BLOOD BANKING M1
transfusion sa mama kay same sa antibody na
Rh-Hr BLOOD GROUP SYSTEM
 Rh has 4 nomenclatures
 The (+)/(-) found after the blood type pertains to the
presence of the Rh antigen
 If Rh+, that means that the patient has Rh antigens
o Rh antigens are: D, C, E, c, e
 In some cases, only one antigen may be present while
other cases may also involve having all five antigens
 It is very hard to determine because Rh antigen
detection is not performed in the lab routinely except
for the determination of the presence of the D antigen
 When you say that the patient is Rh+, that means na
only the D antigen is detected
 On the other hand, if you say Rh-, that means the
patient does not have the D antigen. But that does not
equate to the absence of the C/c and E/e antigens
because the reagent used is the anti-D antisera
 Why D lang? because D is the most immunogenic
antigen in the immune system: grabe sya maka induce
ug antibody production compared to C/c and E/e
 Rh is the 2nd major blood group after ABO BGS
 the term Rh refers to a specific BGS located very near to
the RBC’s membrane
 Rh is one of the antigens enhanced if you will use
enzymes: will cleave taller proteins to unveil proteins
found in RBC membrane
HISTORY
 Until 1939, people thought that only the ABO antigens
were present on the red blood cells
 1940
o HDFN linked to Rh BGS by Levine and Stetson
o Woman gave birth to a still-born baby because of
HDFN
o While giving birth, mother required blood
transfusion.
o Chosen donor was husband since same silag ABO
blood type
o But during transfusion, nagka hemolytic transfusion
reaction si mother
o Meaning, father and baby naay same antigen na
wala kay mother, and the mother was able to
produce antibodies against the antigens
o In this case, most probably 2nd pregnancy na ni kay
if first child pa lang, mainly exposure lang ang
mahitabo so maka survive pa ang first child but may
have minor hemolysis
o 2nd child will always end up dying because the
mama already has pre-formed antibodies
o So, further experimentation happened and found
out that other blood antigens may be present on the
red cell and not just ABO
o REMEMBER THAT ANTIBODIES AGAINST Rh ARE
NOT NATURALLY-OCCURING; SENSITIZATION IS
NEEDED FOR THEM TO BE PRODUCED, UNLIKE
THE ABO BGS
 Rh ANTIGENS
o Rhesus monkey cells
 Rh ANTIBODIES
o Demonstrated by Landsteiner and Weiner
o The red cells from Rhesus monkeys were given to
guinea pigs and rabbits wherein the animals
produced antibodies against the injected antigen
(from Rhesus monkey)
o When they tested the antibodies produced by the GP
and rabbit on the human RBC, 85% sa human RBC
kay nag agglutinate. So they believed na ang
antibody na nag cause sa HTR during blood
naproduce sa GP and rabbit (ginadefine daw sa
duha ka antibodies ang same blood group)
o But they later found out na the two antibodies may
not be identical but they could have cross-reacted to
the same antigen
o The term Rh was retained for humans while for
monkeys, LW ang term used for the blood group
o However, in some humans, LW antigen may be
present. So dili exclusive ang LW for monkeys
INHERITANCE
Current Rh Genetic Theory
 RHD and RHCE genes linked in chromosome 1
o RHD and RHCE are located on separate loci but have
close proximity and are usually inherited as a unit
(haplotypes) like the MNSs – MN and Ss are
separate blood groups
o RHD and RHCE are from the same blood group that
contains two different genes that control what
antigens are to be presented on the red cell
o RHD gene
 Alleles: D
 Antigens: D positive
 No D allele = no D antigen: considered as Rh-
