Immunohematology

Journal of Blood Group Serology and Education

Celebrat ing

Yea rs

Volume 25, Number 2, 2009

Journal of Blood Group Serology and Education Volume 25, Number 2, 2009

Immunohematology

Contents

39 44 48 60 63 67 75 81 84 83 84 88

Invited Review: Milestones Series Milestones in laboratory procedures and techniques M E !eid Case Report nti!"pa#induced se$ere delayed hemolytic trans%usion reaction ! "o#$y, B %atel, and J S &arri#on Review &he '( blood group system re$isited) a re$ie* and update J ! Storry and M ' (l##on Case Report +linical e$aluation %or lymphoproli%erati$e disease prompted by %inding o% IgM *arm autoanti!I& in t*o cases ! M 'eger, ) 'o*der, M + ,ungo, - +$en, & M Ma#on, and G Garratty Original Report ,outheast sian o$alocytosis is associated *ith increased e-pression o% .u%%y antigen receptor %or chemo/ines 0. 1+2 . J -oolley, % &utc$in#on, J + !eeder, J - "a/ura, and 0 +ort1# Review ,ic/le cell disease) a re$ie* S , !o#eff Report +onsortium %or 'lood 3roup 3enes 0+'332) 4008 report G 0 ,enomme, + M -e#t$off, ' +a#til$o, and M E !eid for t$e +BGG Special Dedication 56 7ohn 7udd8 9I'M,8 MI'iol , Mallory

Letter from the Editors

Announcements

Advertisements

Instructions for Authors

,andra :ance8 M,8 M&0 ,+;2,'' %$iladelp$ia, %enn#yl2ania +onnie M6 5estho%%8 ;h.8 M&0 ,+;2,'' %$iladelp$ia, %enn#yl2ania

Editors in Chief

Managing Editor

+ynthia 9lic/inger8 M&0 ,+;2,'' %$iladelp$ia, %enn#yl2ania

!echnical Editor

Senior Medical Editor

3eralyn M6 Meny8 M. %$iladelp$ia, %enn#yl2ania

+hristine <omas!9rancis8 M,c Ne* 3or4 +ity, Ne* 3or4

Associate Medical Editors

.a$id Moolten8 M. %$iladelp$ia, %enn#yl2ania 1alph 16 =assallo8 M. %$iladelp$ia, %enn#yl2ania

Editorial "oard
;atricia rndt8 M&0 ,+;2,'' %omona, +alifornia 7ames ;6 u'uchon8 M. 'ebanon, Ne* &amp#$ire Martha 16 +ombs8 M&0 ,+;2,'' ,ur$am, Nort$ +arolina 3eo%%rey .aniels8 ;h. Bri#tol, 5nited "ingdom nne 96 >der8 M. -a#$ington, ,i#trict of +olumbia 3eorge 3arratty8 ;h.8 91+;ath %omona, +alifornia 'renda 76 3rossman8 M. St 'oui#, Mi##ouri 56 7ohn 7udd8 9I'M,8 MI'iol 0nn 0rbor, Mic$igan +hristine <omas!9rancis8 M,c Ne* 3or4 +ity, Ne* 3or4 3ary Moro%%8 ;h. !oc42ille, Maryland 7ohn 76 Moulds8 M&0 ,+;2,'' S$re2eport, 'oui#iana ;aul M6 :ess8 M. Baltimore, Maryland 7oyce ;oole8 9I'M, Bri#tol, 5nited "ingdom Mar/ ;opo$s/y8 M. Braintree, Ma##ac$u#ett# Marion >6 1eid8 ;h.8 9I'M, Ne* 3or4 +ity, Ne* 3or4 ,6 3erald ,andler8 M. -a#$ington, ,i#trict of +olumbia 7ill 16 ,torry8 ;h. 'und, S*eden .a$id 96 ,tronce/8 M. Bet$e#da, Maryland

