Rh BLOOD GROUP SYSTEM

1. 004

2. Rh

3. 1

4. 57

RH BLOOD GROUP SYSTEM

1. ISBT number

2. ISBT name

3. Chromosome

4. Number of antigens

Rh Blood Group

It is highly complex, and the alloimmunization to the antigens in this blood group can complicate transfusion and pregnancy.

Rh

This refers to a specific red blood cell antigen (D) and to a complex of blood group system currently composed of 61 antigenic specificities.

• ABO antibodies is routinely found in individuals who lack the corresponding antigen.

• Rh antibodies are produced only after exposure to foreign red blood cells.

• What is the difference between ABO and Rh antibodies?

• Hemolytic Disease of the Fetus/Newborn

• Hemolytic Transfusion Reactions

Rh antibodies can cause what diseases?

Levine and Stetson (1939)

They discovered a novel antibody and antigen (D) through a mother requiring a blood transfusion, wherein the blood of father with the same blood type was given but still executed acute HTR.

Landsteiner and Weiner (1940)

They discovered an antibody made by guinea pigs and rabbits when transfused with rhesus macaque monkey RBCs. It agglutinated with almost 85% of human RBCs.

1. Anti-Rh

2. Anti-LW

3. Phenotypically

Give the designated terms.

1. Antibody from humans react with these

2. Antibody from animals react with these

3. In which aspect are they similar?

1. D antigen - 99%

2. e antigen - 96%

3. C antigen - 93%

4. c antigen - 47%

5. E antigen - 39%

Antigen Frequency in Asians

From highest to lowest. State the percentage of the highest and lowest Rh blood groups.

1. e antigen (98%) and E antigen (29%)

2. e antigen (98%) and E antigen (22%)

1. Highest and lowest antigen frequency in Caucasians

2. Highest and lowest antigen frequency in Afro-Americans

1. Genetic theories of inheritance

2. Presence or absence of antigen

3. ISBT Committee on Terminology for Red Cell Surface Antigen

There are four terminologies used to describe the Rh system.

1. Two are based on?

2. Third is based on?

3. Fourth is based on?

• Fisher-Race

• Wiener

• Rosenfield

• ISBT Numeric Terminology

What are the different systems of nomenclature that theorize the inheritance of Rh system?

D → c → E → C → e

The immunogenicity of Rh antigens

1. ISBT (numeric)

2. Fisher-race (DCE)

3. Rosenfield (alphanumeric)

4. Weiner (Rh-Hr)

Determine the Terminology used in the ff:

1. 004001, 004002, 004003, 004004, 004005

2. D, C, E, c, e

3. Rh1, Rh2, Rh3, Rh4, Rh5

4. Rho, rh’, rh”, hr’, hr”

1. Fisher-Race Nomenclature

2. Ronald Fisher and Robert Race

3. Haplotype (single set of gene → Dce) and Genotype (two sets of genes → Dce/Dce)

1. It is a theory wherein the Rh antigens are controlled by a complex of 3 sets of genes with closely linked loci. This terminology is the most commonly used.

2. Who developed this nomenclature?

3. What is its haplotype and genotype?

1. 8

2. Weak antigens

3. Deletions (Rh null)

4. The d antigen is not produced

FISHER-RACE NOMENCLATURE

1. How many gene complexes are at the Rh locus?

2. When a letter is in a parenthesis, it indicates?

3. When the haplotype has a dash, it represents?

4. In a graph, if “d” is encircled, it means?

1. Weiner nomenclature

2. 1

3. 8

4. Agglutinogen

1. A single gene at the Rh locus that leads to the expression of the Rh antigens. It is rarely used.

2. Each parent contributes __ genes

3. How many alleles exist at each gene locus?

4. Each gene controls production of an ___ that is composed of 3 Rh factors

1. R

2. r

3. h’

4. h”

5. r’

6. r”

7. z or y

WEINER NOMENCLATURE

1. It indicates presence of D antigen

2. It indicates absence of D antigen

3. It indicates C antigen

4. It indicates E antigen

5. It indicates c antigen

6. It indicates e antigen

7. It indicates DCE

1. Superscript

2. Subscript

WEINER NOMENCLATURE

1. Genes are expressed as?

2. Antigens are expressed as?

1. Short-hand notation

2. Dce

3. DCe

4. DcE

5. DCE

6. dce

7. dCe

8. dcE

9. dCE

1. Modified Weiner is what notation?

2. R0 means?

3. R1 means?

4. R2 means?

5. Rz means?

6. r means?

