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Transcript of m4440090_27_2_11 Immunohematology
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V O L U M E 27, NU M B E R 2, 2011
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75ADVERTISEMENTS
79INSTRUCTIONS FOR AUTHORS
Immunohematology Volume 27, Number 2, 2011
C O N T E N T S
41REV IEW
Scianna: the lucky 13th blood group system
P.A.R. Brunker and W.A. Flegel
68REV IEW
XG: the forgotten blood group system
N.C. Johnson
58CASE REPORT
Possible suppression of fetal erythropoiesis by the Kell bloodgroup antibody anti-Kpa
M. Tuson, K. Hue-Roye, K. Koval, S. Imlay, R. Desai, G. Garg, E.
Kazem, D. Stockman, J. Hamilton, and M.E. Reid
61REPORT
Challenging dogma: group A donors as “universal plasma” donorsin massive transfusion protocols
E.J. Isaak, K.M. Tchorz, N. Lang, L. Kalal, C. Slapak, G. Khalife, D. Smith,
and M.C. McCarthy
66REPORT
Prevalence of RHD*DOL and RHDCE*ce(818T) in two populations
C. Halter Hipsky, D.C. Costa, R. Omoto, A. Zanette, L. Castilho, and M.E. Reid
72COMMUNICAT ION
Erratum
Vol. 27, No. 1, 2011, pp. 14, 16, and 18
73ANNOUNCEMENTS
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Immunohematology is published quarterly (March, June, September, and December) by the American Red Cross, National Headquarters, Washington, DC 20006
Immunohematology is indexed and included in Index Medicus and MEDLINE on theMEDLARS system. The contents are also cited in the EBASE/Excerpta Medica and Elsevier
BIOBASE/Current Awareness in Biological Sciences (CABS) databases
The subscription price is $40.00 (U.S.) and $50.00 (foreign) per year
Subscriptions, Change of Address, and Extra Copies
Immunohematology, P.O. Box 40325Philadelphia, PA 19106
Or call (215) 451-4902
Web site: www.redcross.org/immunohematology
Copyright 2011 by The American National Red CrossISSN 0894-203X
EDITOR- I N-CHIEF
Sandra Nance, MS, MT(ASCP)SBB
Philadelphia, Pennsylvania
MANAGING EDITOR
Cynthia Flickinger, MT(ASCP)SBB
Philadelphia, Pennsylvania
SENIOR MEDICAL EDITOR
Geralyn M. Meny, MD
Philadelphia, Pennsylvania
TECHNICAL EDITORS
Christine Lomas-Francis, MSc
New York City, New York
Dawn M. Rumsey, ART (CSMLT)
Glen Allen, Virginia
ASSOCIATE MEDICAL EDITORS
David Moolten, MD
Philadelphia, Pennsylvania
Ralph R. Vassallo, MD
Philadelphia, Pennsylvania
EDITORIAL ASSISTANT
Sheetal Patel
COPY EDITOR
Mary L. Tod
PROOFREADER
Lucy Oppenheim
PRODUCTION ASSISTANT
Marge Manigly
ELECTRONIC PUBLISHER
Paul Duquette
EDITORIAL BOARD
Patricia Arndt, MT(ASCP)SBBPomona, California
James P. AuBuchon, MDSeattle, Washington
Martha R. Combs, MT(ASCP)SBBDurham, North Carolina
Geoffrey Daniels, PhDBristol, United Kingdom
Anne F. Eder, MD Washington, Distr ict of Columbia
George Garratty, PhD, FRCPathPomona, California
Brenda J. Grossman, MDSt. Louis, Missouri
Christine Lomas-Francis, MScNew York City, New York
Gary Moroff, PhDRockville, Maryland
Paul M. Ness, MDBaltimore, Maryland
Joyce Poole, FIBMSBristol, United Kingdom
Mark Popovsky, MDBraintree, Massachusetts
Marion E. Reid, PhD, FIBMSNew York City, New York
S. Gerald Sandler, MD Washington, Distr ict of Columbia
Jill R. Storry, PhDLund, Sweden
David F. Stroncek, MDBethesda, Maryland
EMERITUS EDITOR
Delores Mallory, MT(ASCP) SBBSupply, North Carolina
ON OUR COVER
Ophelia by John William Waterhouse
Ophelia is a favorite subject of the pre-Raphaelites and, in particular, John William Waterhouse. The
painting, completed in 1910, is one of his more famous. It depicts the doomed daughter of Polonius pickingowers near the river in the moments before she drowns. The red and white blossoms represent both the
vitality and the transience of life, as well the curse and fate of lost innocence. The scene is pastoral, but th
darker hues and the intensity in her gaze and in how tightly she clutches the owers and her dress betray
her true state of mind. Ophelia mirrors Hamlet in her brooding over the moral collapse around her but is
unable to resist the descent into madness.
Like sweet bells jangled, out of tune and harsh;
That unmatch’d form and feature of blown youth
Blasted with ecstasy: O, woe is me,
To have seen what I have seen, see what I see!
The XG blood group, reviewed in this issue, has been investigated in genetic marker studies suggesting
possible linkage with manic-depressive illness.
D AVI D MOOLTEN, MD
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Scianna: the lucky 13th blood group systemP.A.R. Brunker and W.A. Flegel
The Scianna system was named in 1974 when it was appreciatedthat two antibodies described in 1962 in fact identied antitheticalantigens. However, it was not until 2003 that the protein on which antigens of this system are found and the rst molecular
variants were described. Scianna was the last previouslyserologically dened, protein-based blood group system to becharacterized at the molecular level, marking the end of an erain immunohematology. This story highlights the critical rolethat availability of laboratory reagents for serologic testing hasplayed in the initial characterization of a blood group and sets thestage for the development of new reagents, such as recombinantproteins, to assist in this process. The central role that genetics
has played, both by classical pedigree analysis and by moleculartechniques, in the discovery and characterization of this bloodgroup is reviewed. Immunohematology 2011;27:41–57.
The high- and low-prevalence antigens that constitute
the Scianna (SC) blood group system are caused by
variants in the erythroid membrane–associated protein
(ERMAP).1 SC was initially identied by serologic methods;
the clinical signicance of antibodies specic to SC is
uncertain, although case reports demonstrating rare cases
of hemolytic disease attributed to SC variants exist. Genetic
analyses in both the classical and molecular approaches,
have been central to the discovery and elaboration of theSC system. This article reviews the story of the SC blood
group from a genetic point of view, emphasizing the way it
has been brought into focus thanks to genetic tools ranging
from pedigree analysis to physical mapping.
History
Nomenclature: Sc1, Sc2, Sc3, and Sc4
The story of the 13th International Society of Blood
Transfusion (ISBT) blood group system began in 1962,
when a new high-prevalence antigen was reported alongside
a coexisting anti-D in a 25-year-old, multiparous woman
of Italian descent in Miami, Florida, who experienced
several fetal deaths as a result of hemolytic disease of the
fetus and newborn (HDFN).2 She came to clinical attention
because of difculty obtaining compatible blood. Her ABO
and Rh typings were O ccddee, and her husband’s were O
CCDee. After an unremarkable rst pregnancy and birth,
she experienced three subsequent and progressively earlier
fetal demises—at term, at 7, and at 6 months’ gestation—
in the late 1950s. After her second fetal death, her anti-D
titer was demonstrated at 256, and the new antibody to a
high-prevalence antigen, originally named anti-Sm, was
demonstrated at a titer of 16. An informative family study
revealed three antigen-negative siblings with a likely
autosomal dominant mode of antigen inheritance, and no
unrelated antigen-negative specimens were identied in a
population survey of 600 D– random individuals. A clue
to the genetic position of the responsible locus was present
even in this dening family: based on the pedigree, it could
not be determined whether the new antigen was part of the
Rh system as it was in linkage disequilibrium with cc inthat kindred.
In spite of this very dramatic introduction, the clinica
importance of the new antigen was uncertain, as the
concurrent anti-D clearly could account for the proband’s
unfortunate obstetric history. While the work of the Miam
group was in the pipeline for publication, the Winnipeg Rh
Laboratory, in Manitoba, reported an antibody to a new
low-prevalence antigen arising in a 50-year-old man with
stomach cancer.3 In this patient, the antibody originally
named anti-Bua, found in serum Char., was identied during
a routine pretransfusion crossmatch. As the patient had
been transfused with three units of blood 14 days earlierthis delayed serologic transfusion reaction was investigated
which revealed that although his serum was crossmatch
compatible with all three donor samples before transfusion
it reacted with one of the three samples after transfusion
A follow-up survey of 18 panel red blood cells (RBCs
demonstrated one reactive cell, suggesting a relatively high
prevalence for this new antigen; however, this proved not to
be the case, as only one of the next 1,000 donors was positive
The families of all three of these probands took part in
pedigree analysis, one of which was extremely informative
with a kindred of both parents and nine offspring. These
studies in classical genetics demonstrated that the new
locus segregated independently from ABO, MNSs, P, Rh
Kell, Kidd, Duffy, and X-chromosome.
Genetics and Inheritance
It did not take long for the relationship between the Sm
and Bua to be postulated, tested, and proven. In 1964, the
anti-Bua serum was used to type the available members of
the index Sm family (Fig. 1). The importance of using this
REVIEW
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P.A.R. Brunker and W.A. Flegel
serum as a typing reagent is underscored by
the fact that it was required to demonstratethat the parent generation consists of
a mating of two Sm/Bua heterozygotes
(parents PM Sr. and RM): the F1 generation
consists of four Sm– homozygotes, one
Sm/Bua heterozygote (individual AM),
and one Bua/Bua homozygote (individual
CS). Without it, the zygosities of AM
and CS could not be determined. This is
the only outbred family in the Sm/Bua
literature in which both parents are Sm/
Bua heterozygotes.
Concurrent with their suggestion
that Sm and Bua were the result of a
biallelic polymorphism, the Winnipeg Rh
Laboratory also reported an extensive
study of a Mennonite population in whom
the Bua antigen had a considerably higher
frequency of 5 in 348 samples than the
1 in 1,000 prevalence observed in other
Caucasian populations.4,5 Although they
tested 145 Caucasian families for Bua and
rigorously examined 19 based on the presence of Bua, it was
not until additional reagent serum was available in 1966
that denitive proof of this relationship was found.
Further examples of anti-Bua were discovered in a
group of individuals from Poland and the United Kingdom
(particularly the strongest serum Soch.) who had produced
anti-Bua after having been articially immunized with D+
cells to stimulate the production of Rh antibodies.6 Through
a careful study of the donors used for these stimulations
three additional subjects who were also stimulated with
these cells were found to have created an anti-Bua, although
it was much weaker than that in the Soch. serum. The
prevalence of the Bua allele was determined as 0.88 percent
in a Warsaw and 0.67 percent in a London cohort.
Using this reagent after adsorption to remove the
iatrogenically generated anti-D also present in the serum
the Winnipeg Rh Laboratory identied a large, six-
generation Mennonite kindred that included two cousinmatings of Sm/Bua heterozygotes, which produced 20
offspring.7 Through a methodical review of the serologic
data from samples from the kindred, which showed the
effects of antibody dosage on antigen expression, this report
conrmed and expanded the denition of the new system
to exclude all blood groups reported before 1962 (except
Diego, Yt, and Auberger) and Doa and Csa. Independence
from Yt was established in two British families.8,9 Finally
the currently accepted nomenclature (Table 1) was proposed
in 1974 to reect the surname of the index family in the
Table 1. Alleles, encoded antigens, and ISBT terminology of the Scianna blood groupsystem
Wild-type Variant
Antigen Trivial n ame Allele Genotype
High-prevalence
antigen Allele Genotype
Low-prevalence
antigen
Sc1 Sca (Sm) SC*01 169g57GlySc1
Sc2 Scb (Bua) SC*02 169a57ArgSc2
Sc3 Sc null SC*03N.01† 307D2Frameshift:
null
Sc3 Sc null 994c 332Arg SC*03N.02† 994t 332Stop:null
Sc4 Rd 178c60ProRd–
SC*04 178g60AlaRd+
Sc5 STAR 139g47GluSTAR+
SC*05 139a47LysSTAR–
Sc6 SCER 242g81Arg
SCER+ SC*06 242a
81GlnSCER–
Sc7 SCAN 103g35Gly
SCAN+ SC*07 103a
35SerSCAN–
†Provisional name suggested by the International Society of Blood Transfusion (ISBT) WorkingParty on Red Cell Immunogenetics and Blood Group Terminology
Fig. 1 Index family in the characterization of the Sm antigen anddemonstration of the antithetical relationship between Sm and Bu a antigens. The proband (patient Ms. Scianna) is indicated by thearrow. Solid color represents Sm+ (Sc:1+) antigen test. Striped fillrepresents Bua+ (Sc:2+) antigen test. Inferred genotype is shownbelow the symbol for each family member. The proband’s parentswere deceased at the time of Bua testing, so are inferred to beheterozygotes, indicated by the interrupted stripes and parenthesesin their genotype designation. The combination of Sm and Bua typingconfirms that subject AM is a heterozygote, which was suggestedby observations of dosage effects in serologic testing. (Redrawnwith data from references 2 and 4.)
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Scianna blood group system: a review
discovery of anti-Sm, Scianna,10 such that Sm was renamed
Sc1 and Bua was renamed Sc2.
The SC Gene Lies on Chromosome 1
The focus then shifted from denition of the system
to characterization of the locus responsible for the antigen
at a chromosomal level. Much of this seminal work was
performed in the Winnipeg Rh Laboratory. So it is not
surprising that their detailed investigations of the genetic
mapping of chromosome 1 contributed signicantly to
the progress on SC. Their unique access to informative
kindreds certainly hastened this process, and in a series
of reports from 1976 to 1978, linkage between RH and SC
was established, showing a logarithm of the odds ratio
(LOD score) of 5.34 at a recombination fraction, θ = 0.10 if
paternally segregated,11 and the relative position of SC was
determined12–14 and rened.15
A Third Antigen in the System: Sc3 or Scianna Null
Alleles
The appearance of “minus-minus” phenotypes, i.e.,
individuals whose RBCs tested negative for both Sc1 and the
antithetical Sc2 antigen (Sc:–1,–2), was rst documented
in 1973 and demonstrated the existence of apparent SC
null alleles.16 However, the term Sc3 was not coined until
1980 when an antibody from an Sc:–1,–2 individual
demonstrated no evidence of a separable anti-Sc1 or anti-
Sc2.17 The index patient examined in 1973 was a female
surgical patient from the Likiep Atoll in the Marshall
Islands, who had been transfused 7 months earlier withoutcrossmatching difculty. Her cells phenotyped as Sc:–1,–
2 as did those from one cousin, but both women’s RBCs
could still adsorb anti-Sc2. Despite four pregnancies with
an Sc:1,–2 husband, the proband’s cousin had a negative
antibody screen. Because these RBCs reduced the titer of
anti-Sc2, but not anti-Sc1, they may have had some weak
Sc2 expression, and a new antigen was not denitively
characterized at that time.
However, in 1980, a 67-year-old man in New York being
treated with chemoradiotherapy for metastasis to the throat
of a carcinoma of unknown origin required a preoperative
transfusion, and demonstrated a positive antibody screen.17
He had been transfused 4 years earlier without event.
Unlike the Likiepian Sc:–1,–2 erythrocytes, RBCs from this
patient did not reduce the titer of either anti-Sc1 or anti-
Sc2. When tested against the Likiepian Sc:–1,–2 cells, the
New York serum did not agglutinate the RBCs. No other
Sc:–1,–2 cells were found in a family study. No separable
anti-Sc1 was present in this patient’s serum, which is
somewhat unusual because patients who completely lack all
known antigens for a blood group and have been transfused
typically make a polyclonal mixture of antibodies directed
at the common epitopes of that system.18
The next report of a null phenotype for SC was described
in 1986, in another Pacic Islander.19 This patient was a
4-year-old girl from Papua New Guinea with thalassemia
major who had been transfused many times. Anti-Sc3 was
demonstrated. Erythrocytes from the patient’s mother
were compatible, and both mother and daughter were
found to have the Sc:–1,–2 phenotype. In this community
the Sc:–1,–2 phenotype was surprisingly common: A survey
of 29 family members and apparently unrelated villagers
revealed 6 others (2 of whom had no obvious relationship
to the patient) who were also Sc:–1,–2. This very high
phenotype prevalence (20.6%) makes heterozygosity for
a putative recessive Sc3 allele in the patient’s father quite
likely (although his RBC phenotype is not reported in the
short abstract), as well as explaining the homozygosity for
the same allele observed in her mother. Additional Sc:–1,–2 individuals have been reported
(including a patient who experienced an apparent delayed
hemolytic transfusion reaction), some of whom have also
lacked several other high-prevalence antigens.18 Evidence
that each patient in their series produced antibodies with
different specicities is discussed in Antibodies section.