Emeritus Editorial "oard

.elores Mallory8 M&0 ,+;2,'' Supply, Nort$ +arolina

Editorial Assistant
7udith brams

#roduction Assistant #roofreader

Marge Manigly <ucy (ppenheim

Cop$ Editor
Mary <6 &od

Electronic #u%lisher
5ilson &ang

Immunohematology i# publi#$ed 6uarterly 7Marc$, June, September, and ,ecember8 by t$e 0merican !ed +ro##, National &ead6uarter#, -a#$ington, ,+ 20009 Immunohematology i# inde:ed and included in Index Medicus and ME,'.NE on t$e ME,'0!S #y#tem ;$e content# are al#o cited in t$e EB0SE<E:cerpta Medica and El#e2ier B.(B0SE<+urrent 0*arene## in Biological Science# 7+0BS8 databa#e# ;$e #ub#cription price i# =>0 00 75 S 8 and =50 00 7foreign8 per year Sub#cription#, +$ange of 0ddre##, and E:tra +opie#? Immunohematology, % ( B(@ >0A25, %$iladelp$ia, %0 B9B09 (r call 72B58 >5BC>902 -eb #ite? *** redcro## org<immuno$ematology +opyrig$t 2009 by ;$e 0merican National !ed +ro## .SSN 0D9>C20A@

Invited Review: Milestones Series

Milestones in la%orator$ procedures and techni&ues

M&E& Reid

$en . left England in B999, $emagglutination *a# done by #edimentation .n Ne* 3or4, . *a# introC duced to centrifugation a# a met$od to #peed t$e proce## Bot$ approac$e# accompli#$ed #imilar goal#, but one *a# more time efficient 5#e of ot$er tec$ni6ue#, #uc$ a# -e#tern immunoblotting, cloning gene#, and polymera#e c$ain reaction, made it po##ible to gain muc$ 4no*ledge about blood group antigen# Immunohematology "eginnings .n B9E5, Sandy Elli#or and . from +entral +alifornia !egion of t$e 0merican !ed +ro## 70!+8 and &elen GlidC den from 0!+ &ead6uarter# 2olunteered to coCedit t$e fir#t American Red Cross Reference Laboratory Newsletter ;$e purpo#e of t$i# ne*#letter, *$ic$ *a# for t$e tec$noloC gi#t# and by t$e tec$nologi#t#, *a# to #$are tec$ni6ue# and tec$nical tip#, educate, and mentor in tec$nical *riting ;$e fir#t year 7B9E98, t$e ne*#letter *a# lo*Ctec$F it *a# #imply p$otocopied ;$at year, t$e 0!+ !eference 'aboratory +ommittee ran a competition and by popular 2ote t$e ne*#C letter *a# renamed t$e Red Cell Free Press 0nd to impro2e it# appearance it *a# printed ;$i# informal ne*#letter *a# publi#$ed for D year#, until in B9D> it e2ol2ed into Immuno- hematology under t$e able editor#$ip of ,elore# Mallory B ,uring t$e 25Cyear life of Immunohematology, tec$ni6ue# e2ol2ed t$at allo*ed t$e gat$ering of an ama/ing amount of 4no*ledge about blood group# and t$e membrane comC ponent# on *$ic$ t$ey are carried ,e#pite t$i# e2olution, to t$i# day *e #till mainly rely on $emagglutination 7direct and indirect8 for detection and identification of antibodie# to blood group antigen# and for te#ting for incompatibility ;$i# ama/ing tec$ni6ue i# $ard to beat in term# of #en#iti2iC ty and #pecificity t$at are appropriate for #afe tran#fu#ion# Earl$ Immunohematolog$ !esting #ractices .n t$e era before t$e ARC Newsletter, it *a# commonC place to perform e:ce##i2e te#ting 7e g , te#ting at room temperature, u#e of en/ymeCtreated !B+# at temperature# belo* AEG+, ab#orbing eluate# from autoimmune $emoC lytic anemia ca#e#, and performing minor cro##matc$e#8 on a #ingle blood #ample )ortunately, Eloi#e Giblett in t$e early B990# ad2ocated #topping unnece##ary te#tingF #$e belie2ed te#ting #$ould be done a# clo#e to p$y#iologic conC dition# a# po##ible, i e , te#ting at AEG+ u#ing pla#maC#u#C pended !B+# &er rea#oning *a# #c$olarly and logical and c$anged t$e *ay te#ting *a# 7and i#8 done GiblettH# laboraC
IMMUNOHEMATOLOGY, Volume !, Num"er , ##$

