually IgG and reactive in the
antiglobulin phase and can cause HTR and HDFN
• Since K antigen is well expressed on erythroid
cells, Kell HDFN is characterized by destruction
of both circulating and immature red cells in
the bone marrow
 Other Kell
Antibodies
• Antibodies to Kp , Js , and Other Low-Prevalence Kell Antigens
a a
• Antibodies to the low-prevalence Kell antigens are rare because so few people are
exposed to these antigens.
• Antibodies to k, Kpb, Jsb, and Other High-Prevalence Kell Antigens
• Antibodies to high-prevalence Kell system antigens are rare because so few people
lack these antigens
 Kellnull(KoKo) and Anti-
• KoKu
RBCs lack expression of all Kell antigens but have the Kx
antigen (found on XK protein)
• Ko RBCs have no membrane abnormality and survive
normally in circulation
• Rare: 1 in 25,000
• If immunized, produce an antibody called anti-Ku which
recognizes the “universal” Kell antigen (Ku) present on
all RBCs except Ko.
• When Ko RBCs are not available, they can be made
artificially by treating normal RBCs with DTT, AET, or
glycine-acid EDTA.
Kx Blood Group
System (ISBT 019)
• Kx is present in all RBCs except those of the
rare
McLeod phenotype
• Knull (K0) and Kmod phenotype have increased amounts
of Kx
• When Kell antigens are denatured with AET or
DTT, the expression of Kx increases.
• The XK gene is located in the short arm of the
X chromosome
 McLeod Phenotype and
•Syndrome
Discovered in 1961 by Allen and coworkers in
a
student (Mr. McLeod) who initially appeared to be Kell
null but who demonstrated weak expression of k, Kpb,
and Jsb detectable by adsorption-elution methods
• Very rare. All who have it are male, and inheritance is
X-linked through a carrier mother.
• McLeod phenotype RBCs lack Kx and another
high
prevalence antigen, Km (K20), and have
marked
depression of all other Kell antigens, designated by a
superscript w for “weak”—for example, K–k+w
Kp(a– b+w).
• Associated with several mutations and deletions
at the XK locus.
 McLeod Phenotype and
Syndrome
• McLeod Syndrome: characterized by acanthocytosis, w e l l -
compensated hemolytic anemia leading to reticulocytosis,
bilirubinemia, splenomegaly, and reduced serum haptoglobin
levels, a slow, progressive form of muscular dystrophy between
ages 40 and 50 years and cardiomegaly elevated serum creatinine
phosphokinase levels of the MM type (cardiac/skeletal muscle)
and carbonic anhydrase III levels.
• M c L e o d Syn d rom e i s a s s o c i ate d w i t h CGD
( C hro n ic
Granulomatous Disease)
• The XK gene resides on the X chromosome near deletions
associated with CGD, Duchenne muscular dystrophy, and retinitis
pigmentosa, in the Xp21 region.
Duffy Blood Group System (ISBT
008)
• Discovered in 1950 by Cutbush and associates
• Named after Mr. Duf fy , a multiply
hemophiliac
transfused who was found to have the first
described example of anti-Fya
• Anti-Fyb discovered by Ikin and coworkers in
1951 from a multiparous female
• Fy(a-b-) discovered in 1955 by Sanger and colleagues
from African blacks (example of natural selection)
Duffy Blood Group
System
• Abbreviation: FY
• Antibody Class: IgG
• Optimal reaction temperature: 37ºC
• Reactive phase: AHG
• Enzyme treatment: destroys antigens
• Antigens: SIX: Fya, Fyb, Fy3, Fy4, Fy5, Fy6
• Alleles: Fya and Fyb, Fy (amorph)
The Duffy and Malaria
Connection
• Most African-Americans are Fy(a-b-)
• In 1975, it was observed that Fy(a–b–) RBCs resist
infection in vitro by the monkey malaria organism
Plasmodium knowlesii and later, P. vivax
• The Fy(a-b-) phenotype is found frequently in West
and Central Africa, supporting the theory of selective
evolution
Duffy
Antigens
• Resides a glycoprotein (Duffy glycoprotein) which
traverse
on the cell membrane seven times (multipass). The
amino acid at position 42 defines the Fya and Fyb
polymorphism: Fya has glycine, and Fyb has aspartic acid.
• Duffy glycoprotein is also known as the Duffy antigen
receptor for chemokines (DARC), thus in addition to being a
receptor for the malaria parasites, the Duffy glycoprotein
binds a variety of proinflammatory cytokines.
• Fya and Fyb antigens are DESTROYED by common proteolytic
enzymes, such as ficin, papain, bromelin, and chymotrypsin,
and by ZZAP
 GLYCINE

