1st SEMESTER

A.Y. 2022 – 2023 |ISBB

[TRANS] IMMUNOHEMATOLOGY Board Exam Reviewer
reinfection with the same microorganism
OUTLINE occurs
I. IMMUNOHEMATOLOGY OVERVIEW ○ final line of defense / third line of defense
a. INTRODUCTION TO IMMUNOLOGY ○ includes: lymphocytes (cellular) and
b. ANTIGEN antibodies (humoral)
c. ANTIBODIES
II. GENETICS
III. ABO BLOOD GROUP SYSTEM ANTIGEN
a. HISTORY
b. ABH ANTIGENS
● Antigen
c. ABO ANTIBODIES ○ substances that can combine with antibodies
d. FORMATION OF ABH ANTIGENS ○ antigens are made of proteins,
i. SUB TOPIC II carbohydrates, and combinations of both
○ found on the surface of cells (RBCs, WBCs,
Platelets, etc.)
IMMUNOHEMATOLOGY OVERVIEW ● Immunogen
TERMINOLOGIES ○ antigens which can stimulate immune
● Immunohematology response
○ Refers to the serologic, genetic, biochemical,
and molecular study of antigens associated
with membrane structures on the cellular
antibodies
constituents of blood, as well as the ● Five classifications: IgM, IgG, IgA, IgD, IgE
immunologic properties and reactions of ● IgM and IgG are the most important in the blood
blood components and constituents. bank section
● Transfusion Medicine
○ A multidisciplinary specialty encompassing
all aspects of blood donation, blood
component preparation, blood cell serology, immunoglobulin (Ig)
and blood transfusion therapy. ● complex proteins that binds to antigens
● Blood Banking ● Produced in response to specific foreign, non-self
○ Emphasizes the importance of patient care proteins or other complex molecules not tolerated
and clinical outcomes in transfusion by the host
medicine
IMMUNOGLOBULIN G
INTRODUCTION TO IMMUNOLOGY ● Clinically significant antibodies in blood banking.
● Immune system ● “immune antibodies” - unexpected antibodies
○ The immune system (IS) includes tissues, and require prior exposure to corresponding
organs, cells, and biological mediators that antigen
coordinate to defend a host organism against ● reacts at 37 degrees celsius / body
intrusion by a foreign substance or abnormal temperature – in vivo
cells of self-origin. ● capable of destroying transfused antigen-positive
● Immunity RBCs, causing anemia and transfusion
○ Refers to the process by which a host reactions of various severities
organism protects itself from attacks by ● have the ability to cross the placenta, which
external and internal agents. occurs during Hemolytic Disease of the Fetus
● Innate Immunity and Newborn (HDFN)
○ “natural immunity” ● Blood group systems with clinically
○ present at birth significant antibodies (reactive at 37°C)
○ non-specific; the same response is used ○ Rh Blood Group
upon repeated exposure to the same ○ Kell Blood Group
organism/s. ○ Duffy Blood Group
○ first line of defense ○ Kidd Blood Group
○ consisted of physical and biochemical ○ Lutheran Blood Group
barriers, as well as numerous cells (e.g., ○ S Blood Group
neutrophils) – IAT and DAT, uses AHG reagent
● Adaptive Immunity
○ “acquired immunity” immunoglobulin M
○ specific; allows the body to recognize,
remember and respond to specific antigen ● all are clinically significant except ABO antibodies
○ expresses immunologic memory; allows ● considered as naturally-occurring antibodies
organism to respond more effectively if ● most commonly encountered antibodies in blood
banking (e.g., ABO blood group antibodies)