7. r’ means?

8. r” means?

9. rY means?

1. Long-hand notation

2. D

3. c

4. e

5. C

6. E

1. This notation is used for blood factors

2. Rh0 means?

3. hr’ means?

4. hr” means?

5. rh’ means?

6. rh” means?

Fisher-Race and Weiner

Between the 4 terminologies, which of them is on the right track?

1. Rosenfield nomenclature

2. 5 (DCEce)

3. Minus sign

4. The designated number will not appear

1. Antigens are designated by number

2. How many antigens are used in this nomenclature?

3. Absence of antigen is represented by?

4. If the antigen is not tested, how is it represented?

1. The RBC phenotype is succinctly described

2. There is a similar nomenclature with Kell, Duffy, Kidd. Due this, both the alpha (Rh:) and numbers are used in Rosenfield.

ROSENFIELD NOMENCLATURE

1. Advantage

2. Limiting factor

1. D

2. C

3. E

4. c

5. e

ROSENFIELD NOMENCLATURE

1. Rh1

2. Rh2

3. Rh3

4. Rh4

5. Rh5

1. ISBT Nomenclature

2. 6

3. 004

4. Rosenfield system number

1. This is done as an attempt to standardize nomenclature

2. How many numbers are assigned to each blood group specificity?

3. This refers to the Rh system

4. The remainder is the?

1. 2

2. 6

3. 1

4. RhD gene

5. RhCE gene

1. Inheritance is found in _ loci theory

2. In what chromosome is RhAG seen?

3. In what chromosome is RhD/RhCE seen?

4. It determines the expression of the D antigen

5. It determines the expression of the C, c, E, and e antigens

• Rh antigens

• D antigen

• These antigens are highly immunogenic (substances that can produce an immune response)

• What antigen is most potent?

D → c → E → C → e

Rh antigens from most potent to least

Less than 1 mL

Exposure to ____ of Rh positive red cells can stimulate Ab production in an Rh negative person.

1. Codominant

2. 10 exons, 97%

3. 250

4. 50

1. RhD and RhCE are ___, which means the products inherited produce antigens seen on RBCs.

2. They have __ exons, and are __% identical

3. How many alleles in RhD gene?

4. How many alleles in RhCE gene?

1. Rh typing

2. Forward typing only

3. Anti-D

4. A monoclonal antibody with a mix of IgM and IgG class.

5. IgG

6. IgM

1. This pertains to the testing of the D antigen only.

2. Is this a Forward, Reverse, or both types of typing?

3. What is the antisera?

4. Is the antisera a polyclonal antibody with IgG only?

5. This Ig class allows Weak D Typing.

6. This Ig class allows direct agglutination in immediate spin

1. Anti-Human Globulin Test (IAT)

2. D^u

1. The weakened expression of D antigen is only detectable through?

2. How is it expressed?

1. Position effect or gene interaction

2. Weak D

3. Partial D

4. Del

What are the categories of Weak D?

• Position effect or gene interaction

• Dce/dCe

• A weak D antigen is categorized when the allele carrying D Ag is trans to the allele carrying C Ag.

• Give an example.

• Weak D antigens

• Mutations in the RhD gene

• D antigens expressed appear to be complete but fewer in number

• They occur because of ___ that causes changes in the amino acids. They contribute to the conformational changes in the protein.

• Rh-associated glycoproteins

• Coexpressor

• Rhnull phenotype

• A polypeptide that is similar in structure as Rh proteins but is glycosylated (carbohydrates are attached).

• It is termed as?

• Mutations in this gene occur will result to?

• Partial D or D mosaic

• Alloantibodies — Wiener and Unger

• RhCE

• This is a weak D variation that has one or more D epitopes that are missing or defective.

• They may produce __ to the missing fraction, according to (_) and (_)

• The RhD gene is replaced with?

• Del

• Adsorption and elution following incubation at 37 C

• Southeast asians

• It is a phenotype wherein red blood cells possess an extremely low number of D antigen sites that most reagent anti-D are not able to detect.