tory u#ed pla#maC#u#pended !B+#, *$ic$ neutrali/ed mo#t antibodie# to 'e*i# and +$<!g antigen# and t$u# t$ey did not #pend time identifying t$e#e clinically in#ignificant anC tibodie# 0bandonment of unnece##ary te#ting dramatically impro2ed t$e efficiency of te#ting by manual $emagglutinaC tion and did not $a2e a noticeable negati2e impact on t$e efficacy of tran#fu#ion (t$er c$ange#, *$ic$ occurred *it$ t$e #ame goal, include u#ing antiC.gG in#tead of t$e broadC #pectrum reagent in routine antiglobulin te#t#, eliminating t$e routine direct antiglobulin te#t 7,0;8, and not preparC ing eluate# from all #ample# *$o#e !B+# *ere po#iti2e in t$e ,0; 0l#o in t$e late B9E0#, an e:traordinary number of cro##matc$e# *ere performed .ndeed, t$e number *a# e:C ce##i2e ;$e concept# of a Itype and #creenJ2 and a Ima:iC mum #urgical blood order #c$eduleJA *ere introduced ;$e#e approac$e# *ere 6uic4ly adopted, and t$ey reduced not only t$e number of cro##matc$e# but al#o t$e number of !B+ component# re#er2ed for a particular patient Soon after, t$e #ugge#tion to drop t$e antiglobulin cro##matc$ for patient# *$o $ad a negati2e antibody #creen *a# unC lea#$ed >K9 ,e#pite concern# t$at antibodie# to antigen# not e:pre##ed on #creening !B+# 7e g , antiC-ra8 *ould be mi##ed, t$i# practice i# no* commonplace .ndeed, t$e p$y#ical immediateC#pin cro##matc$ i# no* fre6uently reC placed by a computer cro##matc$ E 'se of Enhancement Reagents and (onserologic !echni&ues (ld #tandby tec$ni6ue# #uc$ a# #aline and albumin fell from fa2or and *ere largely replaced by lo*CionicC#trengt$ #olution 7'.SS8 met$od# in t$e midCB9E0#D and by '.SSCadC diti2e #olution# #$ortly t$ereafter '.SS rapidly gained popuC larity becau#e it #imultaneou#ly reduced incubation time and increa#ed #en#iti2ity .n B9D>, t$e #ame year t$at t$e fir#t 2olC ume of Immunohematology appeared, a #olidC p$a#e ad$erC ence a##ay for detection of antibodyCantigen reaction# *a# introduced )or a re2ie* of t$i# tec$nology, #ee Bec4 et al 9 Sub#e6uently, ot$er tec$ni6ue# *ere reported and 6uic4ly became popularF t*o e:ample# are t$e u#e of polyet$ylene glycol 7%EG8 a# a potentiator of antibodyCantigen reaction# in B9DEB0 and t$e column agglutination tec$nology, u#ing a gel a# t$e #upport medium, in B990 BB 0utomated a##ay# ba#ed on $emagglutination and manual or automated #olidC p$a#e ad$erence a##ay# are no* in u#e, but t$ey $a2e not replaced $emagglutination te#t# in tube# in many #etting#
%$