ASPARTIC ACID

42
 Duffy
Antigens
• The Duffy gene is the first human gene to
be assigned to a specific chromosome.
• The Fy locus is syntenic with Rh locus
at
chromosome 1
• Fy3 – determinant common to Fya and Fyb
• Fy5 – results from the interaction of Rh and
Duffy genes. Not present on Rhnull RBCs
• Fy6 antigen – receptor for P. vivax
Duffy
Antibodies
• IgG and react best at the antiglobulin phase. Cause HTR and HDFN
• Do NOT react with enzyme-treated RBCs
• Show dosage (stronger reaction with RBCs that have a double dose than
RBCs from heterozygotes)
• Anti-Fy3: found in the serum of an Fy(a–b–) individuals
Kidd Blood Group System (ISBT
009)
• Discovered by Allen and coworkers in 1951
• Named after the sixth child of Mrs. Kidd (John
Kidd)
who has HDFN.
• Jkb discovered in 1953 by Plaut and associates
• Jk(a-b-) described in 1959 by Pinkerton and associates
• Simple and straightforward system consisting of
only
three antigens. (Jka, Jkb, Jk3)
Kidd Blood Group
System
• Abbreviation: JK
• Antibody Class: IgG
• Optimal reaction temperature: 37ºC
• Reactive phase: AHG
• Enzyme treatment: enhanced
(increased agglutination
• Antigens: Jka, Jkb, Jk3
• Four phenotypes: Jk (a+b-), Jk (a-b+), Jk (a+b+), Jk (a-
b-)
Kidd
Antigens
• Jka and Jkb antigens are well developed on the RBCs
of neonates.
• RBCs carry 14,000 antigen sites per cell
• Enhanced by enzymes
• Jknull RBCs are resistant to lysis by 2M urea, a lytic
agent used by some automated hematology
analyzers.
• Found on Kidd glycoprotein which is a urea
transporter (multipass)
Kidd
Antibodies
• Demonstrate dosage
• Difficult to detect.
• Weak, titer of anti-Jka or anti-Jkb quickly declines in vivo.
• Found in combination with other antibodies
• These antibodies bind the complement
• These antibodies are associated with HTR
and HDFN
• The decline in antibody reactivity and the difficulty
in detecting Kidd antibodies have a notorious
reputation in blood bank as a common cause of
delayed HTR
 The Jk(a-b-)/Jknull
Phenotype
• Very rare, except among Polynesians, Filipino (≤1%)
and Finns.
• Two types
1. Recessive type Jk(a–b–) (JkJk)
• Lack Jka, Jkb, and the common antigen Jk3.
• Produce an antibody called anti-Jk3 which reacts
with all rbcs except Jknull
2. Dominant type Jk(a–b–),
• Due to inheritance of the dominant gene In(Jk)
• Adsorbs and elutes anti-Jk3 and anti-Jka or anti-Jkb
• Do not produce anti-Jk3
Lutheran Blood Group System (ISBT
005)
• In 1945, anti-Lua was found (and described in detail a year later)
in the serum of a patient with lupus erythematosus, following
the transfusion of a unit of blood carrying the corresponding
low-prevalence antigen.
• The new antibody was named Lutheran for the donor; the
donor’s last name was Lutteran but the donor’s blood sample
was incorrectly labeled.
• Anti-Lub discovered by Cutbush and Chanarin in 1956

• Dominant type Lu(a-b-) was discovered in 1961 by Crawford

and
coworkers
• Recessive type Lu(a-b-) was described in 1963
• Recessive X-Linked Inhibitor Type -All Lu(a–b–) family members
were male and carried trace amounts of Lub detected by
adsorption-elution.
Lutheran Blood Group
System
• Abbreviation: LU
• Antibody Class: IgM- anti-Lua
IgG-anti-Lub
• Optimal reaction temperature: 37ºC and 4ºC
• Reactive phase: room temperature and AHG
• Enzyme treatment: variable effect
• Alleles: Lua, Lub
• Antigens: 23 including Lua, Lub, Aua and Aub
Lutheran
Antigens
• Antigens have been detected on fetal RBCs as early as
10 to 12 weeks of gestation but are poorly developed
at birth, thus HDFN is rare and only mild
• Lutheran antigen expression is variable from one
individual to another
• Located on a type 1 transmembrane adhesion protein
that bind laminin
• A linkage between Lu and the Se gene (FUT2) at
chromosome 19 was the first example of autosomal
linkage described in humans.
Lutheran
Antibodies
1. Anti-Lua
• Non RBC Immune (Naturally Occurring)
• Mostly IgM
• React best at room temp
• Most are clinically insignificant
• Can be recognized by its characteristic loose, mixed-field reactivity in
test tubes
 Lutheran
Antibodies
2. Anti-Lu
b

• RBC Immune, mostly IgG (few IgM and IgA)