• Due this, how is the D antigen detected?

• In which ethnicity is it common?

R0-Har (RH33)

It results from a hybrid gene RHCE-RHD-RHCE, in which only a small portion of RHD is inserted into the RHCE gene.

1. Rh-Positive

2. D-positive, but should be reported as RhD-negative since they do not have RhD protein.

1. If R0-Har is paired with a normal RHD gene, it is?

2. If R0-Har is paired with D-deletion, it is?

1. Crawford (ceCF); RH34

2. African descent

1. It results from a specific amino acid change in the RHce gene, resulting in an RhD epitope on the Rhce protein.

2. It is more common in what descent?

• Partial D or D Mosaic

• Del

• R0-Har

• Crawford (ceCF)

What are the variations of D antigen expression?

Rh antigens

These are nonglycosylated proteins in the RBC membrane.

• Transfusion

• Pregnancy

How are Rh antibodies produced?

D

Which among D,C,E,c,e is not an allele?

1. IgG

2. IgG1 and IgG3

3. 37 degrees Celsius

4. Indirect Antiglobulin Test

5. No. (RBC destruction by Rh antibodies are extravascular.)

1. What is the immunoglobulin present in Rh antibodies?

2. What are of greatest clinical significance?

3. In vitro, at what temperature do they bind?

4. What laboratory test can this action be seen?

5. Do Rh antibodies bind complement?

1. Further tested using Weak D testing

2. Rule out possibility of Weak D expression and for Pretransfusion testing.

1. Any Rh negative result in the Rh typing should be?

2. Why?

• Anti-D testing is negative

• Anti-D reactions are less than or equal to 2+

• But detectable using IAT

Serologic Weak D Testing is noted when?

No. Coomb’s Check Cells is the final step in the confirmation of Rh negative red blood cells.

Can you report as Rh negative if the patient does not show any agglutination after adding Anti Human Globulin reagent? Why?

1. Du negative

2. Rh- and Du- results confirms patient or donor is Rh- negative.

The Du reaction is O.

1. What is the manner of reporting?

2. Why?

• Du positive

• Patient: Rh Negative

  Donor: Rh Positive

The Du is reaction is (+).

• The manner of reporting

• Specificity

• Saline anti-D reagent

• High-protein Anti-D

• Chemically modified

• Monoclonal antibody reagents

What are the 4 variety of Rh Typing Reagents?

To use an antisera that can quickly and accurately type Rh Ags on RBCS.

Goal of Rh Typing Reagents

1. Saline anti-D reagent

2. IgM

3. Low protein

4. IgG antibody

5. Limited availabity, cost of production, lengthy incubation time

1. These are the first typing reagents to be used for D antigen.

2. Contains __ immunoglobulin

3. It is ___ based

4. It is used to test cells that are coated with?

5. Disadvantages

1. Bovine Serum Albumin (BSA), Dextran, Polyvinyl Pyrrolidone

2. Reduced incubation time, used for Weak D

3. Increased false positive results

4. Rh control reagent (no Anti-D

5. Rh testing

HIGH-PROTEIN ANTI-D

1. What are the potentiators added?

2. Advantage.

3. Disadvantage.

4. It uses what control?

5. It is tested parallel with?

Chemically modified reagents

It alters the IgG anti-D molecule by breaking the disulfide bonds of the IgG Anti-D molecule, allowing the antibody to relax and span distance between RBCs.

1. Slide and tube testing

2. Weak D

3. A, B, O

4. Saline control or 6-8% of albumin control

5. Fewer false positives

CHEMICALLY MODIFIED REAGENTS

1. Can be used for what method of testing?

2. Can be used for testing of?

3. Does not require separate manufactured Rh control as long as the samples type?

4. What are the controls used?

5. What is the advantage?

Monoclonal antibody reagents

These reagents are derived from single clones of antibody-producing cells.

1. Myeloma cells

2. IgM (monoclonal); IgG (polyclonal)

3. Low protein

4. Rh control reagent

MONOCLONAL ANTIBODY REAGENTS

1. The antibody-producing cells are hybridized with ____ to increase their reproduction.

2. It is a blend of monoclonal _ and polyclonal _

3. ___ based

4. Does not require ___ as long as type A,B,O

1. Immunology/Serology

2. Antihuman globulin (Weak D test)

3. Slide, tube, microwell, automated, column agglutination techniques

MONOCLONAL ANTIBODY REAGENTS

1. IgM reacts with?

2. IgG reacts with?

3. Can be used in what tests?

No.