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● react best at ambient room temperature (22 - 24 Females can exhibit the trait but must inherit
degrees celsius) it from both carrier mother and affected
● Blood group systems with naturally occurring father
antibodies: ● Homozygous
○ ABO Blood Group ○ individual inherits identical alleles
○ Lewis Blood Group ● Heterozygous
○ P Blood Group ○ individual inherits different alleles
○ MN Blood Group ● Dosage Effect
○ Etc: Hh, Ii ○ agglutination reactions are generally stronger
– DAT for homozygous cells and slightly weaker for
heterozygous cells
GENETICS ● Law of Segregation
○ two members of single gene pair are passed
● Chromosomes from one generation to the next in separate
○ structures that carry genetic information gametes
encoded on double stranded DNA ● Law of Independent Assortment
● Mitosis ○ traits inherited from different chromosomes
○ Cell division that results in the same number are expressed separately and discretely
of chromosomes in new and old cells ● Silent genes
● Meiosis ○ genes that do not produce a detectable
○ Cell division that occurs in gametes that product
results in one-half the number of
chromosomes in each new cell
● Phenotype ABO BLOOD GROUP SYSTEM
○ Physical, observable expression of inherited history
traits; readily observable characteristics
● Genotype ● Karl Landsteiner (1901)
○ Inherited genes; genetic makeup of an ○ discovered the ABO blood groups system
organism ● Alfred von Decastello and Adriano Sturli
○ two alleles inherited ○ discovered the 4th Blood Group (Type AB)
● Gene
○ Smallest unit of inheritance ABH ANTIGENS
● Loci
○ produces specific glycosyltransferases
○ Site on a chromosome where specific genes
○ found on RBCs, WBCs, platelets, tissue
are located.
cells, bone marrow, and other organs
● Allele
○ these antigens can be expressed by tissue
○ Alternative forms of a gene
cells in response to the genes inherited
● Antithetical
○ ABH antigens on RBCs are produced in
○ Opposite form of a gene; a different allele of
response to the inheritance of Hh, A, B & O
a gene
genes
● Dominant
○ ABH antigens on RBCs are glycolipids or
○ The gene that is expressed at the phenotypic
glycoproteins
level.
● Recessive
○ The gene that is masked; Must be in the abo antibodies
homozygous state to be expressed. ● Landsteiner’s Rule
○ unexpressed trait ○ if an individual has the antigen, that
● Codominance individual will not have the antibody
○ Equal expression of both alleles at the ○ individuals normally produce antibodies
phenotypic level against antigen absent in their RBCs
● Autosomes ● ABO antibodies are:
○ Genes expressed with equal frequency in ○ IgM
males and females, on non-sex ○ reacts at 22 - 24 degrees celsius – direct
chromosomes. agglutination reaction
● X-linked Dominant ○ tested at 22 - 24 degrees celsius – acute
○ Carried on the X chromosome; no father-to- hemolytic transfusion reaction
son transmission; will be expressed if passed ○ naturally occurring
from father to daughter or from mother to ○ causes intravascular hemolysis
son.
● X-linked Recessive
○ Carried on the X chromosome; males inherit FORMATION OF ABH ANTIGENS
it from carrier mothers; mostly affects males. ● Paragloboside / Glycam

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○ precursor structure on which A, B, and H BLOOD TYPE ANTI-A ANTISERA ANTI-B ANTIS
antigens are made
● H antigen A 0 4+
○ the building block of A and B antigens B 4+ 0
○ prerequisite for the formation of A and B O 4+ 4+
antigens
○ the “acceptor” molecule for A and B antigens AB 0 0
○ HH, Hh
○ hh - bombay phenotype – lacks ABO BOMBAY PHENOTYPE
specificity
● O Bombay phenotype; hh genotype
● A antigen
○ double dose of the h gene, which is not
○ produced by the A gene
capable of producing L-fucosyltransferase
○ contains N-acetyl galactosamine
○ autosomal recessive trait
● B antigen
● ABH gene cannot be expressed and ABH
○ produced by the B gene
antigens cannot be formed, since there is no H
○ contains D-galactose
antigen made in the Bombay phenotype
● O antigen
○ does not exist
○ O gene is an amorph; does not elicit BOMBAY PHENOTYPE VS TYPE O
production of catalytically active polypeptide BLOOD TYPE ANTI-A ANTI-B ANTI-H LE
transferase (ULEX
● Immunodominant sugar
○ sugars occupying the terminal positions of
EUROPEA
the precursor chain and conferring blood BOMBAY 0 0 0
group TYPE O 0 0 4+
GE GLYCOSYLTRANSFE IMMUNODIMIN ANTIG LECTIN SOURCE
NE RASE ANT SUGAR EN
ANTI-A1 LECTIN Dolichos biflorus
H a-2-L- L-fucose H
- distinguishes A1
fucosyltransferas
cells from A2 cells
e
ANTI-B LECTIN Bandeiraea
A a-3-N- N-acetyl-D- A
“Grifonia simplicifolia
acetylgalactosami galactosami
simplicifolia”
nyltransferase ne
ANTI-H LECTIN Ulex europeaus
B a-3-D- D-galatose B
- distinguishes
galactosyltransfer
Type O from
ase
Bombay
O N/A L-fucose H
REACTIVITY OF RBCS WITH ANTI-H LECTIN (ULEX
ABO TESTING
EUROPEAUS)
● Forward Typing - using known sources of
commercial antisera to detect antigens on an O > A2 > B > A2B > A1 > A2B > BOMBAY
individual’s RBC
● Reverse Typing - detecting ABO antibodies in SUBGROUPS OF ABO
the patient’s serum by using known reagent
RBC: A1 and B cells
PHENOTYPE ANTI-A ANTI-A1 LECTIN
– have an inverse reciprocal relationship
(DOLICHOS
BIFLORUS)
FORWARD GROUPING
A1 + +
BLOOD TYPE ANTI-A ANTISERA
A2 + 0
A 4+
B 0 ABO DISCREPANCIES
O 0 ● due to problems with patient’s serum (reverse
AB 4+ grouping), problems with the patient’s RBCs
(forward grouping), or problems with both the
REVERSEGROUPING serum and cells