Radin: A “New” Low-Prevalence Antigen Is Linked to
Scianna (via RH)
When Radin was rst described, in 1967,20 the
relationship between Radin and Scianna was not
appreciated. Although the clinical signicance of antibodiesgenerated to antigens within the SC system in genera
is controversial, the analysis of the antibodies that led to
the discovery of the Radin antigen is based on its clinical
importance, with the initial description encompassing
ve cases of mild to moderate hemolytic disease of the
newborn, of which one required exchange transfusion and
one appeared in the rst pregnancy.20 Additional cases
and conrmation of the low general frequency (1 in 205)
appeared shortly thereafter.21
Once again, it was the unique analysis performed by
the Winnipeg Rh Laboratory that elucidated the putative
connection between Radin and SC. Linkage analysis
of eight propositi in ten nuclear families demonstrated
linkage between Rd and RH.22 Similar to the Sc1/Sc2
linkage analysis in the present dataset, the Winnipeg
analysis demonstrated heterochiasmy, with the paterna
LOD score exceeding 3 at a recombination fraction, θ =
0.10, whereas the corresponding maternal LOD neither
suggests nor refutes linkage (LOD = 0.41 at θ = 0.10 )
This nding was only sufcient to propose the connection
between SC and Rd, as heterozygotes at both of these (i.e.
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P.A.R. Brunker and W.A. Flegel
double recombinants) had not been found. Incorporation of
the gene encoding the Rd antigen into the bigger picture of
chromosome 1 mapping placed it so close to SC that it was
proposed even at that time that the gene encoding Rd “is
either very closely linked to or identical with SC.”23
There were few additional reports on the SC blood group
system for more than 20 years until its molecular basis was
nally resolved in 2003.1 Since then, molecular analysis
has identied the three additional alleles underpinning
the three antibodies described by Devine and coworkers in
1988.18
Molecular Basis
The ERMAP Expresses the SC Antigens
The molecular basis of the SC blood group system was
identied in 2003 by merging the genetic mapping data
with protein chemistry showing that the SC antigens wereon a single glycoprotein of approximately 60 to 68 kDa
that must be expressed by RBCs.24,25 The SC gene had been
mapped to chromosome 1, and based on its linkage to the
RH genes, the chromosomal location had been further
rened to 1p34 to 1p36. This led to the identication of a
strong candidate gene.1
The ERMAP is a 475-amino acid, type 1 single-pass
membrane glycoprotein that is a member of the butyrophilin
(BTN) family and is encoded by the ERMAP gene.26,27 It
consists of a predicted signal sequence of 29 amino acids
at the NH3 terminus, an extracellular immunoglobulin
V domain (amino acids 50–126), a short transmembranedomain spanning amino acids 157 through 176, and an
intracellular carboxyl terminus encompassing a B30.2
domain from amino acids 238 through 395.1
The nomenclature for the transcripts of ERMAP is
complicated and has been revised many times. At least
two transcript variants have been described, which
result from use of an alternative upstream promoter
and alternative splicing.28 The longer variant is 3,423
bp and is designated as transcript 1, or as transcript b
by GenBank curators,29 as it was the second transcript
variant identied, and it includes an additional upstream
exon (GenBank NM_001017922.1). The shorter variant is
designated as transcript 2 or as transcript a, is 3,369 bp,
excludes this upstream exon (GenBank NM_018538.3),
begins transcription 45 bp upstream from the start of exon
2, and was the rst variant discovered; thus, early reports
describe this gene as consisting of 11 exons. However, the
revised current nomenclature for this gene is based on the
presence of 12 exons spanning approximately 28 kb. The
relative production of these two mRNAs is not known, nor
has it been determined whether the use of either promoter
is favored in some tissue types or physiologic conditions
Both transcripts share the common ATG start codon in
exon 3; thus, there is no predicted difference in the protein
product of the two transcripts. They differ in both the
transcript initiation site and the DNA stretch of exon 2 that
becomes part of the nal transcript; consequently, there are
two alternative exon 2s, named exon 2a and exon 2b. The
longer transcript 1 comprises exon 1, exon 2b, and exons
3 through 12, whereas the shorter transcript 2 starts with
exon 2a and also includes exons 3 through 12 (Fig. 2).
The Ensembl genome browser curators have delineated
ve transcripts in ERMAP,30,31 three of which are protein
coding and two of which generate a processed transcript only
Two of the Ensembl transcripts correspond to GenBank’s
transcripts 1 and 2; however, unique to the Ensemb
database is a 3,949-bp transcript (named ERMAP-002),3
which is reported as protein coding and generates a short
protein encoding 385 amino acids rather than the usual475. However, only the two transcripts that encode the
475–amino acid protein are included in the Consensus
Coding Sequence Project (CCDS; both with identication
number CCDS475), so the biological signicance of the
3,949-bp transcript is unclear.
In addition to explaining the Sc1/Sc2 biallelic
single nucleotide polymorphism (SNP) at Gly57Arg, a
binucleotide GA deletion was identied at nt307 (now
known as SC*03N.01, provisional name suggested by
the ISBT Working Party on Red Cell Immunogenetics
and Blood Group Terminology). This deletion causes a
frameshift and premature stop codon, which explain theSC null phenotype.1 The Rd antigen (Sc4) was dened as
the Pro60Ala variation, and two other variants in the
presumed leader signal peptide (54C>T and 76C>T) were
described in the original study elucidating the molecular
basis by Wagner and colleagues1 (Table 2).
Understanding the Variants Discovered in the Post-
ERMAP Era
The knowledge of the gene responsible for the antigens
of this blood group protein opened the oodgates through
which variant descriptions of unknown, unresolved sero-
logic cases promptly ow. This was clearly the case for SC, for
which three new variants were discovered within just a few
years after the characterization of ERMAP as the SC gene
Careful molecular follow-up of the three patients described
by Devine and coworkers18 in 1988 revealed three distinct
ERMAP/SC variants, demonstrating the importance of
molecular testing in the resolution of serologic SC mysteries
The success of these investigations depended not only on
the cooperation among an international collaborative, but
also on the supportive participation of two patients and
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a family who kindly released two autologous RBC units.
It was appreciated in the initial case reports in 1988 thatthe SC protein carried multiple high-prevalence antigens
other than Sc1/2.18 Sera or eluates from these three Sc:1,–2
patients who had developed high-prevalence antibodies did
not react with the Sc:–1,–2 null RBCs, but the samples were
not mutually compatible.
Sc5 (STAR)
In 1982, a 65-year-old man with a history of transfusion
of three units of crossmatch-compatible whole blood
before presentation underwent routine preoperative blood
bank testing, demonstrating anti-C and anti-e. He was
transfused with another three units of C–e– RBCs, and 1
week later, a new anti-Jk b and an antibody against a high-
prevalence antigen were detected. Because his serum
reacted with all cells except his own (phenotyped as Sc:1,
–2), those of a sibling, and Sc:–1,–2 RBCs, it was suspected
that he had developed an antibody to another antigen on
the SC protein.35 Blood needs for the patient were met with
autologous units. Blood samples from the proband and 16
family members had been frozen. Sequencing of the exons
encoding the extracellular and transmembrane domains
demonstrated homozygosity at a new nonsynonymous
polymorphism at amino acid 47 (glutamic acid to lysine) which is in the N-terminal domain.36 This variation is
catalogued as rs56047316 in the SNP database (dbSNP), and
it results from the guanine–adenine transition at nucleotide
139 in the complementary DNA (cDNA). Frequencies of this
allele in population studies have not been reported, nor
have additional cases of this antibody.
Sc6 (SCER) and Sc7 (SCAN)
The remaining two antibody cases described by Devine
and colleagues18 were concomitantly resolved using the
same approach as for the Sc5 antigen.37 These investigators
sequenced all 11 exons of ERMAP known at the time
which encompasses all cDNA. They also solicited others to
submit suspected SC variants and the eight other orphan
low-prevalence antigens By, Toa, Pta, Rea, Jea, Lia, SARA
and Sk a. The proband for case 1 reported by Devine and
colleagues18 demonstrated homozygosity for a guanine–
adenine transition at cDNA nucleotide 242, predicted to
cause an amino acid change at position 81 (from arginine
to glutamine), which is in the immunoglobulin V loop.1
The case 2 proband demonstrated a new homozygous
Scianna blood group system: a review
Fig. 2 Transcripts, exon structure, and variants of erythroid membrane-associated protein (ERMAP ). Codon numbers are indicated aboveamino acids involved in described variants. The immunoglobulin variable domain is underlined. Exon 4 is expanded to the nucleotide levein the gray box to show the locations of most ISBT-recognized Scianna polymorphisms. The wild-type reference sequence is under thecorresponding amino acid and is the chromosome 1 reference sequence GenBank NC_000001.10. * = nucleotide deletion.
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P.A.R. Brunker and W.A. Flegel
Table 2. Erythroid membrane–associated protein polymorphisms in the coding region and global population frequencies
Sc name Descriptive name dbSNP ID: cDNA nt mRNA* Wild-type (WT) Variant Protein effectAmino acid (aa)
codon
rs35757049 11 281 c t nonsynonymous substitution 4
rs33950227 54 324 c t silent 18
rs33953680 76 346 c t nonsynonymous substitution 26
Sc7 SCAN 103 373 g a nonsynonymous substitution 35
Sc5 STAR rs56047316 139 409 g a nonsynonymous substitution 47
Sc1 vs. Sc2 rs56025238 169 439 g (Sc1)a
(Sc2)nonsynonymous substitution 57
Sc4 Rd rs56136737 178 448 c g nonsynonymous substitution 60
rs33954154 219 489 c t silent 73
Sc6 SCER 242 512 g a nonsynonymous substitution 81
Sc null (D ga together) rs55695242 307 577 g del –1 frameshift 103
Sc null (D ga together) rs56151267 308 578 a del –1 frameshift 103
rs35147822 775 1045 t c nonsynonymous substitution 259
rs34441268 788 1058 g a nonsynonymous substitution 263
rs35972628 888 1158 g a silent 296
Sc null 994 1264 c t nonsense (STOP) 332
rs55773259 1227 1497 a g silent 409
rs55872827 1324 1594 t c nonsynonymous substitution 442
rs56405033 1355 1625 t c nonsynonymous substitution 452
rs55677363 1356 1626 g t silent 452
*NCBI Reference Sequence Position: NM_001017922.1†Minor allele frequencies for some populations are determined by reports of serologic phenotype and assuming individuals positive for a rare antigen areheterozygotes.
cDNA = complementary DNA; dbSNP = single nucleotide polymorphism database; IgV = immunoglobulin V; mRNA = messenger RNA; nt = nucleotide.
nonsynonymous variant at cDNA nucleotide position 103
(again a guanine–adenine transition), corresponding to
a glycine to serine change at amino acid 35 in the NH3
terminus. This specimen also demonstrated two other SNPs
(at cDNA nucleotides 54C>T and 76C>T), which had been
previously reported, are common in Caucasian populations,
and are in tight linkage disequilibrium (LD).1 Because these
variants are both in the predicted leader sequence (and the
54C>T is a silent mutation), they are not predicted to directly
impact on ERMAP structure. This report also excluded the
eight orphan low-prevalence antigens from the SC system
because the only variants found were in the leader sequence
or in introns.
Molecular Basis of SC Null Phenotypes
Central to the set of specimens originally reported with
the discovery of ERMAP as SC was an Sc:–1,–2 sample
from a Saudi Arabian pedigree,1 which demonstrated
homozygosity at three SNPs: the common 54C>T and
76C>T (described in an earlier section) as well as a 2-bp
deletion starting at cDNA nucleotide 307 (307Δga) that
is predicted to cause a frameshift mutation and early
termination codon after 113 amino acids. The nt54 and nt76
SNPs were genotyped in an additional 111 European blood
donors and were found in tight LD. The frameshift would
account for a complete lack of an intact ERMAP protein in
the cell membrane.
Two Sc:–1,–2 individuals from northern and southern
California were then sequenced in a follow-up study,37 and
both shared a new SC null allele formed by a nonsense
mutation at codon 332. This is the rst report of a variant
in the B30.2 intracellular domain in a patient immunized
to SC. It is not, however, the only variant in the B30.2
domain (Table 2), because three others have been described
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in dbSNP, two of which are nonsynonymous amino acid
changes (C259R and G263E) and one of which is silent
(E296E). This result suggests that an early translation
termination, even as late as at codon 332 of the expected
475, sufciently interferes with correct protein trafcking,
membrane insertion, or stability so as to render the
individual susceptible to alloimmunization at the Sc1/2 site
(codon 57).
Other Variants in ERMAP : Using dbSNP and HapMap
Variants in the coding region, particularly those in the
extracellular domain of transmembrane proteins, are of
particular clinical interest in transfusion medicine, as their
location provides an obvious mechanism for putative clinical
signicance by alloimmunization. However, much variation
in the human genome is found outside of coding regions,
and ERMAP is no exception. Studies of this variation are a
critical tool in the investigation of human disease and basic
sciences. Several collaborative projects in human genomics
focus on gathering, sharing, and interpreting human
genetic variation, and although a full cataloguing of these is
beyond the scope of this review, we will present variants in
ERMAP that are part of two such projects: dbSNP38 and the
International HapMap Project.39 Table 2 integrates some of
these variants (identied by their rs numbers) with those
described in the transfusion medicine literature. These
data allow informative LD studies of ERMAP (Fig. 3). This
LD map shows two distinct LD blocks that correspond to
the exons encoding the extracellular immunoglobulin-like
domains and the intracellular B30.2 domains of ERMAP
The importance of this pattern of LD is that it reveals a
possible evolutionary vestige of the modular nature of the
butyrophilin-like (BTNL) protein family and is even more
pronounced in the Nigerian population. Long stretches of
Scianna blood group system: a review
WT aa Variant aa Exon Protein domain Minor allele frequency in blood donors†
Ala Val 3 Leader 0.054 (dbSNP)
Leu Leu 3 Leader 0.28 (German1), 0.1 (dbSNP)
His Tyr 3 Leader0.33 (German1), 0.25 (Caucasian North American32), 0.1 (dbSNP),
0.05 (African-American32)
Gly Ser 4 NH3-terminus
Glu Lys 4 NH3-terminus
Gly Arg 4 IgV loop0.01 (Caucasian North American,33 Brazilian34), 0.008 (German1),
0.005 (Hispanic American33), 0.002 (African-American33), 0 (Asian American33)
Pro Ala 4 IgV loop0.003 (Slavs33), 0.002 (Caucasian North American,33 Danish,21 German,1
New York Jewish20)
Arg Arg 4 IgV loop 0.017 (dbSNP)
Arg Gln 4 IgV loop
Asp frameshift 4 IgV loop
Asp frameshift 4 IgV loop
Cys Arg 12 B30.2 domain 0.022 (dbSNP)
Gly Glu 12 B30.2 domain 0.011 (dbSNP)
Glu Glu 12 B30.2 domain 0.011 (dbSNP)
Arg STOP 12 B30.2 domain
Leu Leu 12 C-terminus
Ser Pro 12 C-terminus
Leu Pro 12 C-terminus at a 3’ dileucine (LL)
phosphorylation motif
Leu Leu 12 C-terminus at a 3’ dileucine (LL)
phosphorylation motif0.054 (dbSNP)
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P.A.R. Brunker and W.A. Flegel
LD such as that illustrated in the extracellular domain of
ERMAP, where all of the SC antigens are encoded, raise the
possibility that a selective advantage by genetic hitchhiking
may be operating at ERMAP.40
Global Variation
Some ethnographic trends have already been
historically appreciated with SC variants during the early
years of their investigation (Table 2). For instance, Sc4 has
been identied most often in Ashkenazi Jews and Slavic
populations, and the few Sc:–1,–2 phenotypes have been
reported particularly in populations from Oceania. Sc2
appears to be more common in a consanguineous Canadian
Mennonite population (derived from a small region in
Eastern Europe),5 but it remains very rare in or absent from
populations of African5,33 or Native American10 descent.
However, it is not sufcient to rely on case reports to
propose generalizations regarding population frequencies.
Fortunately, recent technologies are available to rapidly
genotype ERMAP variants using an automated genotype-
calling platform, and additional population studies wil
continue to be reported.33
Biochemistry and Physiology
ERMAP Is a Member of the Butyrophilin-like Family of
the Immunoglobulin Superfamily
By virtue of its extracellular immunoglobulin V and
the intracellular B30.2 domains, ERMAP is a member
of the BTNL protein family, which is a subset of the
immunoglobulin superfamily.41 The compact, globular
110–amino acid immunoglobulin domain denes this
superfamily and is found in three operational domain
subclasses: variable (immunoglobulin V), intermediate
(immunoglobulin I), or constant (immunoglobulin C).42,4
These proteins are central to many immunologic processes
especially cell adhesion, costimulation, and signalling.44,4
The immunoglobulin superfamily is one of the largest in
all eukaryotic organisms.46 Other members of this family
well known to the transfusion medicine community
Fig. 3 Pairwise linkage disequilibrium (LD) heat plot of the logarithmic odds ratio (LOD) score for single nucleotide polymorphisms inerythroid membrane–associated protein (ERMAP) in a Nigerian population. Darker shades (black) = areas of high LD, lighter shades (lightgray) = areas of lower LD. The areas of tightest LD correspond to the extracellular domains of ERMAP, on the left-hand side of the figure.Increased LD is also seen in the intracellular domains, at the right side. This segmental pattern of LD reveals a possible evolutionary vestigeof the modular nature of the butyrophilin-like protein family. YRI = Yoruba in Ibadan, Nigeria. (Source: Haploview™ software run at http://
hapmap.ncbi.nlm.nih.gov/cgi-perl/gbrowse/hapmap3r2_B36/#search; accessed April 27, 2010.)
