Thoughts on Cw and Cx.

Introduction.

Callender and Race1 first described the Cw antigen (or Rh8), in detail, in 1946,
although they had referred to it in a separate paper with Paykoç a year
earlier2. The antibody was found in the serum of a patient, who had been
stimulated to produce multiple antibodies in response to transfusion, including
anti-c, the first example of anti-Lua, the third example of anti-N in a human,
and what was then called anti-Levay; what we now know to be anti-Kpc
(KEL21).

Originally, Cw and Cx were thought to be alleles at the Cc locus. A précis of

the original description by Race3 of the original case, and the proposed
genetics behind it is as follows:
The propositus, treated for SLE at the Radcliffe Infirmary, needed numerous
transfusions. She was of the probable Rh genotype DCe/DCe and, as she
had already made anti-c, required blood of her own Rh type. A new antibody
appeared in her serum following this transfusion, however, which agglutinated
the blood of the donor. This serum was tested against a large number of
samples of “known genotype”: 12 of 193 C+c- were positive, 7 of 342 C+c+
were positive and none of 214 C-c+ was positive. This suggested that the
antigen recognized by this antibody was connected with C, and that an
unusual gene at the “Cc locus” was present: this gene was called Cw. Race
stated that,
“Genetically, the relationship between C, c and Cw is clear; they are
allelomorphs.”

The name of the donor was Willis, leading to the antigen being called Cw.

Genetics and Biochemical Background.

Two related genes, RHD and RHCE, encode amino acids in the RhD and
RhCcEe polypeptides respectively. The RhD polypeptide carries the D
antigen and its variants, and the RhCcEe polypeptide the C, c, E, e, Cw, Cx
and other related antigens4.

The C/c polymorphism is believed to involve six nucleotide substitutions in the

RHCE gene, resulting in four amino acid changes, but the only one that is
thought to be extracellular, in the second extracellular loop, is the Ser103Pro
amino acid change, encoded by exon 2. A serine residue leads to the
expression of the C antigen, and a proline residue leads to the expression of
the c antigen4.

A single nucleotide change in exon 1 of RHCE, encoding a single amino acid

residue substitution (arginine, instead of glutamine), in the first extracellular
loop at position 41, is responsible for the Cw polymorphism.
Similarly, a single nucleotide change in exon 1 of RHCE, this time encoding a
single amino acid residue substitution (threonine, instead of alanine), in the
first extracellular loop at position 36, is responsible for the Cx polymorphism.
It is thought that conformational changes are brought about by these amino
acid substitutions, and it is these changes that may result in a weakened
expression of the C antigen, according to the antisera used4.

Frequency.

In most populations, the frequency of Cw is very low. It is about 2%% in the

White population, and about 1% in the Black population. In the Finnish and
Latvian populations, however, it can reach a frequency of 9%.

The frequency of Cx is even less in most populations than Cw, being 0.12 in
British donors, and 0.29% in American donors. Once again, however, there is
a higher frequency in the Finnish population (1.8%)4.

High Frequency Allele to Cw and Cx.

In 1994, Sistonen et al5, published a paper, in which they described a Finnish

woman with the Rh phenotype of Cw+, Cx+, D+, C+, c-, E-, e+ (probable Rh
genotype DCwCe/DCxCe). Her serum contained an antibody that reacted with
all cells except Rhnull, D--, D.. or DCw-. The antibody was called anti-MAR, and
MAR has now become RH51. Cw, Cx and MAR are said to be antithetical
antigens. A similar “anti-MAR-like” antibody has been found in two R1wR1w
individuals9-10, and highlighted the problems of finding compatible blood for a
patient with a rare, and clinically significant antibody.

The wild type MAR epitope is likely to be expressed on the amino acid
residues between positions 36 to 41 inclusive (Ala-Ser-Leu-Glu-Asp-Gln) of
the RhCcEe polypeptide.

Screening for Cw+ Donations – The NBS-Tooting Experience.