Many reagent# became commercially a2ailable, and a# compliance re6uirement# became more #tringent, laboraC torie# reduced t$e number of reagent# t$ey prepared inC $ou#e Safety concern# prompted many c$ange# )a2orite met$od# fell from grace, #uc$ a# t$e u#e of et$erLa# a reC #ult of concern# about it# lo* fla#$ point 0l#o, teratogenic, carcinogenic, and neuroto:ic c$emical# became le## readC ily a2ailable 0*arene## of t$e potential $a/ard# of *or4C ing *it$ certain c$emical# and *it$ blood #ample# t$at may contain 2ariou# pat$ogen# led to t$e #trict re6uirement to *ear per#onal protecti2e e6uipment #uc$ a# glo2e#, laboraC tory coat#, eye protection, and clo#edC toed #$oe# ;$e longC #tanding practice of drin4ing, eating, and #mo4ing in t$e laboratory *a# aboli#$ed ;$e 2alue of proteolytic en/yme#, notably ficin, for enC $ancing t$e reacti2ity of #ome antibodyCantigen reaction# *$ile *ea4ening or ablating ot$er# $a# been appreciated for many year# B2 (t$er red cell modification# #uc$ a# diC t$iot$reitol 7,;;8, tryp#in, and 'Cc$ymotryp#inBA *ere inC troduced &o*e2er, it too4 #ome time before t$e full po*er of u#ing t$e combination 7i e , te#ting !B+# treated *it$ ficin or papain, tryp#in, 'Cc$ymotryp#in, or ,;;8 of t$e#e met$od# to aid in antibody identification *a# appreciated 0lt$oug$ cla##ic antibody identification approac$e# 7and appropriate control#8 are #till nece##ary to name an antiC body #pecificity po#iti2ely, a #y#tem of parallel te#ting of t$e #ame !B+# untreated and treated *it$ different reagent# pro2ide# a 2aluable tool in $elping to guide u# in t$e rig$t diC rection, *it$out re6uiring a 2a#t library of rare reagent# B>,B5 -$en u#ing en/yme# for t$i# purpo#e, it i# important to include a negati2e 7or auto8 control, a# a proportion of $uman #era contain antibodie# t$at attac$ to !B+# treated *it$ a proteolytic en/yme 'se of Monoclonal Reagents )or many year#, *e *ere dependent on polyclonal antiC bodie# from $uman or rabbit #era or from plant lectin# #uc$ a# icia graminea, !lex euro"eaus, and #olichos biflorus for blood grouping reagent# .n B9E5, "M$ler and Mil#tein de#cribed a tec$ni6ue to fu#e murine myeloma cell# *it$ antibodyC#ecreting B cell# to produce monoclonal antibodC ie# B9 ;$i# tec$ni6ue *a# embraced, and monoclonal anC tibodie# *ere produced to $ig$ly immunogenic antigen# #uc$ a# to carbo$ydrate $uman blood group antigen# 70 and B, 'e*i#, and %B8 and $ig$ copy number glycoprotein# 7M, N8 BE .t too4 #e2eral year# before $uman B cell# *ere u#ed in place of mou#e cell# -it$ t$i# ad2ancement came t$e production of monoclonal antiC, in B9DA B9 MonocloC nal antibodie# *it$ ot$er #pecificitie# $a2e been made in t$e la#t 25 year# B9 ;$ey are no* t$e predominant #ource of typing reagent#, and t$ree international *or4#$op# $a2e been $eld to #tudy reaction c$aracteri#tic# of numerou# monoclonal antibodie# Monoclonal antibodie# $a2e $ad a maNor impact on our ability to define 2ariant !B+#, e#peC cially partial , antigen#, and to optimi/e tec$ni6ue# #uc$ a# flo* cytometry and -e#tern immunoblotting Molecular