• Reacts at 37°C and AHG phases
• Mild HDFN and HTR
• Implicated with shortened survival of transfused
cells and post-transfusion jaundice
3. Anti-Lu3
• Inseparable anti-Luab
• Recognizes a common antigen, Lu3, that is
present whenever Lua or Lub is present
• Reacts with all red cells except Lu (a-b-)
• Found in Lu (a-b-) phenotype
Lu(a-b-)
Phenotypes
1.Dominant Type In(Lu)
• NORMAL inheritance of Lutheran genes
• Due to inheritance of a rare dominant regulator gene called In(Lu)
for “inhibitor of Lutheran."
• Related to mutations in the gene for Erythroid Krüppel-like Factor
(EKLF)
• Adsorbs and elutes Lutheran antibodies
• Do NOT make anti-Lu3
• Red cells also have reduced expression of CD44 and a
weak
expression of P1, i, AnWj, MER2, and Inb blood group antigens.
Lu(a-b-)
Phenotypes
2.Recessive Type Lu(a-b-)
• Inheritance of two rare silent alleles LuLu at the Lutheran locus
• Lack all Lutheran antigens, hence will NOT adsorb and elute Lutheran
antibodies
• Produces anti-Lu3 antibody
• NORMAL antigen expression of P1, i, and the other antigens that are
weakened with the dominant type.
Lu(a-b-)
Phenotypes
3.Recessive X-linked Inhibitor Type
• Rare, only males are affected
• Red cells carries trace amounts of detected by adsorption-
Lub
elution.
• NO anti-Lu3
• Due to inheritance of XS2 suppressor gene
P Blood Group System (ISBT 003), GLOB
Blood Group System (ISBT 028) and ISBT
Collection
• Discovered209by Landsteiner and Levine in 1927
• In 1951, Levine and colleagues described anti-Tja
( now known as anti-PP1Pk)
• Pk described by Matson and coworkers in 1959
• Initially composed of P, P1, P2, P1k, P2k, Luke(LKE), PX2 &
NOR.
• Currently, in ISBT nomenclature, P1, Pk, and NOR are
assigned to the P1PK blood group system (003, symbol
P1PK), P and PX2 are assigned to the Globoside blood group
system (028, symbol GLOB), and LKE is assigned to the
Globoside collection (209, symbol GLOB).
P Blood Group
System
• Abbreviation: P1PK
• Clinically significant: NO
• Antibody class: IgM
• Optimal reaction temperature: 4ºC
• Reactive phase: immediate spin, 37ºC and AHG
• Enzyme treatment: enhanced (increased agglutination
• Alleles: P1, PK
• Phenotypes: P1, p, P1k
• P1 phenotype: P1 and P antigens
• P2 phenotype: P antigen ONLY
P1Pk Antigens/ P Blood Group Antigens

• Like the ABH antigens, P antigens are synthesized by

sequential action of glycosyltransferases, which add
sugars to precursor substances
• P1, P, or Pk may be found on RBCs, lymphocytes,
granulocytes, and monocytes
• P can be found on platelets, epithelial cells, and
fibroblasts.
• P and Pk have also been found in plasma as
glycosphingolipids and as glycoproteins in hydatid cyst
fluid.
 P1
• Antigen
Antigen strength in adults varies from one individual
to another. Some P1+ individuals are P1 strong (P1+s)
and others are P1 weak (P1+w).
• Blacks have a stronger expression of P1 than whites
• Expression is inhibited when the rare modifier
dominant gene for the In(lu) type Lu(a-b-) is inherited.
P+ may type as P-
• Deteriorates rapidly on storage. False negative result
may resulf from use of old RBCs
AABB Technical Manual, 14th Edition, Page 291.
P
null
• p phenotype
• Very rare, 5.8 in a million
• Slightly more common in Japan, North Sweden, and in an Amish
group in Ohio
• Produces anti-PP1Pk (formerly anti-Tja)
 Anti-
•P1Naturally occurring IgM found in P2 individuals
• Typically a weak, cold-reactive saline agglutinin
optimally reactive at 4°C and not seen in routine testing.
• Can be neutralized or inhibited with soluble P1
substance (hydatid cyst fluid and pigeon egg white)
• Enhanced with enzyme treatment of reagent red blood cells
• Strong anti-P1 are discovered in two P1– individuals infected
with Echinococcus granulosus tapeworms
• Strong antibodies to P1 have also been found in patients with
fascioliasis (bovine liver fluke disease) and in bird handlers
Anti-
P
1. Alloanti-P
• Component of the anti-PP1Pk
• Found as a naturally occurring
alloantibody in the sera of Pk individuals
• Rarely seen, but because it is hemolytic
with a wide thermal range of reactivity, it
is very significant in transfusion
 Anti-
P
2. Auto Anti-P (Donath–Landsteiner antibody, IgG)
• Associated with Paroxysmal Cold Hemoglobinuria (PCH)
• Biphasic hemolysin:
• Antibody binds to RBCs at cold temperature and fixes complement and lyses rbcs at
37°C when complement cascade proceeds to completion
• Patients with autoanti-P may require a blood warmer
for transfusion
• Demonstrable only by the Donath-Landsteiner test.
Donath-Landsteiner Test

