RH Blood Group System

The Rh Blood Group System
Overview
 Discovered by Landsteiner and Weiner
in 1940 when deliberately immunizing
guinea and rabbits with the red cells of
rhesus monkeys
 Sera from the immunized animals
agglutinated not only rhesus monkeys,
but, the red cells of 85% of humans
 It is now known that the animal anti-
rhesus antibodies are not identical in
specificity to those of human origin.
 Term Rh-positive indicates only one
specific antigen, Rh0 (D)
 In 1941 recognized the relationship
between Hemolytic Disease of the Fetus
and Newborn (Erythroblastosis fetalis)
and Rh blood group incompatibility
between mother and fetus.
Models of Inheritance
 Blood group antibodies recognize gene
products, not the genes directly
 Gene products are always a combination
of those inherited from both parents
 Antibodies directed to the products of
allelic genes (antithetical antibodies)
 Absence of the product of any gene of a
known allelic pair implies homozygosity
for its allele
 An allele with no detectable product is
an amorph
 The expression of a gene product may be
altered by the influence of another gene
Nomenclature
Rh-hr Terminology of Wiener
Genetic theory
 That the Rh genes occur at a single
complex locus code for a specific
“agglutinogen” comprised of a
potentially infinite number of “factors.”
Each factor could be demonstrated on the
red cell.
 Each individual factor is detectable by its
own specific antibody
Weiner System
Genes Agglutinogen Factors
R° Rho Rho, hr’, hr”
R1 Rh1 Rho,rh’, hr”
R2 Rh2 Rho, hr’, rh”
Rz Rhz Rho, rh’, rh”
R rh’ hr’, hr”
r’ rh’ rh’, hr”
r” rh” hr’, rh”
ry rhy rh’, rh”
CDE Terminology of Fisher and Race

Genetic theory
 That there are three closely linked gene
loci, each of which has allelic pairs
 Recognized that d is an amorph
 Eight possible combinations of Fisher’s
six genes, in descending order of
frequency, CDe, cde, cDE,cDe, Cde,
cdE, CDE and CdE
 It is currently believed that the Rh genes
occupy many mutational sites on the
chromosome
Fisher-Race
Gene Antigens
Complex
Dce D,c,e
DCe D,C,e
DcE D,c,E
DCE D,C,E
dce c,e
dCe C,e
dcE c,E
dCE C,E
Factor (Ag) Antigen Agglutinogens
Rh0 = D Rh1 =DCē Rhz=DCE
rh’= C Rh2 =DE Rho = Dce
rh”= E rh =ce rh’ = Ce
hr’= c rh” = cE rhy= CE
hr” = e
Qualitative and Quantitative Variation of
Antigens
Diminished Expression of D
 Term Weak D (formerly called Du) is
used to describe diminished D
expression-A red cell sample carrying D
antigen detectable only by application of
indirect antihuman globulin with potent
IgG anti-D sera.
Three mechanisms of Weak D (Du)
High-Grade Weak D (Du) – position
effect or gene interaction effect
 Most often results from gene interaction,
or from a position effect exerted by
another Rh gene
 Genotype CDe/Cde may exhibit
weakened expression of D because of a
depressing effect by Cde on the D that is
the product of CDe.
 Effect possibly aggravated by the
presence of C in both gene complexes.
 Condition is not inheritable
 Individuals do not form anti-D
Low-Grade Weak D (Du) – Inherited

weakened expression of D
 Cells do not agglutinate directly by anti-
D sera, at least when tests are performed
in tubes, even after incubation
 Seen most frequently in Blacks carrying
a variant of Ro
Subdivision of D (D “Mosaic”)
 In rare occurrences, a person who is D-
positive or Weak D (Du) - positive may
make an alloantibody appearing to have
anti-D specificity.
 Believed that the D antigen is comprised
of a mosaic genetically determined
subunits.
 Four individual determinants were
recognized–RhA, RhB, RhC, and RhD.
 Absence of one or more of these would
not necessarily be recognized on testing
the cells with most anti-D sera, but the
individual would be susceptible to
producing antibody to the missing
component.
 The antibody formed is indistinguishable
from anti-D, except that it is nonreactive
with the patient’s own cells, and with
other rare bloods that similarly lack the
relevant subunit.
 Some rare alleles do occur such as: CW,

f(ce), rhi (Ew),G, etc
Some Practical Considerations

 Immunoglobulin Classes IgM and IgG
 Most Rh antibodies are not saline-
reactive, except anti-E (rh”) and anti-CW
(which often react in all phases of
testing)
 Antibodies to Rh antigens are most
commonly IgG
Disease states
 Warm autoimmune hemolytic anemia –
the autoantibodies implicated
demonstrate specific with the Rh system
 Many cases of severe hemolytic disease
of the fetus and newborn- caused by anti-
Rh0 (D)
 Hemolytic transfusion reactions have
been attributed to all antibodies of the Rh
system
Testing for Antigens of the Rh Blood