Is it necessary to put weak D phenotypes on labelling?

Rh-immune globulin

Pregnant women are tested for the D antigen to see if they are candidates for?

1. D antigen

2. C, E, c, e

3. To resolve or confirm antibody identification

   Reduce alloimmunization

1. Routine donor or recipient typing is based on?

2. What are the other common Rh antigens?

3. Why is Rh typing performed?

1. 45-50 degrees C

2. 37 degrees C

3. Rh positive

4. Rh negative then proceed to weak D test

Rh TYPING - SLIDE METHOD

1. The Rh view box is incubated at?

2. The Rh antibodies are warmed at?

3. If (+) agglutination, how is it reported?

4. If (-) agglutination, how is it reported?

1. 1 drop of 2%-5% of RBC suspension

2. 1 drop of anti-D antisera

3. 1 drop of 22% BSA

4. Centrifuge

5. (+): Rh positive

   (-): Rh negative then proceed to weak D testing

Rh TYPING - TUBE METHOD

1. How much RBC suspension?

2. In a sample, what will you add to the RBC suspension?

3. In a negative control, what will you add to the RBC suspension?

4. What is the step before the sample is dislodged and interpreted?

5. Manner of reporting

1. 37 C // 30 minutes

2. 3 times, NSS

3. AHG

4. Dislodge

5. Rh positive, Du negative

6. Rh negative, Du negative

7. Check cells

Rh TYPING - TUBE METHOD pt. 2

1. Incubate at _ for _minutes

2. Wash _ times with _

3. Add _ reagent

4. Centrifuge, _, and interpret

5. (+):

6. (-):

7. Add _

• Cell suspension is too heavy

• Cold agglutinins

• Test Incubated too long or drying

• Rouleaux

• Fibrin interference

• Contaminating low-incidence antibody

• Polyagglutination

• Bacterial contamination of reagnt vial

• Incorrect reagent

• Centrifugation too long

Give examples of instances that can cause FALSE POSITIVES.

1. Adjust suspension, retype

2. Wash with warm saline, retype

3. Follow manufacturer’s instructions precisely

4. Use saline-washed cells, retype

5. Use saline-washed cells, retype

Give the corrective actions.

1. Cell suspension is too heavy

2. Cold agglutinins

3. Test Incubated too long or drying

4. Rouleaux

5. Fibrin interference

1. Try another reagent or use a known serum antibody

2. Open new vial of reagent, retype

3. Repeat test, read vial label carefully

4. Repeat testing user shorter centrifugation time

5. Repeat testing using lower RPM

Give the proper corrective action.

1. Contaminating low-incidence antibody

2. Bacterial contamination of reagnt vial

3. Incorrect reagent

4. Centrifugation too long

5. RPM too high

• Immunoglobulin-coated cells (in vivo)

• Saline-suspended cells (slide)

• Failure to follow manufacturer’s directions precisely

• Omission of reagent manufacturer’s directions

• Resuspension too vigorous

• Incorrect reagent

• Variant antigen

• Reagent deterioration

• Centrifugation too short

• RPM too low

Give causes of False Negatives.

1. Use saline-active typing reagent

2. Use unwashed cells

3. Add reagents first, check, them add cells

4. Resuspend all tube tests gently

5. Refer sample for further investigation

Give the corrective action.

1. Immunoglobulin-coated cells (in vivo)

2. Saline-suspended cells (slide)

3. Omission of reagent manufacturer’s directions

4. Resuspension too vigorous

5. Variant antigen

Rh null

A Rh Deficiency Syndrome that has complete lack of Rh antigen expressions on red blood cells.