o RHCE gene
 Alleles: RHCE, RHCe, RHcE, Rhce
 Antigens: CE, Ce, cE, ce
 Depends on the genetic variation of your parents
 In combination with the D gene
 If wala na inherit ang D gene: CE, Ce, cE, ce;
considered to be Rh-
o RHAG gene
 Required for the expression of the D gene
 Product: Rh-associated glycoprotein (RhAG)
 Where Rh antigens are located
 Chromosome 6
 Co-expressor of Rh antigens
 No RHAG gene = No RHD and RHCE genes = no
Rh Ag expressed on RBC = Rhnull phenotype
 The Rh glycoprotein traverses the red cell membrane
12 times, that’s why it is known as a transmembrane
protein: inserting/ going in and out of the red cell
membrane parts
 Other Rh antigens can be found on specific parts of the
Rh glycoprotein
 Since it is a transmembrane protein, it maintains the
integrity of the red cell membrane (vital role)
 Rhnull individuals tend to have RBC form abnormally:
red cells produced are called stomatocytes: may result
from absence of Rh glycoproteins, so RBCs produced
are fragile
 coffee-bean-shaped RBC
 Rhz Rhz Rh0rh’rh” Rz DCE
rh rh hr’hr r ce
DIFFERENCES IN AMINO ACID SEQUENCE FOR THE rh’ rh’ rh’hr” r’ Ce
ANTIGENS PRODUCED BY RHCE GENE rh” rh” hr’rh” r” cE
ANTIGEN AMINO ACID NUMBER rhy rhy rh’rh” ry CE

C SERINE 103 Cc
c PROLINE 103 Cc NOMENCLATURE
E PROLINE 226 Ee 3. CONVERTING FISHER-RACE TO WEINER
e ALANINE 226 Ee FISHER-RACE ANTIGEN WEINER TERMINOLOGY
D Rh0
TWO MAJOR THEORIES ON HOW Rh IS EXPRESSED ON C rh’
THE RED CELLS E rh”
c hr’
e hr”
 R denotes D is present
 r denotes D is absent
 1 or ‘ denotes C is present
 2 or “ denotes E is present
 No 1 or ‘ denotes C is absent
 No 2 or “ denotes E is absent
 z or y denotes presence of C and E
 Rhmod
 Rhnull is equivalent to rr, read as little r double bar
 Fisher-Race Genetic Theory/ DCE Terminology (Harmening)
o There are three alleles/genes responsible for the
coding of each of the Rh antigens NOMENCLATURE
o These three genes are located on three different loci 4. ROSENFIELD NUMERIC TERMINOLOGY
on the same chromosome: chromosome 1 (Rh gene),  In order
on very close proximity D C E c e
o d denotes absence of D antigen 1 2 3 4 5
o either one of C/c and one of E/e will be inherited  Example
 Weiner/Wiener Genetic Theory D+ C+ E- c+ e+
o Only one allele/genes must be inherited for the Rh: 1 2 3- 4 5
expression of 3 antigens
NOMENCLATURE
NOMENCLATURE 5. ISBT NUMERIC TERMINOLOGY
1. FISHER-RACE: DCE TERMINOLOGY  ISBT: International Society of Blood Transfusion
GENE COMBO (Harmening)
 Six-digit number for every authenticated blood group
Dce
specificity
dce  FIRST THREE NUMBER: SYSTEM (004)
DcE  REMAINING THREE: Antigenic specificity
DCe  Mainly for computer encoding
dCe
D C E c e
dcE Rh1 Rh2 Rh3 Rh4 Rh5
DCE  Example
dCE o Rh0 004001
o rh’ 004002
o hr” 004005
 d Antigen
o Does not exist
ANTIGENS
o Denotes the absence of D antigen
 D > c > E > C > e: based on immunogenicity
 Deletion phenotypes
 Well-developed early in fetal life
o During meiosis, there is exchange of genetic
 Exposure to at least 1 mL of Rh positive cells would
materials, known as crossing-over; there could be
stimulate antibody production of Rh negative persons
instances of deletion
o -De or -DE
ANTIBODIES
o DC- or dc-
o -D- (double deletion)  IgG1
 Rhnull or (-/-)  IgG2 Have been reported
o No Rh antigens  IgG3
 Rhmod  IgG4
o Weakened expression: (D), (C), (e)  IgG1 and IgG3 are the most significant IgG types
because they are easily identified by the
reticuloendothelial system. If there is attached IgG,
your RBC will be destroyed in the spleen. There will be
immediate extravascular hemolysis.