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Scianna blood group system: a review
include the Lutheran, LW, OK, JMH, and Indian blood
groups, which are found on the B-CAM, ICAM4, CD147,
CD108, and CD44 molecules, respectively.47 BTN proteins
are within the B7-CD28-like branch of this superfamily 48
and have been extensively studied in cows.49 The prototypeof the human BTN family of proteins is BTN1A1, which is
primarily expressed in the lactating breast, where it makes
up 20 percent of the protein in the membrane of milk
fat globules. The name derives from the Greek butyros
and philos, meaning “having an afnity for butterfat.”
Although ERMAP is carried on chromosome 1, the genes
for many members of this family are located in the major
histocompatibility complex (MHC) on chromosome 6.50
The lactational and immunologic functions of BTNs
as a part of the secretory granule-to-plasma membrane
zipper complex and as an inhibitor of T-cell activation are
only recently described,51,52 and even less is known about
the BTNL proteins. There are six known human BTNL
proteins, which are dened by their homology to BTN
proteins (Fig. 4). The most extensively studied of these is
BTNL2, the gene for which is located in the MHC class II
cluster at 6p21.3. A truncating splice site mutation in BTNL2
has been associated with sarcoidosis,53 and although this
SNP has been investigated in many other infectious and
autoimmune diseases, some of these associations have
been attributable to LD with the MHC.54 BTNL2 inhibits
T-cell activation by inhibiting proliferation in response to
the stimulatory T-cell receptor signal.55 This inability for
BTNL2 to propagate a cell signal has led some investigators
to propose its role as “decoy receptor” because it lacks the
B30.2 intracellular domain present in most other BTN andBTNL proteins.54
The B30.2 Cytoplasmic Domain: A Role in
Erythropoiesis?
The B30.2 (or PRYSPRY) domain was described in 1993
with the discovery of an exon in the MHC class I region
showing similarity to other mammalian and amphibian
proteins, which have since been termed the tripartite
motif family.56,57 Such a domain was demonstrated in
bovine BTN58 and in human BTN proteins.59 The B30.2
domain is proposed to be a recent evolutionary adaptation
in the immune system of mammals as a fusion of two
ancient domains (PRY and SPRY), which are found in
all eukaryotes.50 The genes for proteins in this family
have a modular structure, suggesting that they arose
by duplication.56 Mutations in the B30.2 domain in the
tripartite motif–branch of the B30.2 proteins have been
associated with Opitz syndrome (MID1 protein) and
familial Mediterranean fever (pyrin protein). However
human syndromes have not been associated with mutations
in the B30.2 domain of the BTN or BTNL families.
Fig. 4 The organization of the butyrophilin-like (BTNL) family incomparison to the butyrophilin (BTN) and B7 families. The B7branch of the immunoglobulin superfamily is characterized byvariable (IgV) and constant (IgC) immunoglobulin domains. TheBTN subfamily includes the B30.2 intracellular domain. The BTNLproteins exhibit various combinations of these features. MOG =myelin oligodendrocyte glycoprotein, an autoantigen implicated inmultiple sclerosis. (Modified from reference 52.)
Fig.5 On the left, blood from a fish of the genus Notothenia (withhemoglobin-containing erythrocytes) and on the right is bloodfrom Chaenocephalus aceratus. Icefish transport oxygen strictly inphysical solution, without a carrier molecule. The recent discoverythat bloodthirsty (bty), a B30.2-domain–containing protein likeERMAP, has dramatically decreased expression in hemoglobinlessicefish provides a fascinating link between this protein domain anderythropoiesis. Courtesy of Professor Guillaume Lecointre.
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P.A.R. Brunker and W.A. Flegel
The crystal structure of the B30.2 domain of pyrin was
recently elucidated. A β-barrel consisting of two antiparallel
β-sheets has been described, forming a central cavity.60 The
ligand(s) that interact with the B30.2 domain have yet to be
described, although binding analyses suggest that it is the
site of protein–protein interactions.61 The crystal structure
of one other B30.2 domain interacting with a peptide has
shown that there is a conformationally r igid peptide binding
pocket (consisting of a core β-sandwich around variable
loops) binding to a short-sequence motif, which may allow
multiple intracellular targets to bind.62 Recently, BTN1A1
has been shown to bind xanthine oxidoreductase via B30.2,
apparently stabilizing the milk fat globule membrane in
mammary tissue, but it is also hypothesized to function
as a novel signaling pathway in nonmammary tissues or
perhaps in the innate immune system via generation of
reactive oxygen species.63
A role for B30.2 domains in erythropoiesis has beenrevealed through study of an unlikely model organism:
Antarctic icesh. These animals are the only vertebrate
taxon that fails to produce RBCs (Fig. 5), and as such
have been studied in a hunt for genes important in
erythropoiesis and cardiovascular biology.64 Using
this approach, a new B30.2-containing protein, called
bloodthirsty (bty), was identied in the pronephric kidney
of a red-blooded Antarctic rockcod ( Notothenia coriiceps),
which was present at levels tenfold higher than those in
an icesh (Chaenocephalus aceratus).65 Interestingly,
disruption of bty synthesis in zebrash suppressed both
erythrocyte production and hemoglobin synthesis, andalthough interactions between bty and ERMAP have been
hypothesized, they have not been empirically demonstrated
(H. William Detrich, personal communication, January
20, 2010).
Functional Studies of ERMAP
The function of ERMAP itself, however, is not well
understood. The murine homolog, Ermap, was described
rst and named as such because it was found to be produced
exclusively in erythroid cells.66 The human homolog was
characterized shortly thereafter, and Northern blots
demonstrated high expression in hematopoietic tissues,
such as fetal liver and bone marrow, with weaker expression
in peripheral blood leukocytes, thymus, lymph node,
and spleen.26 Sc1 has been demonstrated on phagocytic
leukocytes using an antibody absorption technique.67
Recent RNA array expression analysis supports this
nding, having detected low levels of ERMAP transcripts
in leukocytes, especially monocytes; however, quantitative
protein expression remains to be assessed.54 An in silico
analysis of nucleotide database searches of human
expressed-sequence tags using the ERMAP transcript 1
(GenBank NM_001017922.1) as the probe detected the
transcript in cDNA libraries from hematogenous tissues
such as bone marrow, a chronic myeloid leukemia cell line
peripheral blood pool, thymus, spleen, and fetal liver, as wel
as in neural tissues.68 However, it is difcult to denitively
ascribe transcript production to the nonerythroid cells in
the neural tissues, as contamination from the vasculature
cannot be completely eliminated. ERMAP mRNA reaches
peak levels in fetal liver in the 18th through 20th weeks
and it is present from the 15th through 32nd weeks in feta
bone marrow, suggesting that ERMAP may be related
to the migration of erythroid cells to these sites during
hematopoietic development.69
Additional evidence that ERMAP may be involved in
erythroid differentiation has been put forward, although
only abstracts of these reports are available in the English
literature. Using uorescent quantitative polymerasechain reaction,70 ERMAP expression has been found in
the K562 cell line, which is derived from chronic myeloid
leukemia and is of undifferentiated granulocytic lineage.7
To test the degree of erythroid-specicity of ERMAP
in hematopoiesis, this group used cytarabine (Ara-C)
to induce these cells toward erythroid differentiation
and 12-O-tetradecanoylphorbol-13-acetate to induce
development toward the macrophage lineage, but found
an increase in ERMAP mRNA after an Ara-C stimulation
only.72 This nding suggests that although ERMAP may be
present on cells of the monocyte/macrophage lineage, its
functional importance may be limited in these cell typesRNA silencing experiments using an ERMAP shRNA/K562
cell line also reported by this group showed decreased
ERMAP expression and morphologic features, including
the relative amounts of surface erythrocyte maturation
markers, leading the authors to conclude that ERMAP
shRNA inhibited Ara-C–induced erythroid differentiation.7
A second model of erythroid differentiation using umbilical
cord blood with two naturally occurring hormones (namely
stem cell factor and IL-3) and erythropoietin to provoke
differentiation also showed a concurrent rise in ERMAP
mRNA with erythrocyte maturation.74
Many structural features of ERMAP point toward a
putative role in immunity, perhaps by adhering to other
cells or pathogens via its extracellular immunoglobulin V
domain, or by immunoregulatory mechanisms such as the
modulation of cellular activation signals via B30.2 as is
observed in its BTN family members.52 Much work is needed
in this area to better characterize the proteins that interact
with ERMAP, both extracellularly and intracellularly
and to determine whether ERMAP has a central role in
erythropoiesis itself.
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Scianna blood group system: a review
Antibodies in the System
The discovery of the SC blood group system began
with and has relied on the detection and investigation of
alloantibodies. The effects of enzymes and chemicals and
the in vitro characteristics of SC antibodies were recently
reported elsewhere.75 In general, SC antigens are resistant
to cin plus papain, trypsin, α-chymotrypsin, sialidase,
and 50 mM dithiothreitol (DTT), and they are sensitive to
pronase and 200 mM DTT. The exception to this trend is the
variable sensitivity of Sc4 to trypsin and α-chymotrypsin.
Enzymatic properties of anti-SCER and anti-SCAN are only
described in the initial case report as showing no change
in the strength of antibody activity when tested with RBCs
that had been treated with cin, papain, trypsin, ZZAP
(mixture of 0.1 M DTT plus 0.1% cysteine-activated papain),
or chloroquine diphosphate.18 Anti-STAR demonstrated
enhanced reactivity with enzyme-treated RBCs.36
Patientsor donors in whom an antibody to an SC antigen has been
reported (Table 3) have been thoroughly reviewed recently.76
Thirteen of the 19 reports of alloantibodies to SC system
antigens listed in Table 3 have occurred in cases in which
they do not appear to manifest a major clinical signicance.
All six of the reports with clinical signicance occurred in
cases of HDFN. All six of the reported autoantibodies to SC
system antigens in patients were in the context of clinically
signicant autoimmune hemolytic anemia, although ve
of these cases were presented as an abstract only, without
the full clinical details. Alleles Sc4–7 were not tested in
any of these cases. Such an investigation is warranted because heterozygosity for alleles with weak expression
in the Rh blood group system has been associated with D
autoantibodies.86
Clinically important reactions to an erythrocyte
antibody typically result from signicant RBC destruction
and usually manifest in the patient as a hemolytic anemia or
HDFN. In the SC system, signicant HDFN dened the blood
group in a patient named Ms. Scianna; however, she also
had anti-D to account for her severe obstetric complications
in addition to the anti-Sc1.2 Anti-Sc2 has been reported in
a case of HDFN requiring simple transfusion in a 20-day-
old infant.83 Importantly, the search for antibodies to low-
prevalence antigens in this patient was only performed
because the neonate and the mother were ABO-compatible:
had they been ABO-incompatible, the HDFN would likely
have been attributed to this, and the anti-Sc2 antibody may
not have been detected.
The recent availability of recombinant reagents to
assist in the detection of SC antibodies87 may bring this
ability into the wider immunohematology arena. This novel
technique will allow one to appraise the relevance of SC
antibodies in conjunction with other antibodies and tease
out their relative clinical importance, which may have been
previously underestimated. The ERMAP protein has been
expressed in its native form in a eukaryotic system,87 and
so although the initial report describes the utility of this
reagent for detecting the high-prevalence SC antigens, a
screening protein for low-prevalence antigens Sc2 and Sc4
would also be feasible.
Some SC alloantibodies (Table 3) resulted in delayed
serologic transfusion reactions without associated
hemolysis, including a so-called naturally occurring anti-
Sc4 described in a 55-year-old man without a transfusion
history.21 Many of these patients were transfused with
crossmatch-compatible blood without incident. However
some surgeries were delayed owing to lack of availability
of crossmatch-compatible units, and other patients
were transfused with autologous products in nonurgent
scenarios.18
The remaining reports of important reactions involving
SC antibodies are in cases of autoimmune hemolytic
anemia. Auto-anti-Sc1 and -Sc3 have been eluted from
direct antiglobulin test–positive RBCs of these patients. In
many cases, these antibodies were transient and associated
with decreased expression of SC antigens.79,84 Severa
patients underwent splenectomy in addition to treatment
with many types of immunosuppressant medications. One
patient with erythroid hypoplasia and diagnosed with an
Evans-like syndrome even underwent a total of 20 plasma
exchanges over the course of 11 weeks.82 After the ninth
exchange, the antibody was no longer detectable, althoughit reappeared 1 week later. He was nally transfused after 16
exchanges, despite the continued presence of the antibody
with a resultant rise in his hematocrit from 14% to 30%.
Clinical Significance
Is It Worth Phenotype or Genotype Matching?
Of the 23 cases of SC alloantibodies catalogued here
(Table 3), one case of HDFN83 and one delayed hemolytic
transfusion reaction (case 2)18 relate sufcient information
in their reports to convincingly attribute clinical relevance
to SC antibodies. The HDFN cases described in the initial
report of the Radin antigen also speak to the potentia
importance of antibodies to Sc4 (especially the case that
required exchange transfusion); however, these cases are
not reported in sufcient detail to denitively implicate
anti-Sc4 to the exclusion of all other causes.20 Even the
very dramatic presentation of Ms. Scianna’s antibody does
not incriminate anti-Sc1 as the cause of her poor obstetric
outcomes, as an anti-D of a higher titer was also found.
The fundamental question of when and whether antibodies
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P.A.R. Brunker and W.A. Flegel
Table 3. Published reports of antibodies to antigens in the Scianna blood group system
AntibodyAllo orauto? Authors Year
Caseidentifier
Sciannaphenotype
Age(years) Sex Ethnicity
Importantreactions?
Otherantibodies
Transfusion/pregnancyhistory
anti-Sc1 Allo Schmidt et al.2 1962 Mrs. N.S. Sc:–1,2 25 F Caucasian HDFN anti-D Multiparous, after 1st baby withHDFN.
Kaye et al.77 1990 Sc:–1,2 28 F Indian No HDFN Excluded all exceptE and Lu(a)
G2, 1st was uncomplicated withnegative Ab screen.
Au to Tregellas et al.78 1979 Sc:1, –2 49
McDowell et al.79 1986 Case 1 Sc:1,–2 Hemolytic anemia
McDowell et al.79 1986 Case 2 Sc:1,–2(1+, but 3+ 2years later)
Hemolytic anemia 4 units RBC transfused earlier.
Owen et al.80 1992 Sc:1,–2 10 months F West Indies Hemolytic anemia
Ramsey andWilliams81
2010 Sc:1 20 F Caucasian Hemolytic anemia,acute hemolysis
15 units RBC 3 years earlierduring chemotherapy, previously
negative Ab screen.
Auto vs. Allonot resolved
Steane et al.82 1982 Case 2: ptC.D.
22 M Caucasian Not reported.
anti-Sc2 Allo Anderson et al.3 1963 Mr. Char. Sc:1,–2 50 M Caucasian DSTR vs. DHTR 3 units RBC transfused 2 weeksearlier.
Seyfried et al.6 1966 Four donors
DeMarco et al.83 1995 Sc:1,–2 29 F Caucasian HDFN Negative maternalAb screen
G0, no transfusion history.
anti-Sc3 Allo McCreary et al.16 1973 Sc:–1,–2 F Likiep Atoll, MarshallIslands
Transfused 7 months earlierwithout difficulty.
Nason et al.17 1980 Sc:–1,–2 67 M Caucasian DSTR Transfused 4 years earlierwithout incident.
Woodfield et al.19 1986 Sc:–1,–2 4 F Papua New Guinea Many transfusions.
Auto Peloquin et al.84 1989 Case 1 weak Sc1 andSc3
64 Hemolytic anemia
Peloquin et al.84
1989 Case 2 weak Sc1 andSc3 54 Hemolytic anemia 4 units RBCs transfused earlier.
anti-Sc4(anti-Rd)
Allo Rausen et al.20 1967 Family 1 –Rd Sc:–4 (Rd+) F Russian Jewish HDFN “Newborn with hemolyticdisease” in 1st and 3rd children.
Rausen et al.20 1967 Family 2 –Fl Sc:–4 (Rd+) F African American HDFN severe “Newborn with hemolyticdisease” in 7th and 9th children
Rausen et al.20 1967 Family 3 –Ha Sc:–4 (Rd+) F Northern European HDFN “Newborn with hemolyticdisease” in 4th child.
Rausen et al.20 1967 Family 4 –We Sc:–4 (Rd+) F Native American HDFN
Rausen et al.20 1967 Family –5 Gr Sc:–4 (Rd+) F German Jewish orScotch-Irish
HDFN
Lundsgaard andJensen21
1968 Mrs. J.P. Sc:–4 (Rd+) 47 F DSTR: No clinicalevidence ofhemolysis
Had a 9-year-old child.2 units blood transfused during
gynecologic operation.
Lundsgaard and
Jensen21
1968 Mr. L.C. Sc:–4 (Rd+) 55 M Never transfused or hospitalized
Winn et al.85 1976 19 M Caucasian DSTR: No clinicalevidence ofhemolysis
ant i-Vw Negat ive DAT, negat ive Ab screebefore transfusion.
anti-Sc5(anti-STAR)
Allo Devine et al.18 and Skradski
et al.35
1988 Case 3 Sc:1,–2 65 M Irish and English DSTR anti-Canti-e
anti-Jk b
3 units RBC 3 years earlier.
anti-Sc6(anti-SCER)
Allo Devine et al.18 1988 Case 1 Sc:1,–2 76 M German DSTR 3 units RBC 12 years earlier; 3units RBC 6 years earlier.
anti-Sc7(anti-SCAN)
Allo Devine et al.18 1988 Case 2 Sc:1,–2 50 M German, English, andNative American
DHTR anti-D 3 units RBC 8 years earlier;2 units RBC 3 years earlier.