Screening for Cw+ reagent red cells is easily performed, and a useful fringe
benefit of the rare donor screening programme at NBS-Tooting Centre, and
occasionally throws up surprises.

Over the last two years, a total of 33 760 group O donors, of all Rh
phenotypes, have been screened for the Cw antigen, yielding 514 positives
(1.5%), all C+. Of these, approximately 313 were of the Rh phenotypes
DCwce (probable Rh genotype R1wr) or DCwceE (probable Rh genotype R1wR2),
and 201 of the Rh phenotype DCwCe (probable Rh genotype R1wR1). Until
recently, those of the latter probable Rh genotypes were considered useful for
reagent screening cells, or for inclusion in an antibody identification panel
(particularly if they expressed presumed homozygosity for the other major
blood group systems).

Several of the other donations found to be Cw+ have, however, been of a

more unusual probable Rh genotype. These include dCwe/dce (r’wr) and
DCwe/DCE or DCe/DCwE (R1wRz or R1Rzw).
Recently, a much more exciting find was made through this serendipitous
approach. A donor was found to be Cw+, but C-. The Rh phenotype was D+,
C-, c+, E-, e+, Cw+! This donor as the very unusual probable Rh genotype of
DCwce/dce (Rowr) or DCwce/Dce (RowRo). We cannot, of course, claim that this
finding is unique. Giannetti et al6 reported just such an unusual combination
in 1983, for example, but it does serve to highlight the necessity of cross-
matching blood for individuals known to have antibodies7, rather than relying
on the fact that, “the units should, by rights, be antigen negative”.

Daniels et al8 recommends that individuals who are known to have anti-Cw in
their serum are given blood that is found to be compatible by IAT cross-
match. In nearly every case, where C- blood is used for the cross-match, this
will result in a compatible cross-match, but, humans being humans, don’t be
at all surprised if, one day, you find the cross-match to be incompatible!
There’s nowt so queer as folk!!.

Alan Gray and Malcolm Needs (RCI, NBS-Tooting Centre)

With thanks to Geoff Poole and Joyce Poole for help with the manuscript.

References.

1. Callender ST, Race RR. A serological and genetical study of multiple

antibodies formed in response to blood transfusion by a patent with
lupus erythematosus diffuses. Ann Eugen 1946; 13: 102-117.

2. Callender S, Race RR, Paykoç ZV. Hypersensitivity to transfused

blood. BMJ 1945; ii: 83.

3. Race RR. The Rh genotypes and Fisher’s theory. Blood 148; 3 (suppl
2): 27-42.

4. Daniels G. Human Blood Groups, 2nd edition, Oxford: Blackwell

Science Ltd. 2002.

5. Sistonen P, Sareneva H, Pirkola A, Eklund J. MAR, a novel high-

incidence Rh antigen revealing the existence of an allelic sub-system
including Cw (Rh8) and Cx (Rh9) with exceptional distribution in the
Finnish population. Vox Sang 1994; 66: 287-292.

6. Giannetti M, Stadler E, Rittner C, Lomas C, Tippett P. A rare Rh

haplotype producing Cw and c, and D and e in a German family. Vox
Sang 1983; 44: 319-321.

7. BCSH Blood Transfusion Task Force. Guidelines for pre-transfusion

compatibility procedures in blood transfusion laboratories. Transf med
1996; 6: 273-283.
8. Daniels G, Poole J, De Silva M, Callaghan T, MacLennan S, Smith N.
The clinical significance of blood group antibodies. Transf med 2002;
12: 287-295.

9. O’Shea KP, Øyen R, Sausais L, Stevens VA, Stillwell GF, Bisgard LA,
Martin J, Reid ME. A MAR-like antibody in a DCwe/DCwe person.
Transfusion 2001; 41: 53-55.

10. Poole J, Davison T, Powell H, Hulston M. Anti-Rh551-like in a rare

CwDe/CwDe individual. Transf med 2001; 11 supplement 1: P26.