Rh Blood Group

System: Part II
Renee Newman Wilkins, Ph.D., MLS(ASCP)CM
CLS 325/435
School of Health Related Professions
University of Mississippi Medical Center
Rh Antigens:

D, C, E, c, and e
 D antigen

 The D antigen is a potent immunogen

(elicits an immune response)…why?
 Structure and number of sites
 Some genotypes have more D antigens
than others
 (D--/D--) has more antigens than a
genotype with only one D gene
(especially when C is on the opposite
chromosome)
 Rh Typing

Routine Rh typing
for donors and
patients involves
typing for only the
D antigen
D Testing

 Routine D antigen testing involves

testing the patient RBCs with anti-D
commercial antisera
 If the D antigen is present, it should
agglutinate strongly with anti-D at
Immediate Spin (IS)
 If you’re Rh+, you have the D antigen
 If you’re Rh-, you do not have the D
antigen
Weak D phenotype

 Some D-positive RBCs DO NOT react

at Immediate Spin using commercial
anti-D
 In these cases, AHG testing is needed
to determine the D status
Weak D testing

 If negative at IS, patient cells and anti-

D reagent are incubated at 37° for 20
minutes, then centrifuge
 If still negative, wash x3 and add AHG

 If negative, add CC and report as Rh

negative (if CC agglutinate)
 If positive, report as Weak D Positive
Patients who require AHG testing to
determine the presence of the D
antigen are called “Weak D Positive”
 RBC with Weak D (Du)
normal amounts
of D antigen
Weak D (Du) Phenotype

 Weak D can be inherited in three

ways:
 Incomplete/Partial antigen (D mosaic)
 Due to the position effect
 Weakened expression of D
Partial D (D Mosaic)

 Missing one or more parts of the D

antigen
 Since the antisera is specific for the
whole D antigen, a weak reaction may
result if patient has a partial antigen
 Why is D mosaic significant?
 D Mosaic/Partial D

 If the patient is transfused with D

positive red cells, they may develop
an anti-D alloantibody* to the part of
the antigen (epitope) that is missing
Missing
portion

RBC RBC

*alloantibody- antibody produced with specificity other than self

 Position Effect

 Gene interaction effect

 C allele is in trans position to D allele

 Does not occur when C is in cis position

 Steric hindrance causes the anti-D

reagent to weakly attach (C antigen
crowds the D antigen)
 D positive blood can be given to patient
Position Effect

C in trans position to D:

Dce/dCe Weak D

C in cis position to D:

DCe/dce NO weak D
Weakened D (Genetic)

 Inherited weak D
 More common in African Americans

 These individuals may inherit the RHD

gene that encodes for a weaker
expression (Dce haplotype)
 Quantitative, meaning less is
expressed
 Detected best at AHG phase
Unusual
Phenotypes
D-Deletion
Rh null
D-Deletion

 No reaction when RBCs are tested

with anti-E, anti-e, anti-C or anti-c
 Requires transfusion of other D-
deletion red cells, because these
individuals may produce antibodies
with single or separate specificities
 Written as D- - or -D-
Rh Null
 This condition occurs when the red cells
have no Rh antigen sites
 The lack of antigens causes the red cell
membrane to appear abnormal leading to:
 Stomatocytosis
 Hemolytic anemia
 2 Rh null phenotypes:
 Regulator type – gene inherited, but not
expressed
 Amorph type – RHD gene is absent, no
expression of RHCE gene
AABB Standards
 Require weak D testing on all donor red
blood cells that do not agglutinate at IS
 DO NOT require weak D testing on
recipient blood
 each facility has their own protocol
 If only IS is performed and patient is
negative, they will receive negative units
 However, some labs don’t like to waste D-
negative units, so they take the test to AHG
 If the patient is positive, they may receive D-
positive units (it would be rare that the
patient is a Partial D)
Other Rh antigens

 Compound antigens are cis-product

antigens (f, rh1, etc)
 f antigens occur when c and e are
found in cis (Example: dce/dce)
 rh1 or Ce antigens occur when C and
e are in cis (example:
 G antigens
 Genes that code for C or D also code
for G; anti-G mimics anti-C and anti-D
Other Rh antigens

 Cw antigen
 low frequency antigen found in only 2% of
Whites and rare in Blacks
 Most individuals who are C+ are Cw+
 Antibodies to these antigens can be naturally
occuring and may play a role in HDN and
HTR
 Others: more antigens can be found in
Table 5-7 of your textbook (page 115)
Rh Antibodies

 Not naturally occurring

 Produced as a result of immune
stimulation from exposure to the
antigen through transfusion and/or
pregnancy
 Implicated in transfusion reactions
 Because they are IgG, they can cross
placenta and cause HDN
 Antibody Characteristics

 Generally IgG (except anti-E)

 React stronger (show dosage) when antigens
are homozygous (C+c-) vs heterozygous (C+c+)
 Warm reacting
 Best at AHG
 Occasionally at 37° phase
 Rarely at IS (room temp)
 Clinically significant
 Because they react at body temp.