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● ABO discrepancies occur when unexpected GROUP 2 DISCREPANCY

reactions are obtained in the forward and/or ● associated with unexpected reactions in the
reverse grouping forward grouping due to weakly reacting or
missing antigens
GROUP 1 DISCREPANCY ● least frequently encountered
● associated with unexpected reactions in the ● causes of discrepancies in group 2:
reverse grouping due to weakly reacting or ○ subgroups of A or B
missing antibodies ○ leukemias
● more common than those in the other groups ○ Hodgkin’s disease
listed ○ Acquired b phenomenon - most often
● one of the reasons for the missing or weak associated with disease of the digestive tract
isoagglutinins is that the patient has depressed (e.g., cancer of colon)
antibody production or cannot produce the ABO ○ BGSS
antibodies
● common populations with discrepancies in Group GROUP 2 DISCREPANCIES - ACQUIRED B PHENOMENON
1 are:
○ newbrons ● the acquired B antigen arises when bacterial
○ eldery patients enzymes modify the immunodominant blood
■ hypogammaglobulinemia - low levels group A sugar (N-acetyl-D-galactosamine) into D-
of antibodies in serum galactosamine
○ chronic lymphocutic leukemia ○ can cross react with Anti-B reagent
○ malignant lymphoma ● this pseudo-B antigen is formed at the expense of
○ immunosuppressive drugs the A1 antigen and disappears following the
○ congenital or asquired agammaglobulinemia patient’s recovery
or immunodeficiency diseases GROUP 3 DISCREPANCY
○ patients with bone marrow or hematopoietic ● These are discrepancies in the forward and
progenitor stem cell (HPC) transplants reverse grouping caused by protein or plasma
○ plasma transfusion or exchange transfusion abnormalities, leading to rouleaux formation or
■ antibodies are diluted pseudo-agglutination
○ ABO subgroups GROUP 4 DISCREPANCY
● chimerism
○ defined as the presence of two cell ● these discrepancies between forward and
populations in a single individual reverse grouping are due to miscellaneous
○ true chimerism - occurs only in twins and is problems
rarely found
■ two cell populations will exist throughout GROUP 1 GROUP 2 GROUP 3 GROUP4
the lives of the individuals Newborns Leukemias Multiple Cold Reactive
Myeloma Autoantibodies
○ artificial chimerism Elderly patients subgroups of A Waldenstrom’s Unexpected
■ blood transfusions or B macroglobuline ABO
■ transplanted bone marrow or HPC of a mia isoagglutinins
different ABO type Immunosuppre Hodgkin’s Plasma unexpected
■ exchange transfusions ssive drugs lymphoma expanders non-ABO
alloantibodies
■ fetal-maternal - resolution
congenital or BGSS (Blood Elevated levels Circulating
group 1 discrepancy resolution acquired Group Specific of fibrinogen RBCs of more
agammaglobuli Soluble than 1 ABO
● obtaining patient clinical history may immediately nemia or Antigens) group due to
resolve this type of discrepancy immunodeficie RBC
● best way: ncy disease transfusion or
○ enhance the weak or missing reaction in the marrow stem
cell transplant
serum by incubating the patient serum
plasma acquired B wharton’s jelly Cis-AB
with reagent A1 and B cells at room transfusion or phenomenon
temperature for approximately 15 to 20 exchange
minutes transfusion
○ no reaction still: incubate the tube for 4 ABO subgroups plasma cell
degrees celsius for 15 to 30 minutes dyscrasias
○ an autocontrol and an O cell control must
always be tested at the same time when RH BLOOD GROUP SYSTEM
resolving Group 1 discrepancy
RH GENETICS
● there are two RH genes that control the
expression of Rh antigens: RHD and RHCE
○ located on chromosome 1

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○ codominant alleles ■ types 1 and 3 - most common