Group System
Overview
 D- The most important blood group
antigen in everyday blood bank routine,
after A and B
 D is powerfully immunogenic -50% of
D-negative recipients who receive a
single unit of D-positive blood will have
an immune response
 After D, The order of immunogenicity
is:c>E>C>e
 Anti-D may be formed by D-negative
women as a result of feto-maternal
immunization during pregnancy.
 Immunization to D can be prevented in
many cases by administering Rh immune
globulin to Rh-negative women within
72 hours of delivering a D-positive or
Weak D (Du) –positive infant.
 Testing for the other antigens of the Rh
system is neither justified nor practical as
a matter of daily routine.
 Testing for D can either by performed by
the slide or tube method.
Tube Testing for D
 A low concentration of cells is required
(3 to5%)
 Low-grade Weak D (Du) cells do not
agglutinate directly
 High-grade Weak D (Du) cells or even
cells possessing a slightly weaker-than –
average expression of D may give or
equivocal reactions on immediate spin,
but show strong and definite
agglutination after 5 to 15 minutes of
incubation at 370C.
 Patients whose red cells show strong and
definite direct agglutination (before the
antiglobulin phase) should be regarded
as D-positive and be given D- positive
blood.
Weak D (Du) Test

 Involves using high-protein anti-D sera
and then performing an antiglobulin test
after washing the cells.
 Must be performed on all apparent D-
negative donor blood to prevent a Weak
D (Du) –positive unit from being
classified as D-Negative and being
transfused into a D-negative recipient.
 AABB Standards do not require that
recipients be tested for Weak D (Du), but
many hospitals prefer to know when
their patients are Weak D (Du )-positive
 Also frequently carried out on the red
cells of D-negative women who have just
delivered a D-Positive infant and is read
microscopicallyas means of recognizing
and roughly quantitating any fetal D-
positive cells present
Interpretation:
 The cells are Weak D (Du) - positive if:
oThe cells are not agglutinated directly
by the anti-D serum
oAre agglutinated at the antiglobulin
phase of the Weak D (Du) test
 There is no agglutination phase of the
test with Rh control reagent (a DAT is
negative)
 Cells should be reported as “Weak D
(Du)-positive”, never as “D-negative
Weak D (Du)-positive”
 In no agglutination at the antiglobulin
phase, the cells may be reported as “D-
negative Weak D (Du)-negative”
Causes of False Reactions
False positives
 The wrong antiserum was inadvertently
used
 An unsuspected antibody of another
specificity is present in the reagent
 Polyagglutinable cells may demonstrate
agglutination with any reagent
containing human serum
 Autoagglutinins and abnormal proteins
in the test sample may cause false
positive test results when the cells are
unwashed.
 Reagent vials may be contaminated with
bacteria, with foreign substances, or with
antiserum from another vial.
False negatives
 The wrong antiserum was used
 Antiserum was not added.
 A particular antiserum fails to react with
a variant form of the antigen.
 An antiserum containing antibody that is
predominantly directed at a compound
Rh antigen may fail to give a reliably
detectable reaction with cells carrying
the individual antigens as separate gene
products.(e.g anti-C serum that may react
more with Ce than with CE)
 The manufacturer’s instructors were not
followed, and the antiserum was used
incorrectly.
 Unduly hard shaking in resuspending the
cell button may disperse weak
agglutination.
 Immunoglobulin in an antiserum may
deteriorate due to contamination or
improper storage.

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The Rh Blood Group System

CDE Terminology of Fisher and Race

Low-Grade Weak D (Du) – Inherited

 Some rare alleles do occur such as: CW,

Some Practical Considerations

Testing for Antigens of the Rh Blood

Weak D (Du) Test

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