1. Draw two tubes of blood (red top)

2. Tube 1: Incubate at 37oC 60 minutes.
(Control
for tube.)
3. Tube 2: Incubate at 4oC for 30 minutes
transferring to 37oC for 30 more minutes.
4. Centrifuge and observe for hemolysis.
• Positive: No hemolysis in tube 1 and hemolysis in tube 2.
• Negative: No hemolysis in either tube.
• Invalid: Hemolysis in tube 1.
Anti-
PP P k
1 called Anti-Tj
• Originally a

• First described in the serum of Mrs. Jay, a p individual

with adenocarcinoma of the stomach
• Produced by all p individuals early in life and reacts with all cells except
P nulls
• IgM/IgG, naturally-occuring
• Clinically significant. Binds the complement. Can cause HTR and HDFN
• Associated with spontaneous abortions in early pregnancies.
 Disease
Associations
• Parasitic infections (Hydatid disease, fascioliasis) are
associated with anti-P1, early abortions with anti-PP1Pk
and PCH with autoanti-P.
• Pk antigen is a receptor for shiga toxins, which cause
shigella dysentery and E. coli–associated hemolytic
uremic syndrome.
• P is the receptor of human parvovirus B19 and P-
fimbriated uropathogenic E. coli.
• Recent studies demonstrate that Pk provides some
protection against HIV infection of peripheral blood
mononuclear cells
MNS Blood Group System (ISBT
002)
• Discovered in 1927 by Landsteiner and Levine after
immunizing
rabbits with human RBCs
• Named from the second and fifth letter of the word “immune”
• S discovered in 1947 by Walsh and Montgomery (named after the
city of Sydney where the first Anti-S was discovered
• s discovered in 1951
• 50 antigens have been included in the MNS system, making
it
almost equal to Rh in size and complexity
 MNS Blood Group System (ISBT
002)
• Anti-U discovered in 1953 by Weiner (stands for the
almost “universal” distribution of the new blood
factor)
• U antigen and S and s antigens are located on a common protein, glycophorin B,
thus their inclusion into a single blood group system
• U- cells were also S-s-
• Ena associated with MNS because M-N- cells are also
Ena-
M and N
antigens
• Found on Glycophorin A (GPA), the major RBC sialic
acid–rich glycoprotein
• M and N antigens differ in their amino acid residues at
positions 1 and 5
• M is defined by serine at position 1 and glycine at position 5
• N is defined by leucine at position 1 and glutamic acid at position 5
• Since M and N are located at the outer end of GPA, they
are easily destroyed by the enzymes ficin, papain,
bromelin, trypsin, pronase and ZZAP
• P. falcifarum uses GPA and GPB as alternative receptors
for cell invasion
S and s
Antigens
• Located on a smaller glycoprotein called glycophorin B (GPB)
• S and s are differentiated by the amino acid at position 29 on
GPB.
• S has methionine in position 29
• s has threonine in position 29
• Less easily degraded by enzymes because the antigens are
located farther down the glycoprotein
• GPB appears to be associated with the Rh protein and Rh-
associated glycoprotein complex as evidenced by the greatly
reduced S and s expression on Rhnull RBCs

NOTES!
Besides Rh antigens, Rhnull individuals also lack
Fy5, LW systems antigens and weakened S and
s expressions
 U Antigen and U-
• U-Phenotype
RBCs also type as S-s-
• U antigen is located on GPB very close to the RBC
membrane between amino acids 33 and 39, making it
resistant to enzyme treatment
• U (“universal”) antigen is found on RBCs of ALL
individuals except in <1% of African Americans because
of complete deletion GYPB.
• These individuals can make anti-U in response to transfusion or pregnancy
• Anti-U is typically IgG and has been reported to cause severe and fatal HTRs and
HDFN.
Mk Phenotype

• The RBCs of these individuals typed M–N–S–s–U–En(a–)Wr(a–b–)

• Mk gene represents a single, near-complete deletion of both GYPA
and GYPB
• MkMk represent the genotype of null phenotype in the MNS system