Ab = antibody; ADCC = antibody-dependent cell-mediated cytotoxicity; AHG = antihuman globulin; AIHA = autoimmune hemolytic anemia; CHF = congestiveheart failure; DAT = direct antiglobulin test; DHTR = delayed hemolytic transfusion reaction; DOL = day of life; DSTR = delayed serologic transfusion reaction;
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Scianna blood group system: a Review
Clinical synopsis Other laboratory data
Impossible to distinguish role of anti-Sc1 in presence of anti-D.
Neonate with 3+ DAT, eluted anti-Sc1, but Hgb = 13.5 g/dL and no HDFN. Mother B, R1r;infant B, rr; husband Sc:1,–2.
IgG3 subclass; steady rise in ADCC despite const ant titer throughout pregnancy; 9 weeks postpar tum ADCCincreased ×4 and titer doubled (16 to 32).
Healthy blood donor. Antibody demonstrated in serum, not in plasma, suggesting autoantibody is only seen when it reacts with acoagulation factor; IgG3; very weak DAT (both IgG and C3b), weak anti-Sc1 eluted.
3+ DAT and anti-Sc1 in IAT. Eluates by heat, ether, and glycine acid were nonreactive, but xylene eluate showedanti-Sc1.
Transient Sc antigen weakening: serum from initial presentation reacted 3+ with patient’s RBCs 2 years later.
Sudden-onset jaundice, pallor, fever with hepatomegaly, Hgb = 4.1 g/dL. AIHA diagnosed,treated with steroids and IVIG , transfusion, urgent splenectomy. Transfusion-dependent for4 weeks, then steroids stopped 7 months after splenectomy.
DAT+ (IgG and C3d), elevated unconjugated bilirubin, reduced haptoglobin, hemoglobinuria. DAT negative withfollow-up. Serum and eluate demonstrated anti-Sc1.
Hodgkin disease in remission, presented with 3 weeks of fatigue, 2-day Hgb decrea se (9.1to 5.7 g/dL). Gross hematuria and T bili = 5.5 mg/dL during 3 units RBC transfusion.
Ab screen 1–2+ in all cells (anti-Sc1 identified). DAT– (hospital), w+ ( ref. lab; negative eluate). Posttran sfusionHgb = 9.2 g/dL. A nti-Sc1 reacted w+ to patient’s cells. Genotyped SC1/SC1. Patient group O–.
Evans-like syndrome with anemia during a lung infection, 2 years of hospitalizations,steroids, splenectomy, immune suppressants. Transfused safely af ter 16 plasma exchanges.
Reported DAT+ , but “presence of an antibody in his plasma which reacted with all ery throcytes tested except hisown.” Antibody undetectable after the 9th exchange, but it r eappeared, then disappeared after 4 more exchanges.
Carcinoma of the stomach, pretransfusion antibody screen positive. Hemolysis could be thereason for the 2nd blood request, but this is not stated.
Whether the patient was hemolyzing and thus required the pretransfu sion testing is not stated; therefore, we cannodistinguish a DSTR from a DHTR as described in this paper.
Healthy donors iatrogenically immunized for anti-D production.
Jaundice in infant (Tbili = 14.3 mg/dL) on DOL2, postphototherapy discharged Hct = 45%,DOL20 Tbili = 6.5 mg/dL , Hct 17.3% with pallor, tachypnea, tachycardia; transfused 45 mL;Hct 4 months later = 36.3% Mother B +; infant B-.
Maternal serum 3+ against paternal RBCs ( titer of 64) and Sc: –1,2 RBCs; Paternal RBCs Sc:1,2. Neonate cord bloodDAT macroscopically + IgG; Neonate peripheral venous blood 2+; Readmission on DOL20 DAT 2+ (polyspec, IgG, andC3); Eluate + on paternal and S c:1,–2 RBCs.
Preoperative testing. Antibody dropped to below detectable levels shortly after discovery.
Preoperative positive antibody screen for metastatic carcinoma surgery. Not transfusedowing to deteriorating clinical condition and lack of compatible blood.
Negative DAT, did not adsorb anti-Sc1 or anti-Sc2.
Thalassemic with new IgG Ab, mother used as only available donor (also S c:–1,–2). Patientunderwent splenectomy.
Antibody was undetectable after splenectomy and not stimulated by use of XM-compatible blood.
Lymphoma patient with severe anemia; 5 units incompatible RBCs transfused withoutdifficulty.
DAT weak with IgG and C3d, eluates negative. Antibody disappeared within 70 days.
Hodgkin disease, CHF, moderate anemia; 6 units incompatible blood tr ansfused withoutdifficulty. DAT 3+ with C3d, negative with IgG , eluate negative. Serum antibody weaker after transfusion ; additional follow-upnot possible.
2 chi ldren Rd+ , both had HDFN; 1 chi ld Rd– , d id not have HDFN. Presumably very m ild HDFN, as case detected by “ rout ine ant i-globul in t es ting o f cord b lood .”
10 children in pedigree: 5 Rd– with no HDFN; 1st 3 Rd+ without HDFN, last 2 Rd+ withHDFN (1st of these requiring exchange transfusion).
4 children in family: 1 Rd– with no HDFN; 1st 2 Rd+ without HDFN, last 1 Rd+ with HDFN. In the same pedigree, Rd– grandmother of HDN proband had 2 children, 1st Rd+ and 2nd Rd–, neither had HDFN.
4 children in family: 1 Rd– with no HDFN; 1st 2 Rd+ without HDFN, last 1 Rd+ with HDFN.
5 children in family: 3 Rd– with no HDFN; 1 stillborn (3rd in birth order) followed by 1 Rd+with HDFN.
No description of pathology of the stillborn fetus.
Moderately strong DAT (polyspecific and IgG-eluate showed an ti-Rd), weakened with time.Negative Ab screen preoperatively.
Patient is O+; 2 weeks after transfusion, strongly r eactive antibody screen at new hospital. Her child’s RBCs do notreact with patient’s posttransfusion plasma.
Preoperative positive antibody screen for atoxic goiter surgery. Considered as a “naturally
occurring antibody.”11 units RBC on 3 dates for gunshot wound surgery (7/5 , 7/17, and 8/5). 1 unit foundincompatible on crossmatch (RT, 37°C, and AHG) but screening RBCs s till negative.
anti-Vw accounts for incompatible RT crossmatch.
1 week after transfusion of 3 units RBC, A b screen showed new anti-Jk b and a high-frequency antigen. DAT–, patient eventually diagnosed with lymphoma and transfused withautologous units.
Serum reacted with all cells except Sc: –1,–2, autologous, and the patient’s sibling (phenotype Sc:1,–2). Identit y ofantigen discovered with molecular testing years afterward.
Preoperative positive Ab screen for revision of right to tal hip arthroplasty, proceduredelayed until autologous units could be collected.
Identity of antigen discovered with molecular testing years after ward.
12 days after transfusion of 2 units RBC after or thopedic surgery, patient had decrease inhematocrit, pretransfusion Ab screen positive, weakly DAT+ (IgG and C3).
Eluate reacted with all cells except Sc: –1,–2. Antibody no longer detected within 9 months. Identity of antigendiscovered with molecular testing years afterward.
Hct = hematocrit; HDFN = hemolytic disease of the fetus and newborn; Hgb = hemoglobin; IAT = indirect antiglobulin test; IgG = immunoglobulin G; IVIG =intravenous immunoglobulin; RBCs = red blood cells; RT = room temperature; Tbili = total bilirubin; XM = crossmatch.
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P.A.R. Brunker and W.A. Flegel
to SC system antigens are of clinical importance remains
unresolved because these antibodies are not routinely
characterized, especially if they are detected along with
other, better-understood alloantibodies that can account
for a clinical presentation.
On the Detection of SC System Antibodies in Routine
Pretransfusion Testing
The most important obstacle to understanding the
clinical consequences of transfusing across SC antigens is
that serologic reagents to simply dene these antigens in
both patients and test RBCs have not been widely available.
As they do for the Dombrock blood group system,88
molecular approaches help resolve these situations. It
has been estimated that approximately 13 percent of the
transfused population are immunologic responders capable
of creating alloantibodies,89 but unless RBC reagents with
SC antigens are included in the routine laboratory workup,these antibodies may go unnoticed. It is also problematic
if an antibody to one of the high-prevalence SC antigens is
in fact detected because the mere presence of the antibody
does not necessarily correspond to clinical importance.
Such a qualitative assay is insufcient. The quantitative
characterization of the antibody, such as by titer, has
only been performed in a few SC antibody cases, and we
recommend that this parameter be more routinely evaluated
in cases of possible hemolysis caused by antibodies in the SC
system and in most other blood group systems. Especially
because HDFN has been reported, establishing a better
understanding of antibody potency as detected by the titer would help inform practice guidelines.
An economic and rational approach would be
the routine use of recombinant SC protein during
pretransfusion testing before titration to effectively screen
only for antibodies present above a threshold titer.87 In
this way, nuisance antibodies (akin to the low-titer cold
autoantibodies detected before routine testing at higher
temperatures) would fall under the radar as desired and
precious laboratory resources would not be spent working
up these most likely incidental ndings. Only higher titer
antibodies would be detected, focusing the laboratory
investigation on cases more likely to be of consequence to
the patient. If these laboratory techniques do lead to the
increased identication of SC system alloantibodies, the
medical importance of respecting them in a particular
patient’s transfusion recommendation remains debatable.
Should We Genotype for SC Alleles?
The integration of molecular diagnostics with trans-
fusion medicine has been a slow, but steady, process, with
applications ranging from individual patient prenatal
diagnosis to routine high-throughput donor testing.90,9
Although the rate of implementation of these technologies
varies among nations92 and local transfusion services,93 it is
expanding.94 The transfusion community should move these
procedures from potentially inaccessible research laboratories
to standard clinical practice.95 For optimal performance of
such an approach toward personalized medicine, ideally al
donors and all recipients should be evaluated at a molecular
level. Economic barriers to this strategy are falling as high-
throughput and multiplexed assays are achieved, because
the incremental cost of adding a handful of additional SNPs
when designing a DNA microarray is negligible. Consequently
molecular testing strategies are shifting from decisions abou
which variants to include in a genotyping system that force the
prioritization of well-studied variants already known to have
medical importance, to nding effective platforms to analyze
data derived from genotyping as many known variants as
possible, regardless of their allele frequencies or uncertainclinical effects.
The most compelling reason to genotype SC variants in
greater depth, both by increasing the number of donors and
patients and also by including more variants regardless of
their prevalence, is that such data are necessary to clarify
the presently ambiguous role of SC in clinical transfusion
practice. At the same time, valuable data for research into
ERMAP biology are accrued without added costs. Inclusion
of the SC*01 to SC*07 alleles in high-throughput assays
would be a move in the right direction, and in cases o
unresolved serology, a referral to the molecular laboratory
for an in-depth investigation may be desirable. By usinga high-throughput genetic test to determine the potential
for alloimmunization by a variant homozygote, we can
collect such genetic data almost for free. The pursuit of
alloantibodies in such variant homozygous patients is
a feasible strategy to achieve complete resolution of al
alloantibodies in a posttransfusion sample submitted as a
transfusion reaction investigation. Consequently, knowing
these genetic data gives us the opportunity to better dene
which antibodies are of clinical importance.
Conclusion
The SC story is an excellent example of the essential
roles that classical genetics played in the original physical
mapping of a blood group system and is an exceptional
illustration of transfusion laboratories that were in the right
place at the right time to nally identify the responsible
locus in the era of whole genome analysis. Parsing out the
meaning of global polymorphism frequency distributions
in light of founder effects or selection pressures would be
a useful adjunct to in vitro studies of transcript utilization
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Scianna blood group system: a review
and protein expression and function. The continued
study of ERMAP homologues, such as the BTNL family of
proteins in general, and their physiologic interactions in
other species, such as the B30.2-containing bloodthirsty
gene in Antarctic iceshes, is a promising avenue to explore
fundamental insights into erythropoiesis. Investigatorsin transfusion medicine are uniquely poised not only to
carry out this work but also to lead the way toward a more
comprehensive understanding of the “lucky 13th” blood
group, SC, making us the lucky ones indeed.
Acknowledgment
We gratefully acknowledge Professor Guillaume
Lecointre for kindly providing the photograph of blood
from the Antarctic icesh (Fig. 5).
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Patricia A.R. Brunker, MD, DPhil, and Willy A. Flegel
MD (corresponding author), Laboratory Services Section
Department of Transfusion Medicine, Clinical Center, Nationa
Institutes of Health, Bethesda, MD 20892.
Scianna blood group system: a review
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Antibodies to antigens in the Kell blood group system are usuallyimmunoglobulin G, and, notoriously, anti-K, anti-k, and anti-Kpa can cause severe hemolytic transfusion reactions, as well as severehemolytic disease of the fetus and newborn (HDFN). It has beenshown that the titer of anti-K does not correlate with the severityof HDFN because, in addition to immune destruction of red
blood cells (RBCs), anti-K causes suppression of erythropoiesisin the fetus, which can result in severe anemia. We report a caseinvolving anti-Kpa in which one twin was anemic and the other was not. Standard hemagglutination and polymerase chainreaction (PCR)-based tests were used. At delivery, anti-Kpa was
identied in serum from the mother and twin A, and in the eluateprepared from the baby’s RBCs. PCR-based assays showed twin A (boy) was KEL*841T/C (KEL*03/KEL*04), which is predictedto encode Kp(a+b+). Twin B (girl) was KEL*841C/C (KEL*04/ KEL*04), which is predicted to encode Kp(a–b+). We describethe rst reported case of probable suppression of erythropoiesisattributable to anti-Kpa. One twin born to a woman whose serumcontained anti-Kpa experienced HDFN while the other did not.Based on DNA analysis, the predicted blood type of the affectedtwin was Kp(a+b+) and that of the unaffected twin was Kp(a–b+).The laboratory ndings and clinical course of the affected twin were consistent with suppression of erythropoiesis in addition
to immune RBC destruction. Immunohematology 2011;27:58–60.
Key words: erythropoiesis—suppression, Kell blood
group system, hemolytic disease of the newborn, Kpa
The rst antigen in the Kell blood group system, K, was
discovered in 1946 as the result of hemolytic disease of the
newborn. The system now includes 31 antigens. Antibodies
to K, k, Kpa, Kp b, Kpc, Jsa, and Js b are the most clinically
important.1 Next to anti-A, anti-B, and anti-D, anti-K is
the most common immune RBC antibody.2 Antibodies to
antigens in the Kell blood group system are usually IgG,
and, notoriously, anti-K, anti-k, and anti-Kpa cause severe
hemolytic transfusion reactions, as well as severe hemolytic
disease of the fetus and newborn (HDFN).3,4
It is well known that the titer of anti-K does not correlate
with the severity of HDFN; indeed, severe HDFN caused
by anti-K has been associated with lower antibody titers,
bilirubin levels, and reticulocytosis than has hemolytic
disease of the newborn caused by anti-D.2,3 The anemia
seen in these infants is caused by a combination of immune
destruction and suppression of erythropoiesis in the
fetus.5,6 Vaughan et al. demonstrated experimentally that
proliferation of K+ erythroid progenitors was inhibited by
anti-K, and suggested that the K glycoprotein plays a role in
erythropoiesis.5
Cases of HDFN involving antibodies to other antigens
in the Kell system of antibodies are rare. We retrospectively
report a case of HDFN in twins of a mother whose serum
contained anti-Kpa. The Kp(a+) twin was anemic, and the
Kp(a–) twin was not.
Case History
A 31-year-old gravida 3, para 2 woman with a history
of a negative antibody screen delivered ABO-identical, Rh-
compatible fraternal twins at full term (37 weeks’ gestation)
The mother had two previous pregnancies delivered by
cesarean section; no problems were noted in the medica
record. At delivery, the cord hemoglobin (Hb) for twin A
(male) was 10.2 g/dL and for twin B (female) was 17.0 g/dL
Unfortunately, there were no cord bilirubin or reticulocyte
counts done for either twin.
Because of anemia, shortly after birth twin A received
a single-aliquot RBC transfusion that was compatible withthe maternal serum. On day 1, he received an additional
single-aliquot transfusion with RBCs and was discharged
on day 5 with a Hb of 15.1 g/dL and an absolute reticulocyte
count of 0.16 × 109/L (normal range of 0.125–0.325 ×
109/L). Transfusion was again required on day 25 when the
Hb reached a nadir of 7.5 g/dL with a decreased absolute
reticulocyte count of 0.007 m/μL. Additional transfusions
were given on days 30 and 39 to maintain a Hb level above
9.0 g/dL. After transfusion of two aliquots on day 39, the
Hb of twin A was 9.6 g/dL and on day 43 and 52 it was 9.3
g/dL and 9.5 g/dL, respectively. Two weeks later the Hb was
10.3 g/dL, and 6 months later it was 12.6 g/dL. The infant’s
bilirubin peaked at 5 mg/dL on day 1 and fell steadily during
the monitoring period. White blood cell and platelet counts
remained normal.