NOMENCLATURE  DO NOT BIND COMPLEMENT
2. WEINER: The Rh-Hr terminology  During Antibody production, Rh antibodies will start as
GENE AGGLUTINOGEN
BLOOD SHORTHAND FISHER- IgM which becomes IgG; IgG lasts longer
FACTORS DESIGNATION RACE Ag
Rh0 Rh0 Rh0hr’hr” R0 Dce
 Rh IgA has also been reported
Rh1 Rh1 Rh0rh’hr” R1 DCe  Therefore, Rh has 3 types of antibodies: IgM, IgG, and
Rh2 Rh2 Rh0hr’rh” R2 DcE IgA

WEAK D
Variations of the Rh0 (D) Antigen Expression
 Weak D antigens may be attributed to the weak genes
that you have inherited: mutated genes, problems in
the production of Rh glycoprotein
 Weak D expression was historically known as Du
phenotype
 Now referred as WEAK D POSITIVE
o Still contain Rh antigens but are weakly expressed:
may have problems in antigen formation, or it could
be only very few antigens are present on the red cell
 3 mechanisms:
o GENETIC WEAK D
o C TRANS
o PARTIAL D (MOSAIC D)
 No differentiation is made in routine blood bank/
serologic studies; unless genetic studies will be
performed
 RHD genes code for weaker expression of D antigen
 Reduced number of D antigens on the red cells
 Most common in blacks
 IAT is required to detect this form of D
WEAK D TESTING (IAT)
Required test for donors who are initially type as D
negative
1. Label 2 tubes as Anti-D and Rh control. Place one
drop of the 2-5% red cell suspension of the sample
to be tested.
a. You can also label the tubes as Patient and Rh
control respectively
b. It is important to place Rh control for IAT.
c. Rh control is only negative because ang lisod
tan-awon na result for Rh is negative. If positive
sya, very strong man jud ang agglutination so no
need for comparison
2. Add one-drop of the Anti-D into one test tube and 1
drop of the Rh control into the other test tube.
a. After adding the Anti-D, you add the patient’s
red cells which may or may not contain Rh
antigens or naay weak D (Patient-labeled tube)
b. For control, you will add the Rh control cells but
it will always be negative since negative man
ang control.
3. Incubate 15-30 minutes. Wash 3x with saline.
a. Incubation is needed since IgG man ang naa. So
incubate at 37℃; if there is LISS, incubation will
only be 10 minutes but if wala kay 30 minutes-1
hour
b. Wash to remove unwanted substances
4. Add 1-2 drops of AHG reagent.
5. Mix and centrifuge.
a. If there is agglutination, it means there is
sensitization kay ang AHG magbind baya sa Fc
portion of the Ab
6. Gently resuspend and examine agglutination, grade,
and record.
7. Add IgG-coated control cells to negative results,
spin, and read.
a. Coombs check cells: IgG-coated RBCs
b. Agglutination: patient is Rh-
c. No agglutination: repeat entire procedure
because AHG might be expired or you have
failed to add AHG or red cell washing is
inadequate
FLOWCHART FOR Rh (D) TEST
 If you are going to test a weak D positive patient for the
presence of the weak D antigen, there is a strong
possibility that it would appear as Rh negative/ no
agglutination because there is only a few amount of
antigen present on the red cell
 If you placed anti-D on the patient’s red cell tapos
walay agglutination reaction, what will you do?
 If you will retest the sample, the reaction will still be
the same. Do not immediately report it as Rh-, instead,
you have to perform Indirect Anti-human globulin
testing (IAT) to determine presence small amounts of
D antigen (weak D)
 What if this person needed transfusion but you
immediately reported it as Rh-? The blood that will be
transfused will be Rh-, so no problem pa sa patient
because Rh- doesn’t have any antigens. No possible
reactions
 The problem occurs if the weak D patient becomes the
blood donor. Why? Weak D lang man siya, not Rh-. So,
naa gihapon syay antigens but gamay lang. So if mag
donate syag dugo sa Rh- na patient, that would lead to
the sensitization of the Rh- recipient mainly because
there is wrong labeling of the blood bag because you
failed to identify the presence of the weak D antigen
 Direct antiglobulin testing (DAT) will be performed
on a different test tube.