NOTES!
En(a-) rbcs are also M-N-,Wr(a-b-)
U- rbcs are also S-s-
MkMk rbcs lack ALL MNS system antigens
Anti-M (lectin: Iberis
amara)
• Clinically significant if IgG; IgM antibodies are NOT
clinically
significant
• Demonstrates dosage effect, react better with M+N– RBCs
• Do not bind complement
• Do not react with enzyme-treated RBCs
• Some examples are pH dependent, reating best at pH 6.5
• Other examples react only with red cells exposed to glucose
solutions
 Anti-N (lectin: Vicia
• graminea)
Cold-reactive IgM or IgG saline agglutinin that
does not bind complement or react with enzyme-
treated RBCs.
• Anti-N demonstrate dosage, reacting better with
M–N+
• Not clinically significant unless it reacts at 37°C
• Seen in renal patients, regardless of their MN
type, who were dialyzed on equipment sterilized
with formaldehyde (anti-Nf)
Anti-S, Anti-s and Anti-
U
• Most examples of anti-S and anti-s are IgG, reactive at 37°C and the
antiglobulin test
• The antibodies may or may not react with enzyme-treated RBCs
• Anti-U is rare and occurs in S-s- people
• Found only in BLACKS
MNS Blood Group
System
• Miltenberger Series
• Low frequency antigens of the MNS blood group system
I Blood Group System (ISBT 027) and
ISBT Collection 207
• Discovered in 1956 by Weiner and colleagues in a
patient with CHAD (cold hemagglutinin disease)
• Used the symbol I to emphasize the “individuality”
of rbc’s failing to react with the patient’s serum at
room temperature
• I and i formerly belonged to ISBT Collection 207
• I given its own blood group system (ISBT 027)
I and i
Antigens
• Both I and i are high-prevalence antigens
• Linear and branched repeats of N-acetyllactosamine
• Infant RBCs are rich in i which gradually converts to I during the
first 18 months of life, thus adult RBCs are rich in I and have only
trace amounts of i antigen.
• I and i antigens are precursors for the synthesis of ABO and Lewis
antigens

i 18 months
i i i N-acetylglucosaminyltransferase
I I I
i i IGnT gene I I
i
i i I
Cord cells Adult cells
 I- phenotype (Adult
i) called adult i.
• Now
• Mutation in the gene (IGnT) responsible for producing the branching
enzyme (N-acetylglucosaminyltransferase) needed to convert i active
straight chains into I active branched chains
• i fail to convert into I
• adult i red cells contains more i antigen than cord cells
• May produce alloanti-I if transfused I+ blood
 Anti-
I
• Three Types:
• Benign Autoanti-I
• Pathologic Autoanti-I
• Alloanti-I
 Benign Autoanti-
I naturally occurring, saline-reactive IgM agglutinin
• Weak,
• Considered a nuisance antibody. C a u s e p r o b l e m s i n
pretransfusion testing.
• Strong examples of anti-I may be picked-up at room temp
(prewarm sample!) and binds complements which reacts with
polyspecific AHG (use monospecific anti-IgG!)
• Prewarming technique, use of monospecific anti-IgG and cold
autoadsorption help eliminate detection of cold-reactive
autoantibodies
• Common cold autoantibody found virtually in all antisera
• Testing at 4°C or enzymatic treatment enhances the detection of
this cold autoantibody
Pathologic Anti-
I
• Wider thermal range of reactivity and higher titer
• Reacts at higher temperatures (may cause in vivo hemolysis!)
• Production may stimulated by microorganisms carrying I-
antigen on their surface
be like(M. pneumoniae)
• Associated with cold agglutinin syndrome
Alloanti-
I
• Exists as an IgM or IgG antibody in the serum of most individuals with
the adult i phenotype.
• NOT associated with HDFN because the antibody is IgM, and the I
antigen is poorly expressed on infant RBCs
Anti-
i
• Alloanti-i never been described
• Autoanti-i is a fairly rare antibody that gives strong reactions with
cord RBCs and adult i RBCs and weaker reactions with adult I RBCs
• Potent examples are associated with infectious mononucleosis
(Epstein-Barr virus infections) and some lymphoproliferative
disorders
 Disease
Association
• Anti- I with cold agglutinin syndrome and M. pneumoniae
infection
• Anti-i with infectious mononucleosis
• Dyserythropoietic syndromes like acute leukemia,
hypoplastic anemia, megaloblastic anemia, sideroblastic
anemia, thalassemia, sickle cell disease, paroxysmal
nocturnal hemoglobinuria (PNH), and chronic hemolytic
anemia are associated with increased i antigen on RBCs
• Chronic dyserythropoietic anemia type II or hereditary
erythroblastic multinuclearity with a positive acidified
serum test (HEMPAS) is associated with much greater i
activity on RBCs than control cord RBCs
Revie
w
 Cold Antibodies
•(IgM)
Anti-Lea
• Anti-Leb
• Anti-I
• Anti-P1
• Anti-M
• Anti-A, -B, -H
• Anti-N
• Anti-Lua

• LIiPMABHN
Naturally Occurring
Warm antibodies
(IgG)
• Rh
• Kell
• Duffy
• Kidd
• Anti-S,-s,-U
• Anti-Lub
Remember enzyme
activity:
Papain, bromelin, Enhanced Destroyed
ficin, and trypsin by enzymes by enzymes