Materials and Methods
Hemagglutination
Standard hemagglutination tests were used throughout
The cord blood samples were tested by tube method for
Possible suppression of fetal erythropoiesis bythe Kell blood group antibody anti-Kpa
M. Tuson, K. Hue-Roye, K. Koval, S. Imlay, R. Desai, G. Garg, E. Kazem, D. Stockman, J . Hamilton, and M.E. Reid
CASE REPORT
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Suppression of fetal erythropoiesis by anti-Kpa
ABO, Rh, and direct antiglobulin test (DAT). The maternal
and paternal samples were tested by MTS gel cards (Ortho
Clinical Diagnostics, Raritan, NJ).
Polymerase Chain Reaction–Restriction Fragment
Length Polymorphism Analysis for KEL*03/KEL*04
Genomic DNA was isolated from epithelial cells
captured by the buccal swabs obtained from the twins
using a DNA kit (QIAamp DNA Blood Mini Kit, QIAGEN,
Inc., Valencia, CA). Exon 8 of KEL was amplied using
a forward oligonucleotide primer (Life Technologies,
Inc., Gaithersburg, MD) designed within exon 8
(TACCTGACTTACCTGAATCAGCTGGGAACC) and a
reverse oligonucleotide primer designed at the 3′ end of
exon 8 and into intron 8 (tcttctggcccccagttccaggcacCATGA).
Five microliters of DNA per reaction was amplied by 5
units of Taq DNA polymerase (HotStarTaq, QIAGEN Inc.,
Valencia, CA) in a 50-μL reaction mixture containing2.5 mM MgCl2, 1 × PCR buffer, 0.2 mM dNTPs, and 100
ng of forward and reverse primer. The PCR amplication
was achieved in 35 cycles with a nal extension time of 10
minutes, using 62°C as the annealing temperature. The
PCR 202-bp products were digested using the restriction
enzyme NlaIII. A restriction enzyme site for this restriction
enzyme is present in the KEL*03 variant (841T) but not in
the wild-type (841C).
Results
Hemagglutination At the time of delivery, anti-Kpa was identied in the
maternal serum. No other unexpected antibodies were
present in the maternal serum. Tests using the serum
from twin A and an eluate prepared from his RBCs also
contained anti-Kpa (Table 1). Antibody testing on days 25,
30, and 39 demonstrated the persistence of anti-Kpa in the
baby’s serum.
Polymerase Chain Reaction–Restriction Fragment
Length Polymorphism Analysis for KEL*03/KEL*04
Twin A (boy) was KEL*841T/C (KEL*03/KEL*04),
which is predicted to encode Kp(a+b+). Twin B (girl) was
KEL*841C/C (KEL*04/KEL*04), which is predicted to
encode Kp(a–b+).
Conclusions
We describe the rst reported case of possible
suppression of erythropoiesis attributable to anti-Kpa. One
twin born to a woman whose serum contained anti-Kpa
experienced HDFN and anemia, while the other did not.
Based on DNA analysis, the predicted blood type of the
affected twin was Kp(a+b+) and that of the unaffected twin
was Kp(a–b+). The laboratory ndings and clinical course
of the affected twin were consistent with suppression of
erythropoiesis in addition to immune RBC destruction. Thesteadily declining bilirubin levels concurrent with a declining
hemoglobin level and decreased absolute reticulocyte
count provide supportive evidence for this interpretation
It is possible that the change in the reticulocyte count was
induced, or exacerbated, by transfusion. Although this was
a retrospective study and not all data were available to us, it
is worth documenting, especially because one twin was an
antigen-negative twin and served as a control.
Antigens in the Kell blood group system appear on
erythroid progenitor cells early in erythropoiesis.7,8 Because
erythroid progenitor cells do not contain hemoglobin
immune destruction of these cells by anti-Kpa couldexplain the absence of hyperbilirubinemia in our patient
The restriction of Kell messenger RNA and protein to
erythroid precursors explains why white blood cell and
platelet counts remained normal in the affected twin.9,10
The anemia of the affected twin resolved after 3 months
and his Hb has remained within the normal range. Twin B
had no postdelivery complications and provides a biologic
control for factors other than maternal alloantibody as a
cause of the anemia. Although anti-K is most commonly
associated with erythropoietic suppression, twin A shows
that antibodies to other antigens in the Kell blood group
system can also have this capability.
Acknowledgments
We thank Yaddanapudi Ravindranath, MD, for follow
up information after the twins were discharged from
the hospital and Robert Ratner for help in preparing the
manuscript.
Table 1. Results of hemagglutination tests
Mother Twin A Twin B Father
ABO/Rh A + A + A + A +
DAT Not tested 4+ 0 Not tested
IAT withmaternal serum
Not tested Not tes ted Compatible Incompatib le
Other studies Anti-Kpa Anti-Kpa inserum and
eluate
Kp(a+)
DNA frombuccal smear
Not tested KEL*03/ KEL*04
KEL*04/ KEL*04
Not tested
DAT = direct antiglobulin test; IAT = indirect antiglobulin test.
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M. Tuson et al.
References
1. Reid ME, Lomas-Francis C. Blood Group Antigens and Antibodies: A guide to clinical relevance and technical tips.New York, NY: Star Bright Books, 2007.
2. Klein HG, Anstee DJ. Mollison’s blood transfusion in clinicalmedicine. 11th ed. Oxford: Wiley-Blackwell, 2006.
3. Roback JD, Combs MR, Grossman BJ, et al. Technicalmanual. 16th ed. Bethesda, MD: American Association ofBlood Banks, 2008.
4. Costamagna L, Barbarini M, Viarengo GL, Pagani A, IserniaD, Salvaneschi L. A case of hemolytic disease of the newborndue to anti-Kpa. Immunohematology 1997;13:61–2.
5. Vaughan JI, Manning M, Warwick RM, Letsky EA, MurrayNA, Roberts IA. Inhibition of erythroid progenitor cells byanti-Kell antibodies in fetal alloimmune anemia. N Engl JMed 1998;338:798–803.
6. Daniels G, Hadley A, Green CA. Causes of fetal anemia inhemolytic disease due to anti-K. Transfusion 2003;43:115–16.
7. Southcott MJG, Tanner MJ, Anstee DJ. The expression ofhuman blood group antigens during erythropoiesis in a cellculture system. Blood 1999;93:4425–35.
8. Daniels G, Green C. Expression of red cell surface antigens
during erythropoiesis. Vox Sang 2000;78(Suppl 2):149–53.
9. Jaber A, Loirat MJ, Willem C, Bloy C, Cartron JP, BlanchardD. Characterization of murine monoclonal antibodiesdirected against the Kell blood group glycoprotein. Br JHaematol 1991;79:311–15.
10. McGinniss MH, Dean A. Expression of red cell antigens byK562 human leukemia cells before and after induction ohemoglobin synthesis by hemin. Transfusion 1985;25:105–9.
Michelle Tuson, MT(ASCP)SBB, Trinity Health, Farmington Hills
MI; Kim Hue-Roye, BSc, Laboratory of Immunochemistry, New
York Blood Center, New York, NY; Karen Koval, MT, Sherwin
Imlay, MD, Rajendra Desai, MD, Gayatri Garg, MD, and Esam
Kazem, MD, St. Joseph Mercy Hospital—Oakland, Pontiac, MI
Diane Stockman, MT(ASCP), and Janis S. Hamilton, MT(ASCP)
SBB, American Red Cross, Southeastern Michigan Region
Detroit, MI; and Marion E. Reid, PhD (corresponding author)
Laboratory of Immunochemistry, New York Blood Center, 310 East 67th Street, New York, NY 10065.
Attention:
State Blood Bank Meeting Organizers
If you are planning a state meeting and would like copies
of Immunohematology for distribution, please send request,
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Notice to Readers
All articles published, including communications and bookreviews, reect the opinions of the authors and do not
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For information concerning the National Reference
Laboratory for Blood Group Serology, including the American
Rare Donor Program, contact Sandra Nance, by phone at
(215) 451-4362, by fax at (215) 451-2538, or by e-mail at
Attention: SBB and BB Students
You are eligible for a free 1-year subscription to
Immunohematology.
Ask your education supervisor to submit the name and
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The use of massive transfusion protocols (MTPs) in
trauma patients presenting with near-exsanguinating
injuries has increased in the past several years. This is
largely a result of the increasing evidence suggesting that
transfusion of blood components in ratios more closely
approximating the composition of whole blood may reduce
mortality.1–4
Inherent in the design of these protocolsis the necessity for the timely transfusion of plasma.
Unfortunately, the need for plasma often precedes the
determination of blood group.
Group AB plasma is commonly used in MTP when
the patient’s blood type has not yet been determined. The
foundation for this practice is rooted in the theory that
group AB plasma is “universal” because of the absence of
anti-A and anti-B hemagglutinins. Likewise, it is analogous
to the belief that group O red blood cells (RBCs) are
universal and may be transfused to all patients, regardless
of blood type. This universal blood component practice
continues to this day, based on concerns that infusion ofincompatible plasma may produce hemolysis, a potentially
fatal complication. Unfortunately, in the United States the
availability of group AB plasma is limited because only 4
percent of all blood donors in North America are group
AB.5 Therefore, plasma from group AB donors may not be
available in sufcient quantities to satisfy the requirements
for an MTP in all trauma settings.
Historically, this risk of hemolysis has outweighed
concerns about the potential risks associated with
compatible but nonidentical plasma. Although experience
in populations receiving apheresis platelets has proved that
the concern about intravascular hemolysis is warranted,6–18
the belief that group AB plasma is universal plasma has
been repeatedly challenged in several patient populations,
including those undergoing cardiac surgery,19 receiving
treatment for hematologic malignancies,20 or receiving
stem cell transplants.21 For patients in whom a hemolytic
reaction may occur, there are three important observations
to consider. First, minor incompatibilities appear to be
rare events, with one study suggesting an incidence of 1 in
9000.22 Second, in these anecdotal case reports in which
hemolytic reactions occurred, the suspected components
contained plasma from group O donors.8,23,24 After carefu
review of these case reports, no patient belonging to group
B or group AB was found to have experienced a hemolytic
event after transfusion with group A plasma. Third, and
most interestingly, it appears that correlations between
these hemolytic episodes and agglutinin titers exist.17,25–27
If the level of anti-A and anti-B agglutinin titers could
be quantied in compatible but nonidentical plasma units
perhaps a novel approach to a plasma substitution could
be made for MTPs. For example, if group AB plasma is
not available or is in short supply from local blood bank
sources, it may be feasible and preferable to use group A
plasma. Because approximately 15 percent of the North
American population are group B or group AB, the use o
group A plasma is already acceptable for approximately 85
percent of the general population. Published experience
from different institutions indicates that transfusion of 300
to 500 mL of incompatible plasma in 1 day and transfusionof 1 L of incompatible plasma in 1 week have been practiced
without signicant clinical sequelae in adult patients. In
addition, many institutions use a critical titer of 64 or higher
as the cutoff when saline solution is used for labeling a unit
as “high-titer.”24 Therefore, it would be logical to conclude
that it may be safe to transfuse 1 L of group A plasma to a
group B or group AB patient as long as the anti-B agglutinin
titer is less than 16.
The goal of this study is to identify acceptable group A
plasma units that could theoretically be safely transfused as
universal plasma to any patient during MTP. To determine
concept feasibility, we propose classifying group A plasma
donors into those with low titers (LT) of anti-B agglutinins
(≤ 64 but > 16) and those with very low titers (VLT) of anti-B
agglutinins (≤ 16). In the trauma setting, while a blood
group determination is being performed, it may be possible
to transfuse more than 1 unit of group A plasma during the
initial MTP shipments if group AB plasma is unavailable
Group A plasma meeting these specications could be
used to supplement the group AB plasma inventory in the
treatment of trauma patients requiring MTP. The solution
Challenging dogma: group A donors as“universal plasma” donors in massive
transfusion protocolsE.J. Isaak, K.M. Tchorz, N. Lang, L. Kalal, C. Slapak, G. Khalife, D. Smith, and M.C. McCarthy
REPORT
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E.J. Isaak et al.
proposed in this pilot study assumes established criteria
supported by the currently documented literature.
Materials and Methods
Fresh plasma (less than 48 hours old) was obtained
from the pilot tubes of 100 consecutive group A blood
donors during December 2008. All donors consented to
research-related activities as part of the general consent
procedure at the Community Blood Center/Community
Tissue Services (CBC/CTS), Dayton, Ohio, and all were
eligible donors based on an approved donor health
questionnaire. These documents were reviewed by the
Food and Drug Administration and are on le at the Center
for Biologics Evaluation and Research as required by the
Code of Federal Regulations. Demographic data including
sex, age, and history of previous pregnancy were recorded
from the information on the questionnaire.The plasma from each of these donors was diluted with
0.85 percent saline solution (Blood Bank Saline, Fisher
Scientic USA, Pittsburgh, PA) to prepare dilutions of 1:16
(1 part plasma and 15 parts saline) and 1:64 (1 part plasma
and 63 parts saline) in sufcient quantities for testing. A
freshly collected random group B donor unit was selected
as the testing RBCs. The group B RBCs were washed and
prepared as a 4% concentration in saline. One drop of the
4% group B RBCs was added to 0.2 mL of each of the 1:16
dilutions of the group A plasmas and mixed well at room
temperature (27°C). The mixtures were centrifuged and
read macroscopically for agglutination; reactions wererecorded as either negative (no agglutination observed)
or positive (any macroscopic agglutination observed,
regardless of strength). All tubes were then transferred
to a 37°C dry heat incubator and were allowed to incubate
for 30 minutes. The tubes were again centrifuged and read
macroscopically for agglutination with the same criteria
used for recording as negative or positive.
Similarly, one drop of the 4% group B RBCs was
added to 0.2 mL of each of the 1:64 dilutions of the group
A plasmas and mixed well at room temperature. These
mixtures were also centrifuged and read macroscopically
for agglutination, and recorded as either negative or
positive using the criteria previously established. All tubes
were then transferred to a 37°C dry heat incubator and
were allowed to incubate for 30 minutes. The tubes were
centrifuged and read macroscopically for agglutination,
and recorded as either negative or positive using the criteria
previously established.
All dilutions and testing were performed by one of
two experienced CBC/CTS immunohematology reference
laboratory technologists. The resulting patterns of
reactivity were analyzed for correlation with age, sex, and
history of pregnancy. Statistical analysis with the Pearson
chi-square test was then used to determine any correlation
between the patterns and age. Signicance was determined
at α = 0.05.
Results
Among the 100 plasma samples, seven different
patterns of reactivity were noted. Sixty three percent of
donor samples were negative at a titer of 64 both at room
temperature and at 37°C. These donor samples can be
classied as LT. Fifteen percent of donor samples were
negative at titers of 64 and 16 both at room temperature
and at 37°C and can be classied as VLT (Table 1).
Although low titers and very low titers occur in both
sexes and across all age ranges, some general patterns do
emerge. The three most commonly observed patterns of
reactivity are (1) positivity at titers of 16 and 64 at room
temperature and 37°C (pattern A), (2) positivity at a titer o
16 at room temperature and 37°C but negativity at a titer of
64 at both temperatures (pattern B), and (3) negativity at
both titers at both temperatures (pattern C).
The ratio of men to women within pattern A is 4:19;
the ratio is more evenly balanced within patterns B and C
The relationship of these three patterns of reactivity with
regard to age is noted in Table 2. There is a statistically
signicant difference (p < 0.029) in the prevalence of
patterns A and C in donors younger than 50 years of age
compared with donors who are older than 50 years. Pattern
A is more common in younger donors, whereas pattern C is
more common in older donors.
Table 1. Donor sample demographic data and agglutinin titer
NMean age,y (range)
Male:f emal e Pregnancies R T(VLT ) RT( LT ) 37 °C (V LT ) 37 °C (LT )
23 39(17–75)
4:19 13/19 + + + +
11 47(19–71)
7:4 4/4 + – + +
39 51(20–72)
19:20 15/20 + – + –
5 48(43–51)
2:3 3/3 – – + –
3 53(50–56)
0:3 3/3 + + + –
4 53(46–59)
4:0 0/0 + – – –
15 54(38–77)
8:7 7/7 – – – –
LT = low titer ≤ 64; RT = room temperature 27°C; VLT = very low titer ≤ 16.
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Group A as universal plasma donors in massive transfusion protocols
Discussion
The results of this laboratory study demonstrate that
evaluation of anti-B agglutinin titers in group A plasma as
VLT may serve to identify acceptable group A plasma unitsthat may be substituted in MTP when blood type has not yet
been determined.
As the demand for plasma resuscitation increases,
transfusion services are developing algorithms for
maintaining an inventory of thawed plasma. Because of the
relative scarcity of group AB plasma, in general, it is simply
not practical to maintain thawed group AB plasma. This
translates into a delay in plasma distribution because the
process of obtaining a blood bank specimen, determining
a blood type, and issuing the plasma can be challenging.
In addition, group AB plasma may involve additional risks
because of the formation of circulating immune complexes,28 especially when transfused to group O patients. In fact, in
one large study mortality was increased whenever type-
compatible but not type-specic plasma was transfused.
However, statistical signicance was reached only when
group AB plasma was given to group O patients, and in
this case when more than ve units of group AB plasma
were transfused to a group O patient, the relative risk of
increased mortality was 1.26 (p = 0.004).29 Thus, even if
group AB plasma were available in sufcient amounts, it
might not be ideal. A possible solution to this dilemma is
to identify a type of plasma that is present in abundance
and can be safely transfused to any trauma patient, at least
up to a certain volume, thus allowing sufcient time for a
blood group determination to be made. Group A plasma
is relatively abundant, and because nearly 85 percent of
trauma patients are group A or group O, they can safely
receive group A plasma. For the 15 percent of patients for
whom the transfusion of group A plasma creates a minor
incompatibility, published experience has demonstrated
that reactions caused by minor incompatibilities are
extremely rare.