● locus 1: codes for the presence or absence of
the RhD protein
● locus 2: codes for either RhCe, RhcE, or RhCE
proteins
● RHAG: Rh-associated glycoprotein
○ coexpressor – not able to bind without this
○ on chromosome 6
RH PHENOTYPES
● based on the presence of the D antigen on the
surface of RBCs
○ RHCE: D antigen is absent
○ RHD: D antigen is present
RH NOMENCLATURE AND TERMINOLOGY
● two are based on postulated genetic theories of
Rh inheritance
○ fisher-race: DCE terminology
○ wiener: Rh-Hr terminology
● the third common terminology used describes
only the presence or absence of a given antigen
○ rosenfield and coworkers: alphanumeric
terminology
● the fourth was established by the International
Society of Blood Transfusion (ISBT)
Committee on Terminology for Red Cell
Surface Antigens
RH ANTIGENS
● made up of proteins
● integral part of the RBC membrane – exclusive to
RBC
● found on transmembrane and are an integral
part of the RBC membrane
● play a role in maintaining the structural integrity of
RBC membranes
● D antigen - the most potent/immunogenic of all
the Rh antigens
○ 85% of the general population - Rh positive
○ 15% of the general population - Rh negative
● immunogenicity: D > c > E > C > E
WEAK D PHENOTYPE
● serologic weak D is noted when;
○ negative or less than or equal to 2+ strong
○ but indirect antiglobulin testing
● Du type - individuals with RBCs carrying weaker
D antigen
● lagyan ng AG reagent
● causes:
○ positive effect / gene interaction effect - C
in trans to D
■ individuals with position effect weak D
can receive D-positive RBCs with no
adverse effects
■ Dce/CE
○ quantitative - D antigen is complete but
fewer in number
■ decreased expression of RHD gene
○ partial D - D antigen is incomplete: “D
mosaic”
■ missone one or more alleles
■ incomplete antigen due to point insertion
of RHCE gene
■ D mosaic - Rh negative blood
RH NULL
● These individuals fail to express any Rh
antigens on the RBC surface
○ mutation in each of the RHCE genes
inherited from each parent and deletion of
the RHD gene found in most D-negative
individuals
● two types of Rh null: amorphic and regulator
● poikilocytes - stomatocytosis (mouth cells)
RH ANTIBODIES
● immune antibodies
● requires prior exposure to the antigen either
through a transfusion or through pregnancy
● IgG reacts at 37 degree celsius reacts at the
AHG phase of testing
● extravascular hemolysis
● can travel across the placenta; HDFN
○ RhoGAM / Rh-immune globulin 45C -
administered after delivery (within 72 hours),
can protect a woman from being immunized
to the D antigen
○ prevents formation of Anti-D
● causes delayed HTR
OTHER BLOOD GROUPS
KELL BLOOD GROUP
● first blood group system discovered after the introduction of a
testing
Abbreviation K
Antibody class IgG
Optimal reaction temp. 37 degree celsius
Reaction phase AHG
Antigens K (Kell), k (cellano), Kpa, K
Jsa, Jsb, Ku
Allelic Pairs K and k, Kpa and Kpb, Jsa
● K is very immunogenic; K is rated second
only to D in immunogenicity; Anti-K
encountered frequently and may cause HTR and
HDFN
● Kell Null - occurs when individuals lack the Kell
antigens but have the Kx antigen
○ McLeod phenotype, affecting only males
● Kx antigen - required for the expression of all
Kell antigens
○ precursors of all K antigens
● McLeod Phenotype

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○ individuals lacks all the Kell antigens,

including Kx
○ neuroacanthocytosis
■ acanthocytes

DUFFYBLOOD GROUP
Abbreviation Fy
Antibody class IgG
Optimal reaction temp. 37 degrees celsius
Reaction phase 37 degrees celsius incubation
Enzyme Treatment destroys antigens

● Clinically significant:
○ Anti-Fya and Anti-Fyb - can cause HTR and
HDN
■ malarial infections
○ Fy(a- b-); resistant to infection with by
plasmodium knowlesi and plasmodium
vivax
● Shows dosage effect

KIDD BLOOD GROUP

● Anti-Jk is more frequently encountered
Abbreviation Jk
Antibody class IgG
Optimal reaction temp. 37C
Reaction phase 37C
Antigens Jka, Jkb, Jk3
Enzyme Treatment Enhances reactivity
● .Clinically significant:
○ causes delayed HTR and HDN
● Shows dosage effect

LUTHERAN BLOOD GROUP

Abbreviation Lu
Antibody class Anti-Lua – IgM
Anti-Lub – IgG
Optimal reaction temp. Anti-Lua - 4 degrees celsius
Anti-Lub – 37 degrees celsius
Reaction phase Anti-Lua - immediate spin
Anti-Lub - AHG
Enzyme Treatment
.
● Clinically significant:
○ Anti-Lub – HTR and HDN
●

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SUBTOPIC II

UNDER SUBTOPICS

KEY TERM

📌 IMPORTANT / PROF’S NOTES

ADDITIONAL / PROF’S NOTES

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