Kidd Fya and Fyb

Rh M, N
Lewis S, s
I
P
 Remembering
•Dosage:
Kidds and Duffy the Monkey (Rh) eat lots of M&Ns

M&Ns

anti-Jka, -Jkb, -Fya, -Fyb, anti-C, -c, -E, -e (no D), -M, -N, -S, -s
MNSs
Kidd Duffy Rh

adapted from Clinical Laboratory Science Review: A Bottom Line Approach (3rd Edition)
Diego Blood Group System (ISBT
010)
• Discovered in 1953 in Venezuelan baby with HDFN named Diego
• Dib discovered in 1967
• Composed of 22 antigens: Dia/Dib, Wra/Wrb, and Wu/DISK
Diego Blood Group
System
• Diego antigens are carried on band 3, a major integral RBC
membrane glycoprotein (multipass) with about 1 million
copies per RBC.
• Dia antigen is almost entirely confined the population of
Asian origin, including Native Americans (anthropologic
marker for studies on Mongolian ancestry)
• Expression of Wrb requires the presence of both band 3
and a normal GPA of the MNS blood group system. GPA-
deficient RBCs are Wr(a–b–).
• Usually IgG, reactive in the indirect antiglobulin test

NOTES!
GPA deficient RBCs lack
M, N, En(a) and Wrb
antigens
Diego Blood Group
System
• Absence of Band 3 is associated with
• Hereditary spherocytosis
• Congenital acanthocytosis
• Southeast Asian ovalocytosis
Yt (Cartwright) Blood Group
System (ISBT 011)
• Two antigens make up the Yt system Yta and Ytb, which
was named in 1956 after Cartwright from whom the
antibody was first isolated
• Three phenotypes are observed: the common Yt(a+b–) and
Yt(a+b+) and the rare Yt(a–b+).
• The Yt(a–b–) phenotype has not been reported
• Yt antigens are foun on the glycosylphosphatidylinositol
(GPI)- linked RBC glycoprotein acetylcholinesterase (AChE).
• The antigens are ABSENT from RBCs of people with
paroxysmal nocturnal hemoglobinuria (PNH) III
• Anti-Yta and anti-Ytb are IgG
Xg Blood Group System (ISBT
012)
• Anti-Xga was discovered in 1962 in the serum of a
multiply transfused man
• Xga expression was controlled by an X-linked gene,
thus the higher prevalence in females
• 66% males, 89% females
• The antigen was named after the X chromosome
and g for “Grand Rapids,” where the patient was
treated
• There are two antigens in the Xg system: Xga and
CD99 (MIC2)
• Anti-Xga is usually IgG
Scianna Blood Group System (ISBT
013)
• Established as a system in 1974
• Currently consists of seven antigens
• Antigens: 7 including Sc1 , Sc2 formerly (low
incidence),
Bua Sc3 (high incidence), Rd (Radin),
Sc5 (STAR), Sc6 (SCER), and Sc7 (SCAN)
• Scianna antigens are located on erythroid membrane
associated protein (ERMAP)
• Rare null phenotype Sc: -1, -2, -3 observed
in Marshall Islands and New Guinea
Dombrock Blood Group
System (ISBT 014)
• Named for the first antibody maker, Mrs. Dombrock
in 1965
• Antigens: 8 including Doa, Dob, Gya, Hy, Joa
• The Gy(a–) phenotype is the Dombrock null since Gy(a-) is
also Hy-, Jo(a-) and Do(a-b-)
• The Dombrock antigens are carried on a GPI-linked protein
called mono-ADPribosyltransferase 4 (ART4)
• The antigens are present on cord RBCs, but are
absent from PNH III RBCs.
• Dombrock antibodies are usually IgG
Colton Blood Group
System (ISBT 015)
• The system was named in 1967 for the first antibody maker; it
should have been named Calton, but the handwriting on the
tube was misread
• Consists of four antigens: Coa, Cob, Co3, Co4
• Phenotypes: Co (a+b-), Co (a+b+), Co (a-b+), Co (a-b-)
• Co3, is present on all RBCs except those of the very rare Co(a–
b–) phenotype
• Colton antigens are carried on an integral membrane protein,
aquaporin 1 (AQP1), which accounts for 80% of water
readsorption in the kidneys
• Antibodies are usually IgG
• Colton null associated with Monosomy-7
Landsteiner-Wiener Blood Group
System (ISBT 016)
• In 1940, Landsteiner and Wiener reported that an antibody
produced in rabbits (and later, guinea pigs) after injection
with RBCs of rhesus monkeys reacted with 85% of human
RBCs. The antibody was called anti-Rh which was later
renamed anti-LW
• There are three LW antigens: LWa, LWab, and LWb
• LW antigens is carried on a glycoprotein known as
intracellular adhesion molecule 4 (ICAM-4)
• Null phenotypes
• LW(a–b–) Big; Named after one individual who made anti-
LWab (Mrs. Big). Elicit the formation of anti-LW in animals
• LW(a–b–) Rhnull. Fail to elicit the formation of anti-LW in
animals
Landsteiner-Wiener Blood Group
System (ISBT 016)
• There is a phenotypic relationship between the D antigen and
anti-LW
• Anti-LW usually reacts strongly with D+ RBCs, WEAKLY
(and sometimes not at all) with D– RBCs from adults, and
NOT at all with Rhnull RBCs. This is because there are more LW
antigen sites on D+ RBCs than on D– RBCs
• Rhnull RBCs lack the LW glycoprotein
• Differentiated from Rh by DTT-treated D+ RBCs: the D
antigen is NOT denatured by DTT, so anti-D would still be
detected; however, LW antigen is destroyed by DTT, so anti-LW
would no longer react
Chido/Rodgers Blood Group
System (ISBT 017)
• Named after the first two antibody producers, Ch for Chido and Rg
for Rodgers described in 1967 and 1976 respectively
• Antigens are NOT intrinsic to the red cell but are adsorbed on the
rbc from the plasma. Rather, they are located on C4 fragments
• The C4 glycoprotein has two isoforms: C4B carries the Ch antigens
and C4A expresses Rg antigens
• Antibodies are generally benign but they are a “great nuisance in
serological investigations”
• Anti-Ch and anti-Rg are usually IgG and react weakly, often
to
moderate or high titration endpoints
Chido/Rogers
Antibodies
High Titer, Low Avidity