Multiple reviews in the published literature have
provided details about the anecdotal cases in which a
minor incompatibility has resulted in a serious adverse
outcome. The overwhelming majority of these cases involve
group O plasma transfused to a group A patient, although
there are sporadic instances in which group O plasma was
transfused to a group B patient.8,23,24 The reports warn
that the issue may be underreported and that physicians
should be vigilant when transfusing incompatible plasma
Nonetheless, the preponderance of the published clinica
experience seems to indicate that the transfusion of
incompatible group A plasma appears to be safe.
Despite the lack of a reported problem with the
transfusion of group A plasma to either a group B or a
group AB patient, additional factors support using group A
plasma. There appears to be a correlation between adverse
clinical consequences and high ABO agglutinin titers, which
provides an avenue for interventions to deal with the issue othe rare but potentially signicant minor incompatibilities
Some transfusion services are identifying agglutinin titers
before issuing platelet components containing incompatible
plasma.23,26 Evaluation of anti-B agglutinin titers in group
A plasma may serve to identify acceptable group A plasma
units that could theoretically be safely transfused to any
patient. In determining these titers, the laboratory method
is important, and various laboratories have used tube
agglutination, gel technology, or microtiter plates in these
determinations.30 In our pilot study, agglutination titers
were determined using tube agglutination, and the titers
we used as thresholds were based on relatively conservative values from reports in the platelet literature in which
tube agglutination was used. A recent review containing
an extensive summary of hemolytic reactions associated
with minor incompatibility in patients transfused with
platelets indicated that the range of titers fell between 128
as a minimum in saline up to 32,000 using antiglobulin
reagent.24 The rationale for the use of titers in our study was
to base our proposed solution on conservative assumptions
with the use of available platelet transfusion data. It may
turn out that these assumptions are overly conservative
Another element that is important in the laboratory
method is the choice of RBCs used to perform the titer.
We used RBCs from a random group B whole blood donor
Because of variation in antigen sites in group A RBCs, titers
are best performed using blended pools of group A RBCs
it is not clear that the same issue exists in group B RBCs
although further investigation of this open question may be
warranted.
In the preceding paragraph, the conservative
assumptions are as follows: (1) group A plasma will be
statistically compatible with 85 percent of patients, (2)
Table 2. Donor sample age group with agglutinin titer patternassociation
Pattern
Age Group A B C Total
< 50 years Count 17 18 5 40
% within age group 42.5% 45.0% 12.5% 100.0%
≥ 50 years Count 6 21 10 37
% within age group 16.2% 56.8% 27.0% 100.0%
Total Count 23 39 15 77
% within age group 29.9% 50.6% 19.5% 100.0%
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E.J. Isaak et al.
minor incompatibilities are extremely rare, (3) there has
been no reported case of a minor reaction with group A
plasma in either a group B or group AB patient, (4) serious
adverse reactions can be associated with certain threshold
agglutinin levels, and (5) conservative values from evidence-
based publications were used to set an acceptable agglutinin
titer threshold level. Based on these assumptions, our study
showed that 63 percent of our donors could safely donate
one unit of incompatible plasma and that 15 percent could
safely donate up to 1 L of incompatible plasma to any patient.
Furthermore, we found that the VLT donors are more
common in donors older than 50 years of age. Therefore,
a possible recruitment strategy in our donor population
would involve screening donors older than 50 years of age
to establish a dedicated group of VLT donors for MTP.
With regard to the limitations of this pilot study, there
are several. First, the donor sample size is only 100. This
number was selected because the purpose of the study was merely to test for feasibility of the proposed approach.
Second, the donor population is a midwest population,
and therefore these results may not extrapolate to other
donor populations. The determinants of agglutinin
levels appear to be largely determined by geography and
environmental factors,31,32 and one study of populations in
Asia found higher agglutinin levels in donors older than
50 years of age.33 Although it is well known that immune
function deteriorates with increasing age, this population
had increased agglutinin titers. Our results of a midwest
North American population demonstrated the opposite.
Surprisingly, our population showed titer levels that appearto be independent of history of pregnancy. The signicance
of these ndings remains to be determined.
Because populations of blood donors will have different
patterns of agglutinin titers based on ethnicity and age,
select blood centers could develop specic recruitment
strategies to provide these VLT universal plasma products
to meet local and regional needs. Finally, and most
importantly, this new concept of VLT group A plasma as
universal plasma in MTP has not been studied in trauma
patients requiring MTP and will require thoughtful study
design to test the hypothesis.
Conclusions
The results of this study suggest a fresh perspective
on resuscitation in trauma patients. When a massively
injured trauma patient arrives at the trauma center, it is
theoretically possible to initiate MTP with thawed VLT
group A plasma instead of thawed group AB plasma.
Because MTP suggests a ratio of one RBC unit to one
plasma unit during acute hemorrhage, the time required to
transfuse the initial MTP shipment of four RBC units and
four plasma units (essentially equivalent to 1 L of plasma)
would provide transfusion services with ample time to
determine blood type and then issue the appropriate type-
specic blood components. When handled in this fashion
group AB plasma may remain frozen and only be thawed
for use in those patients with group AB blood.
References
1. Borgman MA, Spinella PC, Perkins JG, et al. The ratio o blood products transfused affects mortality in patientsreceiving massive transfusions at a combat support hospitalJ Trauma 2007;63:805–13.
2. Bormanis J. Development of a massive transfusion protocolTransfus Apher Sci 2008;38:57–63.
3. Gonzalez EA, Moore FA, Holcomb JB, et al. Fresh frozenplasma should be given earlier to patients requiring massivetransfusion. J Trauma 2007;62:112–19.
4. Huber-Wagner S, Qvick M, Mussack T, et al. Massive bloodtransfusion and outcome in 1062 polytrauma patients: aprospective study based on the Trauma Registry of theGerman Trauma Society. Vox Sang 2007;92:69–78.
5. Roback JD, Combs MR, Grossman BJ, et al (eds). Technicamanual. 16th ed. Arlington, VA: American Association oBlood Banks, 2008.
6. McLeod BC, Sassetti RJ, Weens JH, Vaithianathan THaemolytic transfusion reaction due to ABO incompatibleplasma in a platelet concentrate. Scand J Haematol 1982;28:193–6.
7. Larsson LG, Welsh VJ, Ladd DJ. Acute intravascularhemolysis secondary to out-of-group platelet transfusionTransfusion 2000;40:902–6.
8. McManigal S, Sims KL. Intravascular hemolysis secondaryto ABO incompatible platelet products. An underrecognizedtransfusion reaction. Am J Clin Pathol 1999;111:202–6.
9. Murphy MF, Hook S, Waters AH, et al. Acute haemolysisafter ABO-incompatible platelet transfusions. Lancet 1990335:974–5.
10. Pierce RN, Reich LM, Mayer K. Hemolysis following plateletransfusions from ABO-incompatible donors. Transfusion1985;25:60–2.
11. Sadani DT, Urbaniak SJ, Bruce M, Tighe JE. Repeat ABO-incompatible platelet transfusions leading to haemolytictransfusion reaction. Transfus Med 2006;16:375–9.
12. Sapatnekar S, Sharma G, Downes KA, Wiersma S, McGrath
C, Yomtovían R. Acute hemolytic transfusion reactionin a pediatric patient following transfusion of apheresisplatelets. J Clin Apher 2005;20:225–9.
13. Oztürk A, Türken O, Sayan O, Atasoyu EM. Acuteintravascular hemolysis due to ABO-incompatible platelettransfusion. Acta Haematol 2003;110:211–12.
14. Barjas-Castro ML, Locatelli MF, Carvalho MA, Gilli SOCastro V. Severe immune haemolysis in a group A recipientof a group O red blood cell unit. Transfus Med 2003;13239–41.
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Group A as universal plasma donors in massive transfusion protocols
15. Chow MP, Yung CH, Hu HY, Tzeng CH. Hemolysis after ABO-incompatible platelet transfusions. Zhonghua Yi XueZa Zhi (Taipei) 1991;48:131–4.
16. Ferguson DJ. Acute intravascular hemolysis after a platelettransfusion. CMAJ 1988;138:523–4.
17. Harris SB, Josephson CD, Kost CB, Hillyer CD. Nonfatalintravascular hemolysis in a pediatric patient after
transfusion of a platelet unit with high-titer anti-A.Transfusion 2007;47:1412–17.
18. Valbonesi M, De Luigi MC, Lercari G, et al. Acuteintravascular hemolysis in two patients transfused withdry-platelet units obtained from the same ABO incompatibledonor. Int J Artif Organs 2000;23:642–6.
19. Blumberg N, Heal JM, Hicks GL Jr, Risher WH. Associationof ABO-mismatched platelet transfusions with morbidityand mortality in cardiac surgery. Transfusion 2001;41: 790–3.
20. Heal JM, Kenmotsu N, Rowe JM, Blumberg N. A possiblesurvival advantage in adults with acute leukemia receiving ABO-identical platelet transfusions. Am J Hematol 1994;45:189–90.
21. Heal JM, Liesveld JL, Phillips GL, Blumberg N. What wouldKarl Landsteiner do? the ABO blood group and stem celltransplantation. Bone Marrow Transplant 2005;36:747–55.
22. Mair B, Benson K. Evaluation of changes in hemoglobinlevels associated with ABO-incompatible plasma inapheresis platelets. Transfusion 1998;38:51–5.
23. Fung MK, Downes KA, Shulman IA. Transfusion ofplatelets containing ABO-incompatible plasma: a survey of3156 North American laboratories. Arch Pathol Lab Med2007;131:909–16.
24. Cooling L. ABO and platelet transfusion therapy.Immunohematology 2007;23:20–33.
25. Eder AF, Chambers LA. Noninfectious complications of
blood transfusion. Arch Pathol Lab Med 2007;131:708–18. 26. Josephson CD, Mullis NC, Van Demark C, Hillyer CD.
Signicant numbers of apheresis-derived group O plateletunits have “high-titer” anti-A/A,B: implications fortransfusion policy. Transfusion 2004;44:805–8.
27. Reesink HW, van der Hart M, van Loghem JJ. Evaluation ofa simple method for determination of IgG titre anti-A or -Bin cases of possible ABO blood group incompatibility. VoxSang 1972;22:397–407.
28. Heal JM, Masel D, Rowe JM, Blumberg N. Circulatingimmune complexes involving the ABO system after platelettransfusion. Br J Haematol 1993;85:566–72.
29. Shanwell A, Andersson TM, Rostgaard K, et al. Post-transfusion mortality among recipients of ABO-compatible but non-identical plasma. Vox Sang 2009;96:316–23.
30. Cooling LL, Downs TA, Butch SH, Davenport RD. Anti-A
and anti-B titers in pooled group O platelets are comparableto apheresis platelets. Transfusion 2008;48:2106–13.
31. Redman M, Malde R, Contreras M. Comparison of IgMand IgG anti-A and anti-B levels in Asian, Caucasian andNegro donors in the North West Thames Region. Vox Sang1990;59:89–91.
32. Toy PT, Reid ME, Papenfus L, Yeap HH, Black D. Prevalenceof ABO maternal-infant incompatibility in Asians, BlacksHispanics and Caucasians. Vox Sang 1988;54:181–3.
33. Mazda T, Yabe R, NaThalang O, Thammavong T, TadokoroK. Differences in ABO antibody levels among blood donorsa comparison between past and present Japanese, Laotianand Thai populations. Immunohematology 2007;23:38–41
Edahn J. Isaak, MD, FACP, Director of Transfusion Medicine
Staten Island University Hospital, Staten Island, NY; Kathryn M
Tchorz, MD, FACS (corresponding author), Associate Professor
Department of Surgery-Division of Trauma/Critical Care
Wright State University-Boonshoft School of Medicine, Miam
Valley Hospital, One Wyoming Street, 7th Floor CHE Building
Dayton, OH 45409; Nancy Lang, SBB, Immunohematology
Reference Technologist, Lawrence Kalal, MT, Immunohematol
ogy Reference Technologist, Colleen Slapak, MS, Transfusion
Safety Director, Ghada Khalife, MD, Medical Director, David
Smith, MD, CEO, Community Blood Center/Community Tissue
Services, Dayton, OH; and Mary C. McCarthy, MD, FACS
Professor, Department of Surgery, Chief, Trauma/Critical CareWright State University-Boonshoft School of Medicine, Miam
Valley Hospital, Dayton, OH.
The editorial staff of Immunohematology welcomes manuscriptspertaining to blood group serology and education for considerationfor publication. We are especially interested in case reports,papers on platelet and white cell serology, scientic articlescovering original investigations, and papers on new methods foruse in the blood bank. Deadlines for receipt of manuscripts forconsideration for the March, June, September, and December
issues are the rst weeks in November, February, May, andAugust, respectively. For instructions for scientic articles, casereports, and review articles, see Instructions for Authors in everyissue of Immunohematology or on the Web at www.redcross.org/immunohematology. Include fax and phone numbers and
e-mail address with all manuscripts and correspondence. E-mail all manuscripts to [email protected]
Manuscripts
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The alleles RHCE*ceBI (RHCE*ce 48C, 712G, 818T, 1132G) and RHCE*ceSM (RHCE*ce 48C, 712G, 818T) encode the low-prevalence Rh antigen STEM. These alleles frequently travel incis with RHD*DOL. To estimate the frequency of these alleles, wetested a total of more than 700 samples in two populations. Bloodsamples were obtained from patients with sickle cell diseaseand from blood donors of African descent. DNA extractions andanalyses were performed by standard methods. In the UnitedStates, none of 70 patient samples had the RHCE*818 nucleotidechange. Two of 220 donors (frequency of 0.009) were heterozygousfor RHCE*818C/T (RHCE*ceBI). One of these samples had RHD/RHD*DOL and the other had RHD/RHD*DOL-2. In these290 samples, no other RHD*DOL alleles were found. In Brazil,
1 of 244 patients with sickle cell disease (frequency of 0.004)and 1 of 171 donors (frequency of 0.006) were heterozygous for RHCE*818C/T (RHCE*ceBI). Testing of more than 500 additionalsamples from people of African descent, selected because theyhad a diverse range of common and variant RHCE alleles, didnot reveal a sample with RHD*DOL or RHD/RHD*DOL-2 in theabsence of RHCE*ce(818T). Although the numbers are small,our study shows that in the United States, the frequency of RHCE*818T is 0.007 (2 in 290 samples) and in Brazil it is 0.004
(2 in 515 samples). The four RHCE*818T alleles were RHCE*ceBI. Immunohematology 2011;27:66–67.
Key words: blood groups, Rh alleles, low-prevalence
antigens, population study
The low-prevalence Rh antigen STEM (RH49) was
reported in 1993. The antigen was serologically shown
to be associated with an altered e phenotype because
approximately 65 percent of hrS– and 30 percent of hrB–
red blood cells (RBCs) from South African donors were
reported to be STEM+. STEM has a variable expression,
which is an inherited characteristic. Anti-STEM has
induced mild hemolytic disease of the fetus and newborn.1
Owing to the paucity of anti-STEM and typed RBCs, little
further work has been done and no other serologic reports
have appeared in the literature.
The STEM antigen is encoded by two RHCE alleles:
RHCE*ceBI (RHCE*ce 48C, 712G, 818T, 1132G) and
RHCE*ceSM (RHCE*ce 48C, 712G, 818T) (Fig. 1A). The
nucleotide (nt) 818C>T change is believed to be associated
with expression of STEM, because the other nucleotide
changes occur in other alleles.2 In analyzing DNA from
samples known to be STEM+ or DAK+, it was revealed
that these variant RHCE are usually in cis to RHD*DOL or
RHD*DOL-2 (Fig. 1B).3 We tested more than 700 samples
in New York and in Brazil to estimate the frequency of
RHCE*ce818C>T and to investigate RHD in these samples.
Prevalence of RHD*DOL and RHCE*ce(818T) in two populations
C. Halter Hipsky, D.C. da Costa, R. Omoto, A. Zanette, L. Castilho, and M.E. Reid
REPORT
Figure 1. Diagram of selected RHCE ( A) and RHD (B) alleles. The10 exons are numbered. Nucleotide changes are indicated in italicsand amino acids are given in parentheses below the exon in whichthey are found. Changes from the wild-type nucleotides and aminoacids are written in bold.
B. RHD alleles
A. RHCE alleles
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Prevalence of RHD*DOL and RHDCE*ce(818T)
Materials and Methods
Blood samples were obtained from patients with sickle
cell disease and from blood donors who self-identied as
being of African descent. Genomic DNA was isolated from
the whole blood samples using the QIAamp DNA Blood
Mini Kit (QIAGEN, Inc., Valencia, CA). Initial screening of
samples was carried out by sequencing RHCE- and RHD-
reverse transcriptase–polymerase chain reaction (PCR)
products, as described previously,4 or analyzing RHCE*818
and RHCE*1132 by standard PCR products generated with
genomic DNA using RHCE-specic primers, followed by
restriction fragment length polymorphism (RFLP) using,
respectively, MwoI and Tsp45 I restriction enzymes.