1. Regulator-type Rh null

2. Amorphic-type Rh null

1. It has a mutation in the RHAG gene but with normal RHD and RHCE complement

2. Mutation in RHCE, Deletion in RHD, Normal RHAG

• Compensated hemolytic anemia

• Stomatocytosis

• Reticulocytosis

• ↓ Hgb and Hct

• ↑ in HbF

• ↓ serum haptoglobin

• ↑ bilirubin

Clinical findings in Rh null

Rh mod

• Have partial suppression of RH gene expression caused by mutations in RHAG gene

• Weakened expression of normal Rh antigens

• Clinical symptoms similar to Rh null but less severe

Compound Antigens

These are combinations of specific genes inherited as a haplotype that are present in cis position to each other.

1. Anti-f

2. f(+), Dce or dce

3. c and e in trans

1. A compound antigen that is expressed on the RBC when both c and e are present on the same haplotype.

2. It only reacts with __ cells (_ or _ haplotype)

3. It has no reactions with cells positive for?

1. Anti-Rhi

2. cE or CE

1. A compound antigen present when C and e are present on the RhCe protein.

2. They will only react with individuals with a haplotype of?

Cw antigen

• An allele at the C/c locus that can be expressed in combinations of C and c or absence of either.

• It is anthithetical to the high-prevalence antigen MAR

• It can be naturally occuring

1. G antigen

2. Anti-G

1. It is an antigen present on most D-positive and C-positive individuals. It codes for C, D, and G.

2. It mimics anti-C and anti-D but activity cannot be separated to either.

1. Rh13, 14, 15, 16

2. Rh17

3. Rh23, Rh30, and Rh40

1. These Rh antigens are part of the D mosaic theory. They are obsolete antigens.

2. It is also known as Hr0 and is present on all RBCs with common phenotypes (R1R1, R2R2, rr).

3. These are low prevalence antigens associated with partial D; results of formation of hybrid proteins.

1. Wiel or Dw

2. Goa or Dcor

3. Tar or Targett

1. Other name for Rh23

2. Other name for Rh30

3. Other name for Rh40

1. Rh32

2. Rh33 (Har)

3. Rh43 (Crawford or ceCF)

1. Rh antigen wherein C and e antigens are weakly expressed, but D antigen is exaggerated.

2. Associated with R0Har

3. Low prevalence antigen on a variant Rhce protein

e Variants

It is similar to partial D, but it results from multiple mutations in the RHCE gene. Individuals possess 2 altered RHCE genes — they are e-positive but behave as anti-e.

hrB (Rh31) and hrs (Rh19)

• (+) in RhCe and Rhce proteins

• (-) in RhcE and RhCE proteins

• (-) in Rhce proteins with RHCE genes

1. V and VS Antigen

2. V antigen (ceS)

3. VS antigen (eS)

4. VS (+)

5. VS (+)

1. It is used as predictors of ethnic background

2. Gly263 amino acid change in Rhce protein

3. Val245 amino acid change in Rhce protein

4. If an individual is hr8 (-) but with r’ genotype, it is?

5. Most V (+) are?

• Deletions

• Dash

• These are very uncommon phenotypes with no Cc and/or Ee reactivity.

• It is indicated by the use of?

• D— variant

• Exalted D

• This phenotype results from individuals possessing normal RHD gene(s) and hybrid RHCE-RHD-RHCE in which the Rhce protein is replaced with RhD.

• When there is no Cc and Ee reactivity but with unusually strong D antigen, it is called?

• D•• variant

• Rh37 (Evans)

• The D antigen is stronger than in DC- or Dc- but weaker than in D-.

• It is associated with what antigen?

• D(+) RBCs

• Rh (-) RBCs

• Rh null

• Cord blood cells

ANTI-LW (LANDSTEINER-WEINER) BLOOD GROUP

• Reacts strongly with _

• Reacts weakly or not at all with _

• Never reacts with _

• In _, there is equal reactivity regardless of Rh type

1. Rh-Mediated Hemolytic Transfusion Reactions

2. Direct Antiglobulin Test

3. Elution studies

1. This causes extravascular destruction of antibody coated RBCs

2. In what test does it react positively?

3. What must be performed to determine Ab specificity?

• unexplained fever

• mild ↑ bilirubin

• ↓ Hgb and haptoglobin

Clinical findings in Rh-Mediated Hemolytic Transfusion Reactions

Levine and Stetson (1939)

Who discovered HDFN?

Rh-immune globulin

A purified preparation of IgG anti-D that is given to D-negative women with D-positive babies to prevent RhD HDFN.