• High titer: 1:64 or greater

• Low Avidity: 1+ or less through all titer dilutions
• Resolution: If you suspect an HTLA antibody you can do
two things:
1)Titer patient serum: HTLA antibodies will titer out a long
way (1:64) while others will not then you can…
2)Neutralize patient serum with normal fresh plasma, it will
remove HTLA antibody.
Gerbich Blood Group
System (ISBT 020)
• Named in 1960 after Mrs. Gerbich, the first
antibody producer and became a system in 1990
• The antigens are carried on GPC and GPD
• There are currently 11 Gerbich antigens (Ge2, Ge3,
Ge4, GEPL, GEAT, and GETI, Wb, Lsa, Ana, Dha, and GEIS).
• Gerbich-negative phenotypes
• Ge:–2,3,4 (Yus type)
• Ge:–2,–3,4 (Gerbich type)
• Ge:–2,–3,–4 (Leach type): Gerbich null
• Gerbich antibodies are usually IgG and may be implicated
in HTR or HDFN
Cromer Blood Group
System (ISBT 021)
• Discovered in 1965 by Stroup and McCreay, recognized as a
system in 1975
• The Cromer system has 18 antigens
• Inab phenotype is the Cromer null phenotype
• The antigens of the Cromer system are carried on GPI-linked
decay accelerating factor (DAF/CD55)
• PNH III RBCs are deficient in DAF so they also lack Cromer
antigens
• Antibodies in the Cromer system are usually IgG, but do not
cause HDFN
Knops Blood Group
System (ISBT 022)
• Named after Mrs. Knops, the first antibody maker.
• Knops antigens which includes Kna, McCa, SIa, Yka, Knb
are located on complement receptor 1 (CR1/CD35)
• Weak and variable reactivity is due to variable expression
of CR1 on different samples of RBCs
• Clinically insignificant with weak and “nebulous” reactivity
in AHG phase
• “Helgeson phenotype” represents the serologic
null phenotype for the Knops blood group
Indian Blood Group
System (ISBT 023)
• The Indian blood group system was named because the first In(a+)
individuals were from India
• There are now four antigens in the system, all located on CD44, an
adhesion molecule
• Antigens: Ina, Inb, INFI, INJA
• Only one case of In(a-b-) reported in a patient with CDA
• CD44 is reduced on RBCs of dominant type Lu(a–b–) individuals
• Anti-Ina is associated with decreased RBC survival
• Antibodies are usually IgG
Ok Blood Group System (ISBT
024)
• Anti-Oka was identified in 1979 and was named after
the antibody maker, Mrs. Kobutso. Established in 1999
• Antigen: Oka, OKGV and OKVM
• Located on basigin/CD147, receptor for falciparum
malaria protein PfRh5
• The original anti-Oka was IgG, reactive in the antiglobulin test.
• The antibody caused reduced survival of 51Cr-labeled Ok(a+)
RBCs
RAPH Blood Group System (ISBT
025)
• Discovered in 1999 and named after the first antibody producer
• The only antigen in the Raph system is MER2
• stands for Monoclonal, and Eleanor Roosevelt (the laboratory
where the antibody was produced)
• MER2 is located on CD151/tetraspanin
• MER2 expression decreases over time with
increasing maturation of erythroid cells
John Milton Hagen Blood Group
System (ISBT 026)
• Formerly belongs to ISBT 901007
• Given its own system when gene location was found in 2004
• Currently consist of six antigens JMH1 through JMH6
• JMH antigens are located on GPI-linked
glycoprotein
CD108/semaphorin
• JMH levels decline during the later years of life
• The patient’s JMH– status is acquired and can be transient.
Once JMH expression is reduced, anti-JMH can be made.
• Anti-JMH is usually IgG
Gill (ISBT
029)
• Anti-GIL was first identified in 1980, but the antigen was
not raised to system status until 2002
• Antibodies are usually IAT-reactive IgG
• There is only one antigen, GIL, found on the
glycerol transporter aquaporin 3 (AQP3)
RHAg
(ISBT
030)
• Established in 2008
• Its presence is essential for Rh antigen expression