Genomic DNA was amplied using RHD-specic primers
anking exon 4 and exon 8, and products were submitted
for sequencing to determine the presence of RHD*DOL (nt
509T>C in exon 4) and RHD*DOL-2 (nt 509T>C in exon 4and nt 1132C>G in exon 8). PCR products were sequenced
in both directions.
Results
In the United States, none of 70 patient samples had
the RHCE*818 nucleotide change. Two of 220 donors
(frequency of 0.009) were heterozygous for RHCE*818C/T.
Both samples had the change at RHCE*ce1132C>G and,
thus, are RHCE*ceBI. One sample had RHD/RHD*DOL
and the other had RHD/RHD*DOL-2. No homozygous
RHCE*818T sample was found. In these 290 samples, noother RHD*DOL alleles were found.
In Brazil, 1 of 244 patients with sickle cell disease
(frequency of 0.004) and 1 of 171 donors (frequency of
0.006) were heterozygous for RHCE*818C/T and for
RHCE*ce1132C/G and, thus, are also RHCE*ceBI. The
samples were not analyzed for RHD.
Taking the combined data, 4 samples in a total of 705
tested had RHCE*818C/T (all 4 were RHCE*ceBI ), which
gives an allele frequency of 0.006.
Conclusions
Although the numbers are small, our study shows
that in the United States, the frequency of RHCE*818T
(RHCE*ceBI) is 0.007 (2 in 290 samples; 580 alleles)
and in Brazil it is 0.004 (2 in 415 samples; 830 alleles)
Our ndings show that RHCE*818T, which encodes the
STEM antigen, is not as rare as previously thought. This
raises the question as to whether anti-STEM is also more
prevalent but not identied. In the cohort of samples tested
the RHD*DOL or RHD*DOL-2 alleles were in cis with the
RHCE*ce(818T) allele; no RHD*DOL or RHD*DOL-2 was
found in the absence of RHCE*ce(818T).
Acknowledgments
This study was supported in part by grant NIH
HL091030 (CHH, MER) and INCTS-CNPQ/MCT/FAPESP
(LC). We thank Robert Ratner for help in preparing this
manuscript.
References
1. Marais I, Moores P, Smart E, Martell R. STEM, a newlow-frequency Rh antigen associated with the e-varianphenotypes hrS-(Rh: -18, -19) and hrB-(Rh: -31, -34)Transfus Med 1993;3:35–41.
2. Halter-Hipsky C, Hue-Roye K, Coghlan G, Lomas-FrancisC, Reid ME. Two alleles with RHCE*nt818C>T changeencode the low prevalence Rh antigen STEM [abstract]Blood 2009;114(Suppl):1226–7.
3. Halter Hipsky C, Hue-Roye K, Lomas-Francis C, Reid MERHD*DOL travels with RHCE*ce(818C>T), which encodesa partial e, hrS–, hrB+, STEM+ phenotype [abstract]Transfusion 2010;50(Suppl):48A.
4. Halter Hipsky C, Lomas-Francis C, Fuchisawa A, et al RHCE*ceCF encodes partial c and partial e but not CELO, anantigen antithetical to Crawford. Transfusion 2011;51:25-3
Christine Halter Hipsky, Laboratory of Immunochemistry, New
York Blood Center, New York, NY; Daiane Cobianchi da Costa,
MS, Ricardo Omoto, MS, Angela Zanette, MD, Lilian Castilho
PhD, Hemocentro-Unicamp-Campinas-Brazil, Campinas
SP, Brazil; and Marion E. Reid, PhD (corresponding author)
Laboratory of Immunochemistry, New York Blood Center, 310
East 67th Street, New York, NY 10065.
Notice to Readers
Immunohematology is printed on acid-free paper.
For information concerning Immunohematology or theImmunohematology Methods and Procedures manual,contact us by e-mail at [email protected]
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The XG blood group system is best known for its contributionsto the elds of genetics and chromosome mapping. This systemcomprises two antigens, Xga and CD99, that are not antithetical
but that demonstrate a unique phenotypic relationship. XG islocated on the tip of the short arm of the X chromosome withexons 1 to 3 present in the pseudoautosomal region of the X(and Y) chromosome(s) and exons 4 to 10 located only on theX chromosome. Xga demonstrates a clear X-linked pattern ofinheritance. MIC2, the gene encoding the CD99 antigen, is foundin the pseudoautosomal region of both the X and Y chromosomes. Anti-Xga is comparatively rare, and only two examples of anti-CD99 have ever been identied. Alloanti-Xga is considered
clinically insignicant; only one example of autoanti-Xga has beenreported, but it resulted in severe hemolytic anemia. Insufcientdata exist to determine the clinical signicance of anti-CD99.Linkage of XG to several X-borne genes encoding inheriteddisorders has been demonstrated. CD99 is an adhesion molecule,and high levels are associated with some types of cancer. Immunohematology 2011;27:68–71.
Key Words: Xga, X-linked, CD99, XG, MIC2, PBDX, 12E7,
Lyonization, qualitative polymorphism, pseudoautosomal
History
The XG blood group system is not revered for itsantigens and antibodies, but is instead respected for its
contributions to the elds of genetics and chromosome
mapping. XG is the rst, and so far the only, blood group
system to be assigned to the X chromosome.1 There are
only two antigens in the system: Xga and CD99. Xga may be
expressed only on red blood cells (RBCs), whereas CD99 is
expressed on many tissue cells. Anti-Xga can be naturally
occurring and is not considered clinically signicant. Only
two examples of alloanti-CD99 have ever been reported; its
clinical signicance is unknown.2
The rst example of anti-Xga was reported in 1961 in
the serum of a man who had been multiply transfused for
severe nosebleeds as a result of familial telangiectasia.3
Shortly thereafter, in 1962, Mann et al. characterized Xga
as originating from a locus on the X chromosome.1 Xga is
named after the X chromosome and Grand Rapids, where
the rst-reported patient to have the antibody (Mr. And) was
treated.4 It was later discovered that PBDX, a gene found to
span the pseudoautosomal boundary on the X chromosome,
is the gene that encodes Xga (see Molecular Basis section).5
The function of the Xga protein is not known.6
Two decades after the rst example of anti-Xga was
reported, Goodfellow and Tippett observed a mouse
monoclonal antibody, 12E7, which recognized another
determinant that appeared to be controlled by a gene also
found on the X chromosome.7 This gene, MIC2, is located
in the pseudoautosomal region of both the X and the Y
chromosomes and encodes CD99. CD99 is an adhesion
molecule,5,8 and high levels are associated with some
types of cancer. Xga and CD99 enjoy a unique phenotypic
relationship, which will be discussed in further detail in
the Genetics and Inheritance section. Fourteen years laterin 1995, Uchikawa et al. reported the only examples of
alloanti-CD99, detected in two unrelated, healthy Japanese
blood donors.2 CD99, became part of the XG blood group
system ofcially in 2000 when it was conrmed that MIC2
and XG are adjacent, homologous genes.4
Because of its location in the pseudoautosomal boundary
region of the sex chromosome, study of the inheritance of
Xga has helped to dene the mechanisms responsible for
Turner, Klinefelter, and other syndromes resulting from an
abnormal number of sex chromosomes. Sex chromosome
aneuploidies are commonly associated with infertility.
Nomenclature
The XG blood group system has been assigned the
ISBT symbol and number XG and 012, respectively. The
ISBT terminology for the two antigens in the system, Xg
and CD99, is listed in Table 1. No antithetical counterpart
to the Xga antigen has been discovered, so the failure of
RBCs to react with anti-Xga denes the silent allele, Xg, or
an absence of Xga.
Genetics and Inheritance
Xga is inherited as an X-linked, dominant trait, and
the pattern of inheritance is as expected for an X-borne
characteristic.1,8 If Xga is present, it is expressed on RBCs
XG: the forgotten blood group systemN.C. Johnson
REVIEW
Table 1. Nomenclature
Xga CD99
ISBT symbol XG1 XG2
ISBT number 012001 012002
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XG blood group system: a review
The Xg(a+) phenotype is found in 88.7 percent of females
and 65.6 percent of males. (Table 2.) Females can have a
single (Xga/Xg) or a double dose (Xga/Xga) of Xga. Having
only one X chromosome, males can be hemizygous for Xga
( Xga /Y ) or be Xg/Y and not express the antigen at all.6
Lyonization is a process by which one X chromosome
is inactivated early in somatic cell development in XX
females.9 The process is random in each cell, ensuring
that all genes on the two X chromosomes are found at the
phenotypic level. By studying RBCs of Xga/Xg women it can
be shown that all cells carry Xga, proving that Xga is not
subject to inactivation or Lyonization. XG was the rst X
chromosome locus proven to escape this process.10 It was
later shown that MIC2 is not subject to Lyonization either.11
New Guineans, Australian aborigines, Navajo Indians,
and Sardinians are reported to have the highest prevalenceof Xga. On the other hand, native Taiwanese; Chinese in
Singapore, Hong Kong, Taiwan, and Hakka; and Malays in
Singapore are observed to have the lowest incidence.3,12–14
Interestingly, Asian populations with a higher prevalence of
Xg(a–) phenotypes do not have a higher incidence of anti-
Xga.6
Using monoclonal antibodies, it has been shown that
CD99 is present on all tissue cells tested15; however, the
expression of the adhesion molecule on RBCs is unique.
CD99 is expressed at different levels on RBCs, and this
expression is directly related to the presence or absence of
Xga .16 In females, the Xg(a–) phenotype is always associated
with low expression of CD99. (Table 3.) Curiously, among
Xg(a–) males, 74 percent are high expressors of CD99.17
To explain this quantitative polymorphism, Goodfellow
and Tippett proposed the existence of a locus on the Y
chromosome, YG, analogous to XG on the X chromosome.
Like XG, YG would have two alleles, Yga and Yg. In Xg(a–)
males, the presence of Yga would result in high expression
of CD99, and the absence of Yga (Yg) would result in low
expression of CD99.7,16
The presence of YG has been substantiated by family
studies,17 but to date, there has been no Yga antigen
identied. It is important to note that MIC2 is responsible
for expression of CD99 on all tissue cells, but XG and YG
create the CD99 quantitative polymorphism observed on
RBCs.8
Molecular Basis
Sex chromosomes have two genetically distinct regions
sex chromosome–specic sequences and pseudoautosoma
sequences. Pseudoautosomal refers to a structurally
homologous region on sex chromosomes, the function
of which is to facilitate pairing during male meiosis.8 XG
spans the pseudoautosomal boundary between the two
regions of the X chromosome at Xp22.3; exons 1 to 3 are
located in the pseudoautosomal region (PAR) and exons 4
to 10 are found in the sex chromosome–specic region. 4–6
MIC2, the closest neighbor to XG, is located in the PAR at
position Xp22.2. An identical copy of MIC2 is found in the
PAR region of the Y chromosome at Yp11.2.4 Almost half(48%) of the predicted amino acid sequences of XG and
MIC2 are identical.18
Biochemistry
Immunoblotting of immunoprecipitates conrmed that
CD99 and Xga antigens are located on different structures
later conrmed to be sialoglycoproteins.18,19 CD99 and Xg
are associated in the membrane, possibly in the form of a
heterodimer.7,18
The RBC membrane molecule expressing Xga was rst
identied in 1989 by Herron and Smith, by immunoblotting
and electropheresis.19 Several years later, Petty and Tippett
used immunoblotting and immunoprecipitation to show tha
Xga is carried on a broad band of apparent molecular weight
24.5 to 29.5 kDa, consisting of a darkly stained component
at 24.5 kDa and a more diffusely stained component
between 26.5 and 29.5 kDa.18 No bands are observed with
protease-treated cells, and the apparent molecular weight
of Xga is decreased after treatment with neuraminidase
suggesting that Xga resides on a sialoglycoprotein.
Table 2. Phenotype prevalence and genotype frequencies
Male (%) Female (%)
Phenotype
Xg(a+) 65.6 88.7
Xg(a–) 34.4 11.3
Genotype
Xga/Xga 0.434
Xga/Xg 0.450
Xg/Xg 0.116
Xga/Xg 0.656
Xg/Xg 0.344
Table 3. Relationship of Xga, Yga, and CD99
Females Xg(a+) CD99 high
Xg(a+w) CD99 high
Xg(a–) CD99 low
Males Xg(a+) CD99 high
Xg(a–) Yga CD99 high
Xg(a–) Yg CD99 low
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N.C. Johnson
Xga is sensitive to treatment with cin, papain, trypsin,
bromelin, α-chymotrypsin, and pronase, and is resistant to
sialidase, 0.2 M dithiothreitol (DTT), neuraminidase, and
2-aminoethylisothiouronium bromide.4,13,20 The effects of
acid are unknown. The expression of the antigen decreases
as the RBC ages and it has been shown by indirect
radioimmunoassay to have an in vivo half-life of 47 days.21
Early experiments using a microcomplement xation
method and indirect radioimmunoassay suggested that
Xga might be present on other cell lines and tissues,22 but
subsequent testing was unable to duplicate these results.
XG is expressed on hematopoietic tissues8 and is strongly
expressed as mRNA in broblasts.20
Apart from humans, the only animals found to have
Xga on their RBCs are one species of gibbons. Of 52 gibbons
tested, 30 percent of males and 53 percent of females were
Xg(a+). Chimpanzees (67); gorillas (2); orangutans (20);
another species of gibbons (5); various monkeys, including60 baboons; and a few nonprimates, including mice and
dogs, were all Xg(a–).3,4
Monoclonal anti-CD99 identify a protein of apparent
molecular weight of 32 kDa.5,8 Immunoblotting and
immunoprecipitate studies suggest the CD99 protein is
composed of two polypeptides, a 32-kDa surface compo-
nent, and a 30-kDa intracellular polypeptide.18 CD99
is sensitive to treatment with trypsin, α-chymotrypsin,
cin, papain, and pronase15 and, like Xga, is carried on a
sialoglycoprotein. CD99 is resistant to 0.2 M DTT and is
usually resistant to neuraminidase treatment; results vary
with sialidase treatment.CD99 is present on all human cell types and tissues
tested.15 High levels of CD99 are a tumor marker in Ewing
sarcoma, some neuroectodermal tumors, lymphoblastic
lymphoma, and acute lymphoblastic leukemia.8 CD99 was
not detected on the RBCs or peripheral blood lymphocytes
of 10 gibbons, regardless of their Xga phenotype. CD99
was detected on RBCs and broblasts of chimpanzees and
gorillas, but not of orangutans or any of the other mammals
tested.23
Antibodies in the System
Anti-Xga is comparatively rare; most immunohema-
tologists will never see anti-Xga in their careers. When
identied, it is usually found as a lone antibody specicity.
Some examples of anti-Xga are naturally occurring, yet
are more frequently IgG than IgM.4 Optimal methods for
identication include room temperature incubation (even
when they are IgG in composition3), indirect antiglobulin
test (IAT), and capillary testing.4 One IAT-reactive anti-
Xga was shown to have IgG1 and IgG2 subclasses.24 Some
examples of anti-Xga have been shown to x complement.
The only reported example of autoanti-Xga was found in
a pregnant woman. The antibody appears to have caused
signicant hemolytic anemia, but the possibility that the
hemolytic anemia was exacerbated by the pregnancy was
not ruled out.25
As a result of the sex-related frequency differences o
Xga, it is expected that men would make more examples of
anti-Xga. Although this is true, it is striking that greater
than 85 percent of antibody makers are men when the
incidence of the Xg(a–) phenotype is only 23 percent higher
in men than in women. It has been postulated, although
not studied, that this higher than expected prevalence
of anti-Xga in men may be associated with the expression
of CD99.6
The rst example of anti-CD99 ever made was a mouse
monoclonal antibody called 12E7, which was generated to
screen for antigen differences in human acute lymphocyticleukemia.26 The only two examples of anti-CD99 ever
detected were found in two unrelated, healthy Japanese
blood donors. One antibody was reported to react with
variable strength with different RBC samples. The second
blood donor had a history of pregnancy. One of the two
siblings of the second blood donor was determined to be
CD99 negative also.2 The antibodies were determined to
be IgG in nature and reacted optimally by the IAT.5 It is
not known whether the antibodies were capable of binding
complement.
Clinical Significance
Alloanti-Xga has never been reported to cause
hemolytic disease of the fetus or newborn or a hemolytic
transfusion reaction.4 One patient received six units of
antigen-positive blood with no signs of a reaction.27 A
chromium survival study on another patient showed norma
survival of Xg(a+) RBCs and no posttransfusion increase
in antibody strength.28 One male Japanese patient had a
slight temperature elevation and exhibited urticaria when
transfused with Xg(a+) blood. Subsequent transfusions
with Xg(a–) blood were tolerated with no symptoms.29
The one example of autoanti-Xga reported was
identied in a pregnant female. The antibody was IgG in
nature, activated complement, and caused severe hemolytic
anemia. The infant was Xg(a+) and demonstrated a strongly
positive direct antiglobulin test at birth, and anti-Xga was
eluted from the infant’s cells. The clinical course was
remarkable only for a mild rise in bilirubin after birth.25
Because the only two examples of anti-CD99 were
found in healthy blood donors, information on the clinical
signicance of this antibody is not known.