 Get a tube, place 5% red cell suspension of the patient’s
red cells and AHG.
 If there is agglutination then it is possible na naay nag
sensitize sa red cell inside the patient’s body, dili si
Anti-D ang nag sensitize kay remember DAT detects in
vivo sensitization, so maong nag positive sya sa IAT kay
naay antibody present na giconnectan si AHG but kato
na antibody is not Anti-D, that’s why inconclusive sya
 No agglutination/ negative for DAT: patient is
confirmed to be weak D positive
Remember that a person can have a weak D when he/she
inherits both weak D genes from the parents.
RESULTS: VERY IMPORTANT (From Sanday, L.)
 Rh (D) test
o the Rh testing that is routinely done together with
ABO typing
o (+) = Rh positive
o (-) = Do not report patient as Rh negative yet
because he/she may have weak D; perform IAT
 IAT
o for weak D detection
o (-) = Rh negative; confirm with Coombs check cells;
 AGGLUTINATION: validation of result = Rh
negative
 NO AGGLUTINATION: repeat entire procedure
o (+) = weak D positive; perform DAT (validation of
weak D)
 to make sure that it was not sensitized in vivo by
other antibodies except anti-D.
 DAT
o get another test tube, place 5% suspension of the
patient’s red cells and add AHG
 o (+) = another antibody that was present in the TYPES OF WEAK DETECTED BY CAN MAKE ANTI-D
patient’s system sensitized the red cells, not the D
anti-D Genetic, Reduced Weak D test No
o (-) = weak D positive D antigen
RhCe in Trans to Monoclonal No
RhD Reagents
WEAK D
Partial D Most monoclonal Yes, antibody to the
Position Effect reagents and missing epitope
Weak D test

UNUSUAL PHENOTYPES AND RARE ALLELE TYPES

ANNTIGEN ANTIGEN ANTIBODY
CHARACTERISTICS CHARACTERISTICS
ce or f Cis product Ag; Rare antibody; can
present when c and cause HTR and
e are inherited as HDFN; c and e
haplotype blood is f
 The genes involved here are the D gene and C gene Ce or Rh7 Cis product Ag; Anti-Ce is often
(take note, it’s the capital C) or rh present when C and made by D+
 TRANS: not found on the same chromosome e are inherited as patients who make
o If D gene is found on another chromosome from C haplotype Anti-C
gene or if in trans position sila, it has an effect on Cw Low frequency Ag; Rare, can cause
the expression of D. 2% in whites and mild HTR and
o It suppresses the expression of the D antigen rarely in blacks; HDFN
o Therefore, there is weak D expression and the most are Cw+ are C+
patient will have the Du phenotype Cx Low occurrence; Rare, can cause
o Remember that the gene found here is okay, weak Cx+ are C+ mild HTR and
lang siya because of the positioning of the genes HDFN
 CIS: D is in the same chromosome with the capital C, V or Ces Found in 30% in Often found with
there will be no problem with the D antigen expression blacks and <1 in other antibodies;
 If small c is in trans with D, there will be no effect. So whites can cause HFN and
always remember na capital C lang ang naga matter HTR
here G Present in most D+ Antibody appears
and C+ cells to be Anti-D and
WEAK D Anti-C; can cause
Partial D (D Mosaic) HDN and HTR
 One or more missing or altered epitopes of the entire D Rh 29 or Present in all red Anti-total Rh is
antigen Total Rh cells and Rhnull made by Rhnull
 Partial D doesn’t mean na gamay lang ang D antigen cells individuals
 In some cases, there is weak D expression that’s why it Rh 17 Present on all red Antibody made by
is included in the weak D phenotype but there may also cells except D- cells individuals who are
be cases na okay ang number of antigens -D-