• Absence of RhAG results in regulator-type Rhnull
• Antibodies are usually IAT-reactive IgG
• Antigen: Duclos or RHAG1 (previously 901013)
and OIa or RHAG2 (previously 700043). DSLK and
RHAG4, newest inclusion
• RHAg is glycosylated on the first extracellular loop
FORS (ISBT
031)
• Established in 2012
• Antigen: FORS1
• Apae, initially thought to be a subgroup of A (genotype OO!) express the
forssman glycolipid
• The rare Apae individuals have Arg296 mutation leading to activation of
Forssman synthase gene and synthesis of Forssman glycolipid
• Antibody to Forssman glycolipid always exists in humans and Forssman
substance may exceptionally be found on some human RBCs =>
Forssman is now considered a RBC antigen
• Exceptional human RBCs that display FORS1 antigen demonstrate the
so called “polyagglutinability” phenomenon of inherited type
• RBCs carrying FORS1 are strongly agglutinated by Helix pomatia lectin
JR (ISBT
032)
• Established in July 2012
• Fomerly ISBT 901005
• Jr(a-) common among Japanese and European Gypsies
• Anti-Jra considered a clinically significant alloantibody, either in obstetrics and
RBC transfusion
• Jra is related to a multi-drug transporter protein ATP-Binding Cassette G2
(ABCG2) or breast cancer resistance protein (BCRP) which is essential in cell
detoxification. It mediates the efflux of several anti-cancer drugs
mitoxantrone, camptothecin derivatives and anthracyclins
like
• Null alleles of ABCG2 due to premature stop codon is responsible for Jr(a-),
(essential in pharmacogenetics!)
• Arg236Ter in European Gypsies
• Gln126Ter in Asians (prevalence in Japan: 1.6-2.4%)
LAN (ISBT
033)
• Established in July 2012
• Formerly ISBT 901002
• Lan antigen is found on ABCB6. Mutation in ABCB6 gene leads to Lan-
phenotype
• ABCB6 reported to be essential in erythropoiesis through mitochondrial
porphyrin uptake
Miscellaneous
Antigens
• Vel (provisionally ISBT034)
• ISBT 212001
• Includes the formerly high-prevalence antigen Vel (212001 -> now ISBT034)
and ABTI (212002)
• Anti-vel is mostly IgG and can activate complement and has caused severe,
immediate HTRs
• Anti-Vel has also caused one case of severe HDFN in which the mother had
previously been transfused.
Miscellaneous
Antigens
• Ata (provisionally ISBT036)
• ISBT 901003
• First described in 1967 in the serum of a black woman named Mrs. Augustine
• High-prevalence antigen, and all At(a–) individuals have been black
• Usually IgG, reactive in the antiglobulin test
• Anti-Ata has caused severe HTRs and one reported mild case of HDFN
 Miscellaneous
• SdAntigens
a

• ISBT901012
• High-prevalence antigen named for Sid, who was the head of
the maintenance department at the Lister Institute in London
• The soluble form of Sda is Tamm-Horsfall glycoprotein found
in urine
• Anti-Sda is usually non-immune IgM agglutinin that is
reactive at room temperature
• Reactivity is described as small, refractile (shiny) agglutinates
in a sea of free RBCs
Miscellaneous WBC Antigens:
Bg
• Human leukocyte antigens (products of the MHC genes!)
• Antibodies to the Bg antigens are directed towards HLA
• Often present in multiparous and multiply transfused patients
• Antibody Class: IgG
• Optimal temperature: 37ºC
• Optimal Phase: AHG
• Antigens (MHC Class I antigens)
• Bga (B7)
• Bgb (B17)
• Bgc (A28)
• Antibodies are usually contaminant of polyclonal typing sera
• Adsorbed by human platelet concentrate
• References:
• Modern Blood Banking and Transfusion Practices, 6th edition,
Denise M.
Harmening
• Henry's Clinical Diagnosis and Management by Laboratory Methods,
22nd
edition, McPherson and Pincus
• http://www.isbtweb.org/working-parties/red-cell-immunogenetics-and-blood-
group-terminology/