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XG blood group system: a review
XG is linked to genes responsible for several genetic
disorders.3,4 Ichthyosis is a disorder in which the skin
resembles scales on a sh. Ocular albinism is unique in that
only the eyes lack pigment. Retinoschisis is a sex-linked
form of macular degeneration affecting only men. High
levels of CD99 have been reported in Ewing sarcoma, some
neuroectodermal tumors, lymphoblastic lymphoma, and
acute lymphoblastic leukemia.8
Summary and Future Perspectives
The XG blood group system is most important for the
insight it has provided into the study and understanding of
meiotic errors that lead to sex chromosome aneuploidies. As
the roles of Xga and CD99 become more clearly delineated,
knowledge of the forgotten blood group system may aid in
the development of cures for certain genetic disorders and
types of cancers.
References
1. Mann JD, Cahan A, Gelb AG, et al. A sex-linked blood group.Lancet 1962;1:8–10.
2. Uchikawa M, Tsuneyama H, Tadokoro K, Juji T, YamadaM, Maeda Y. An alloantibody to 12E7 antigen detected in 2healthy donors [abstract]. Transfusion 1995;35:23S.
3. Race RR, Sanger R. The Xg blood groups. In: Blood groupsin man. 6th ed. Oxford, PA: Blackwell Scientic Publication,1975:578–635.
4. Reid ME, Lomas-Francis C. The blood group antigenfactsbook. 2nd ed. San Diego, CA: Academic Press, 2004:338–43.
5. Ellis N, Tippett P, Petty A, et al. PBDX is the XG blood groupgene. Nat Genet 1994;8:285–90.
6. Issitt PD, Anstee DJ. Applied blood group serology. 4th ed.Durham, NC: Montgomery Scientic Publications, 1998.
7. Daniels G. Xg blood group system. In: Human blood groups.2nd ed. Malden, MA: Blackwell Science, 2002:374–86.
8. Tippett P, Ellis NA. The Xg blood group system: a review.Transfus Med Rev 1998;12:233–57.
9. Lyon MF. Gene action in the X-chromosome of the mouse( Mus musculus L.). Nature 1961;190:372–3.
10. Lawler SD, Sanger R. Xg blood-groups and clonal-origintheory of chronic myeloid leukaemia. Lancet 1970;1:584–5.
11. Goodfellow P, Pym B, Mohandas T, Shapiro LJ. The cellsurface antigen locus, MIC2X, escapes X-inactivation. Am J
Hum Genet 1984;36:777–82. 12. Dewey WJ, Mann JD. Xg blood group frequencies in some
further populations. J Med Genet 1967;4:12–15.
13. Siniscalco M, Filippi G, Latte B, et al. Failure to deteclinkage between Xg and other X -borne loci in Sardinians Ann Hum Genet 1966;29:231–52.
14. Simmons RT. X-linked blood groups, Xg, in Australian Aborigines and New Guineans. Nature 1970;227:1363.
15. Goodfellow P. Expression of the 12E7 antigen is controlledindependently by genes on the human X and Y chromosomes
Differentiation 1983;23(Suppl):S35–9. 16. Goodfellow PN, Tippett P. A human quantitative polymorphism related to Xg blood groups. Nature 1981;289404–5.
17. Tippett P, Shaw M-A, Green CA, Daniels GL. The 12E7 redcell quantitative polymorphism: control by the Y-bornelocus, Yg. Ann Hum Genet 1986;50(Pt 4):339–47.
18. Petty AC, Tippett P. Investigation of the biochemicarelationship of the blood group antigens Xga and CD99(12E7 antigen) on red cells. Vox Sang 1995;69:231–5.
19. Herron R, Smith GA. Identication and immunochemicacharacterization of the human erythrocyte membraneglycoproteins that carry the Xga antigen. Biochem J 1989262:369–71.
20. Ellis NA, Ye T-Z, Patton S, German J, Goodfellow PN, Welle
P. Cloning of PBDX, and MIC2-related gene that spans thepseudoautosomal boundary on chromosome Xp. Nat Genet1994;6:394–400.
21. Campana T, Szabo P, Piomelli S, Siniscalco M. The Xgantigen on red cells and broblasts. Cytogenet Cell Genet1978;22:524–6.
22. Fellous M, Bengtsson B, Finnegan D, Bodmer WF. Expressionof the Xga antigen on cells in culture and its segregation insomatic cell hybrids. Ann Hum Genet 1974;37:421–30.
23. Shaw MA, Tippet P, Delhanty JD, Andrews M, GoodfellowP. Expression of Xg and the 12E7 antigen in primates. JImmunogenet 1985;12:115–18.
24. Devenish A, Burslem MF, Morris R, Contreras M. Serologiccharacteristics of a further example of anti-Xga in North
London blood donors. Transfusion 1986;26:426–7. 25. Yokoyama M, McCoy JE Jr. Further studies on auto-anti-Xga antibody. Vox Sang 1967;13:15–17.
26. Levy R, Dilley J, Fox RI, Warnke R. A human thymus-leukemia antigen dened by hybridoma monoclonaantibodies. Proc Natl Acad Sci U S A 1979;76:6552–6.
27. Cook IA, Polley MJ, Mollison PL. A second example of anti-Xga. Lancet 1963;1:857–9.
28. Sausais L, Krevans JR, Townes AS. Characteristics of a thirdexample of anti-Xga [abstract]. Transfusion 1964;4:312.
29. Azar PM, Saji H, Yamanaka R, Hosoi T. Anti-Xga suspectedof causing a transfusion reaction. Transfusion 1982;22340–1.
Nanette C. Johnson, MT(ASCP)SBB, Director, Immunohematol
ogy Reference Laboratory, Greater Chesapeake and Potomac
Region, 4700 Mt. Hope Drive, Baltimore, MD 21215.
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Erratum V OL . 27, NO. 1, 2011, PP. 14, 16, AND 18
Red blood cell phenotype matching for various ethnic groups
The author has informed the editors of Immunohematology that there is an error on pages 14, 16, and 18. The running head
should appear as K.S.W. Badjie et al.
COMMUNICATION
Free Classified Ads and Announcements
Immunohematology will publish classified ads and announcements (SBB schools, meetings, symposia, etc.) without charge.
Deadlines for receipt of these items are as follows:
Deadlines
1st week in January for the March issue 1st week in July for the September issue
1st week in April for the June issue 1st week in October for the December issue
E-mail or fax information to [email protected] or phone (215) 451-2538
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Monoclonal antibodies available at no charge:
The New York Blood Center has developed a wide range of
monoclonal antibodies (both murine and humanized) that
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positive DAT. These include anti-A 1, -M, -s, -U, -D, -Rh17,
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-H, -Ge2, -Ge3, -CD55 (both SCR2/3 and SCR4), -Ok a, -I,
and anti-CD59. Most of the antibodies are murine IgG and
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For additional information, contact: Gregory Halverson,
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NY 10021/e-mail: [email protected], phone:
(212) 570-3026, FAX: (212) 737-4935, or visit the Web
site at www.nybloodcenter.org >research >laboratories
>immunochemistry >current list of monoclonal antibodies
available.
Specialist in Blood Bank (SBB) Program
The Department of Transfusion Medicine, National
Institutes of Health, is accepting applications for its 1-year
Specialist in Blood Bank Technology Program. Students are
federal employees who work 32 hours/week. This program
introduces students to all areas of transfusion medicine
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conduct a research project. NIH is an Equal Opportunity
Organization. Application deadline is December 31, 2011
for the July 2012 class. See www.cc.nih.gov/dtm > education
for brochure and application. For further information
contact Karen M. Byrne at (301) 451-8645 or KByrne@
mail.cc.nih.gov
ANNOUNCEMENTS
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ADVERTISEMENTS
Masters (MSc) in Transfusion and Transplantation Sciences
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Applications are invited from medical or science graduates for the Master of Science (MSc) degree
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Fax +44 1179 595 342, Telephone +44 1779 595 455, e-mail: [email protected].
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Diagnostic testing for:• Neonatal alloimmune thrombocytopenia (NAIT)• Posttransfusion purpura (PTP)• Refractoriness to platelet transfusion• Heparin-induced thrombocytopenia (HIT)
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National Platelet Serology Reference Laboratory
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Our laboratory specializes in granulocyte antibody detection
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Methodologies employed:
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National Neutrophil Serology Reference Laboratory
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Antibody identication and problem resolution
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AABB, ARC, New York State, and CLIA licensed24-hour phone number:
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What is a certied Specialist in Blood Banking (SBB)?
• Someone with educational and work experience qualications that successfully passes the American Society for Clinical Pathology (ASCP)
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• This person will have advanced knowledge, skills, and abilities in the eld of transfusion medicine and blood banking.
Individuals who have an SBB certication serve in many areas of transfusion medicine:
• Serve as regulatory, technical, procedural, and research advisors
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• Develop, validate, implement, and perform laboratory procedures
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Supervisors of Transfusion Services Executives and Managers of Blood Centers LIS Coordinators Educators
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CAAHEP-accredited SBB Technology program or grandfather the exam based on ASCP education and experience criteria.
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Additional information can be found by visiting the following Web sites: www.ascp.org, www.caahep.org, and www.aabb.org
Program Contact Name Phone Contact Email Contact WebsiteOnsite orOnline Program
Walter Reed Army Medical Center William Turcan 202-782-6210 [email protected] www.militaryblood.dod.mil/fellow Onsite
American Red Cross, Southern California Region Michael Coover 909-859-7496 [email protected] none Onsite
ARC-Central OH Region Joanne Kosanke 614-253-2740 x 2270 [email protected] none Onsite
Blood Center of Wisconsin Lynne LeMense 414-937-6403 [email protected] www.bcw.edu Onsite
Community Blood Center/CTS Dayton, Ohio Nancy Lang 937-461-3293 [email protected] www.cbccts.org/education/sbb.html Online
Gulf Coast School of Blood Bank Technology Clare Wong 713-791-6201 [email protected] http://giveblood.org/index.php?page =sbb-distance-program Online
Hoxworth Blood Center/Universit y of Cincinnati Susan Wilkinson 513-558-1275 Pamela.inglish@ [email protected]
www.hoxworth.org Onsite
Indiana Blood Center Jayanna Slayten 317-916-5186 [email protected] www.indianablood.org Online
Johns Hopkins Hospital Lorraine Blagg 410-502-9584 [email protected] http://pathology.jhu.edu/department/divisions/tranfusion/sbb2.cfm
Onsite
Medical Center of Louisiana Karen Kirkley 504-903-3954 [email protected] none Onsite
NIH Clinical Center Department of Transfusion Medicine Karen Byrne 301-496-8335 [email protected] www.cc.nih.gov/dtm/research/sbb.html Onsite
Rush University Veronica Lewis 312-942-2402 [email protected] www.rushu.rush.edu/catalog/acadprograms/chs/cls/clssbbcert.html
Online
Transfusion Medicine Academic Center at Florida BloodServices
Marjorie Doty 727-568-5433 x 1514 [email protected] www.fbsblood.org Online
University Health System and Affiliates, San Antonio Linda Myers 210-731-5526 [email protected] www.sbbofsa.org Onsite
University of Texas Medical Branch at Galveston Janet Vincent 409-772-3055 [email protected] www.utmb.edu/sbb Online
University of Texas SW Medical Center LeAnne Hutson 214-648-1780 [email protected] http://utsouthwestern.edu/mls Online
Becoming a Specialist in Blood Banking (SBB)
Revised August 2009
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I. GENERAL INSTRUCTIONSBefore submitting a manuscript, consult current issues of
Immunohematology for st yle. Double-space throughout the manuscript.
Number the pages consecutively in the upper right-hand corner, beginning
with the title page.
II. SCIENTIFIC ARTICLE, REVIEW, OR CASE REPORT WITH
LITERATURE REVIEW
A. Each component of the manuscript must star t on a new page in the
following order:
1. Title page
2. Abstract
3. Text
4. Acknowledgments
5. References
6. Author information
7. Tables
8. Figures
B. Preparation of manuscript
1. Title page
a. Full title of manuscript with only first letter of first word
capitalized (bold title)
b. Initials and last name of each author (no degrees; all CAPS), e.g.,
M.T. JONES, J.H. BROWN, AND S.R. SMITH
c. Running title of ≤40 characters, including spaces
d. Three to ten key words
2. Abstract
a. One paragraph, no longer than 300 words
b. Purpose, methods, findings, and conclusion of study
3. Key words
a. List under abstract
4. Text (serial pages): Most manuscripts can usually, but not
necessarily, be divided into sections (as described below). Survey
results and review papers may need individualized sections
a. Introduction — Purpose and rationale for study, including
pertinent background references
b. Case Report (if indicated by study) — Clinical and/or hematologic
data and background serology/molecular
c. Materials and Methods — Selection and number of subjects,
samples, items, etc. studied and description of appropriate
controls, procedures, methods, equipment, reagents, etc.
Equipment and reagents should be identified in parentheses by
model or lot and manufacturer’s name, city, and state. Do not
use patient’s names or hospital numbers.
d. Results — Presentation of concise and sequential results,
referring to pertinent tables and/or figures, if applicable
e. Discussion — Implication and limitations of the study, links to
other studies; if appropriate, link conclusions to purpose of study
as stated in introduction
5. Acknowledgments: Acknowledge those who have made substantialcontributions to the study, including secretarial assistance; list any
grants.
6. References
a. In text, use superscript, Arabic numbers.
b. Number references consecutively in the order they occur in the
text.
7. Tables
a. Head each with a brief title; capitalize the first letter of first word
(e.g., Table 1. Results of . . .) use no punctuation at the end of
the title.
b. Use short headings for each column needed and capitalize first
letter of first word. Omit vertical lines.
c. Place explanation in footnotes (sequence: *, †, ‡, §, ¶, **, ††).
8. Figures
a. Figures can be submitted either by e-mail or as photographs
(5ʺ×7ʺ glossy).
b. Place caption for a figure on a separate page (e.g. Fig. 1 Results
of...), ending with a period. If figure is submitted as a glossy,
place first author’s name and figure number on back of each
glossy submitted.
c. When plotting points on a figure, use the following symbols if
possible:llssnn.
9. Author information
a. List first name, middle initial, last name, highest degree,
position held, institution and department, and complete address
(including ZIP code) for all authors. List country when applicable.
III. EDUCATIONAL FORUM
A. All submitted manuscripts should be approx imately 2000 to 2500 words
with per tinent references. Submissions may include:1. An immunohematologic case that illustrates a sound investigative
approach with clinical correlation, reflec ting appropriate
collaboration to sharpen problem solving skills
2. Annotated conference proceedings
B. Preparation of manuscript
1. Title page
a. Capitalize first word of title.
b. Initials and last name of each author (no degrees; all CAPs)
2. Text
a. Case should be written as progressive disclosure and may
include the following headings, as appropriate
i. Clinical Case Presentation: Clinical informat ion and
differential diagnosis
ii. Immunohematologic Evaluation and Results: Serology and
molecular testing
iii. Interpretation: Include interpretation of laboratory results,
correlating with clinical findings
iv. Recommended Therapy: Include both transfusion and
nontransfusion-based therapies
v. Discussion: Brief review of literature with unique features of
this case
vi. Reference: Limited to those directly pertinent
vii. Author information (see II.B.9.)
viii. Tables (see II.B.7.)
IV. LETTER TO THE EDITOR
A. Preparation
1. Heading (To the Editor)
2. Title (first word capitalized)
3. Text (written in letter [paragraph] format)
4. Author(s) (type flush right; for first author: name, degree, institution,
address [including city, state, Zip code and country]; for other
authors: name, degree, institution, city and state)
5. References (limited to ten)
6. Table or figure (limited to one)
Send all manuscripts by e-mail to [email protected]
Immunohematology Journal of Blood Group Serology and Education
Instructions for Authors
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Ordering Information
The book, which costs $25, can beordered in two ways:
Order online from the publisher•
at: www.sbbpocketbook.com
Order from the authors, who•
will sign the book. Send a check,made payable to “New York BloodCenter” and indicate “Pocket-book” on the memo line, to:
Marion ReidLaboratory of ImmunochemistryNew York Blood Center310 East 67th StreetNew York, NY 10065
Please include the recipient’scomplete mailing address.
Blood Group
Antigens & Antibodies A guide to clinical relevance& technical tips
by Marion E. Reid & Christine Lomas-Francis
Pocketbook Education FundThe authors are using royalties generated from the sale of
this pocketbook for educational purposes to mentor peoplein the joys of immunohematology as a career. They willaccomplish this in the following ways:
Sponsor workshops, seminars, and lectures•
Sponsor students to attend a meeting•
Provide copies of the pocketbook •
(See www.sbbpocketbook.com for details to apply for funds)
This compact “pocketbook” from the authors of the Blood
Group Antigen FactsBook is a must for anyone who is involvedin the laboratory or bedside care of patients with blood group alloantibodies.
The book contains clinical and technical information about the nearly 300 ISBT recognized blood group antigens and their corresponding antibodies. The information is listed inalphabetical order for ease of finding—even in the middle of the night. Included in the book is information relating to:
Clinical significance of antibodies in transfusion and HDN.•
Number of compatible donors that would be expected•
to be found in testing 100 donors. Variations in differentethnic groups are given.
Characteristics of the antibodies and optimal technique(s)•
for their detection.
Technical tips to aid their identification.•
Whether the antibody has been found as an autoantibody.•
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FIRST CLASS
U.S. POSTAGE
PAIDSOUTHERN MD
PERMIT NO. 4144Musser Blood Center
700 Spring Garden Street
Philadelphia, PA 19123-3594
(Place Label Here)