 Because it may react strongly, weakly, or may not react H E-like antigens Antibodies found
with commercial Anti-D reagents produced by all Rh when an e+ person
 Partial D phenotypes should be suspected if: genes that make e; makes an apparent
o A D person makes an Anti-D that would react to D associated with Anti-e
red cells but is not reactive to his/her own red cells weak e antigen
o Remember that Rh glycoproteins will traverse 12- typing
13 times through the red cell membrane
o Since it is a a transmembrane protein, it is also DELETION PHENOTYPE
responsible for maintaining the morphology/ -D- OR D--
integrity of the red cell membrane  Rhnull
o Remember, if you are Rh null: stomatocytes are o Could be REGULATORY TYPE or AMORPH
present because it is possible na wala kay RHAG o Regulatory type: there is mutation in the RHAG
gene gene
o Remember the concept of epitopes, possible na o Amorph: no RHAG gene
daghan kaayo sya sa isa ka antigen. So, if you are o have membrane abnormalities that shorten RBC
Rh null, you could have 30 types of anti-Rh survival and cause Hemolytic Anemia; remember,
antibodies since wala man kay Rh antigen you don’t have RHAG gene -> no glycoprotein ->
 The problem with partial D kasi is naay missing na isa unstable RBC -> very prone to damage
ka epitope. o Usually if Rh null, patients are anemic / prone to
 What happens if there is a missing epitope? In most RBC membrane abnormalities
cases, it is going to react weakly o If anti-Rh is detected, Rhnull cells are needed for
 D POSITIVE as a DONOR and D NEGATIVE as a transfusion
RECIPIENT o Nganong Rh null jud and not Rh negative? Kay si Rh
negative, D antigen lang ang wala but naa pay C/c
and E/e and Rh null does not have any antigens jud
pati glycoproteins
 Rhmod
o Partial suppression of Rh antigens due to the
inheritance of modified RHAG gene
CLINICAL CONSIDERATIONS THE LW BLOOD GROUP SYSTEM
 HDFN: Hemolytic Disease of the Fetus and Newborn  Chromosome 19
 Alleles:
o LWa, Lwb, LW (amorph)
 Most common phenotype:
o LW(a+b-): LWa/LWa
 Amorph gene:
o LW
 Null phenotype
o LW(a-b-): LW/LW
 Similar to Rh:
o SEROLOGICALLY
 Different to Rh:
o GENETICALLY
 Anti-LW
 It is not possible for the baby to become Rh- since Rh+ o Reacts strongly with D positive red cells
is dominant. The baby will always inherit the father’s o Clinically insignificant and rare
Rh+
 The baby’s red cells will go to the mother’s system
during and after childbirth
 That’s why, if it is the Rh- mother’s first time giving
birth to an Rh+ child, butangan dayon ug Rhogam si
mother (Rhogam: Antibody against Rh antigens; gam:
gammaglobulin)
 When Rhogam is injected to the mama, it will
immediately coat the baby’s red cells left at the
mother’s circulation in order to avoid sensitization of
mama by the Rh antigen. Because if dili ka magbutang,
naga circulate freely ang red cells sa baby na naa sa
mother. Tapos marecognize to sila sa immune system
sa mother, but recognition takes time.
 So before marecognize to sa immune system ni mother,
Rhogam is injected to the mother is Rh-, during and
after her childbirth
 Sometimes, even before birth, gina injectan na ang
mother ug Rhogam
 Rh- patient needs emergency transfusion because of
excessive bleeding. First choice is to use type O- but
there is no O-
 So, maghatag kag Rh+ na blood or no?? first, prioritize
the survival of the patient. If baby or tigulang ang
patient, pwede ka muhatag ug Rh+ since weak ilang
antibody production. Ang dili pwede hatagan is if the
patient is in a child-bearing age (female only duh
hahaha)

 HTR: Hemolytic Transfusion Reactions