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).
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