biology tec$ni6ue# $a2e made it po##ible to con2ert murine .gG monoclonal antibodie# to $uman .gG or directly aggluC tinating .gM 20 !echni&ues to #redict Clinical Significance of Anti %odies &emagglutination detect# antibodie#, but in it#elf doe# not predict t$eir clinical #ignificance +riteria #uc$ a# titer, p$a#e of reacti2ity, .g cla##, .gG #ubcla##, and #pecificity 7and t$e $i#toric 4no*ledge of t$e clinical #ignificance of an antibody in ot$er patient#8 are u#eful indicator# but are not une6ui2ocally good predictor# of clinical #ignificance ;$e monocyte monolayer a##ay 7MM08 i# a# clo#e to condition# in 2i2o a# i# po##ible to e#tabli#$ in 2itro and pro2ide# inC #ig$t into t$e potential clinical #ignificance of an antibody .t $a# been applied to predicting t$e clinical rele2ance of antibodie# in tran#fu#ion 2B and $emolytic di#ea#e of t$e ne*born,22K2> but i# a $ig$ly #peciali/ed and tec$nically difC ficult te#t t$at belong# in a #mall number of laboratorie# 0not$er tec$ni6ue, flo* cytometry, $a# been u#ed to detect minor !B+ population# in a fetal maternal $emorr$age and to follo* t$e #ur2i2al of tran#fu#ed !B+#,25,29 to determine t$e do#age of a blood group antigen on !B+#,2E and 6uantiC tation of !B+Cbound .gG 2D Numerou# tec$ni6ue# $a2e been u#ed to identify alC loantibodie# underlying autoantibodie# 29KA2 0ll are timeC con#uming, a# are met$od# to #eparate patient !B+# from t$o#e of tran#fu#ed donor !B+# #o t$at t$e patientH# !B+# can be p$enotyped AA -a#$ing perip$eral blood !B+# from tran#fu#ed patient# *it$ #ic4le cell di#ea#e *it$ a $ypotonC ic #olution i# a #imple and cle2er tec$ni6ue to obtain t$e patientH# !B+# for typing by $emagglutination A> 0lt$oug$ t$e#e tec$ni6ue# $a2e 2alue, t$ey al#o $a2e limitation# Molecular !esting 0lt$oug$ $emagglutination remain# t$e predominant te#t for detecting antibodyCantigen interaction#, unrelated tec$ni6ue# $a2e pro2ided in#ig$t into !B+ component# t$at carry blood group antigen# .n t$e decade before Immunohematology fir#t appeared, t$e -e#tern immunoC blotting met$od *a# u#ed e:ten#i2ely to #tudy c$aracteri#C tic# of component# carrying blood group# ;$i# approac$, toget$er *it$ cloning and #e6uencing of t$e gene# encoding blood group antigen#, A5 $a# re2ealed #e6uence $omology to 4no*n protein# in ot$er cell type# and pro2ided in#ig$t# into t$e #tructure and function of t$e !B+ membrane comC ponent# carrying blood group# 7;able B8 A9 ;$e cloning and #e6uencing of gene# laid t$e groundC *or4 for analy#i# of many allele# encoding 2ariant blood group antigen# and p$enotype# and, t$u#, our ability to te#t ,N0 by t$e polymera#e c$ain reaction 7%+!8 to predict a blood group Sub#e6uent manufacturing of mac$ine# to automatically perform %+! amplification made it po##ible to perform t$i# tec$ni6ue in a clinical laboratory #etting %+!Cba#ed te#t# on ,N0 to predict a

blood type $a2e #e2eral application# t$at pro2ide a #ub#titute for p$enotyping AE ;$e

Milestones in l("or(tor) *ro+edures (nd te+,ni-ues

pre#ence of donor !B+# in a patientH# blood #ample or .gG on !B+# 7po#iti2e ,0;8 doe# not interfere *it$ t$e te#t# !B+# are not re6uired to type a fetu# at ri#4 for $emolytic di#ea#e of t$e ne*born 7;able 28 ;$u#, during t$e life of Immunohematology, *e $a2e $ad a re2er#al of p$enotype and genotype -e u#ed to p$enotype !B+# to predict t$e genotypeF no* *e te#t ,N0 to predict t$e p$enotype, bot$ *it$ t$e under#tanding t$at 2ariant and null allele# e:i#t .f $ig$Ct$roug$put platform# *ere ine:pen#i2e enoug$, ,N0 te#ting and prediction of antigen type# could be u#ed a# a #creening met$od to increa#e antigenCnegati2e in2enC torie# -$ere anti#era are a2ailable, negati2e ,N0 #creening re#ult# could be confirmed by $emagglutination met$od#, t$ereby con#er2ing reagent# -$en anti#era are not a2ailC able, 7e g , antiC,ob, antiC&y8 t$e predicted type i# often more reliable t$an t$e cro##matc$ ;$e a2ailability of increa#ed in2entorie# of !B+ component# *it$ 2ariou# combination# of antigenCnegati2ity *ould ma4e it po##ible to more preci#ely matc$ a patientH# p$enotype, before t$e patient *a# immuni/ed ;$e tec$ni6ue could be u#ed to e#C #entially eliminate repetiti2e timeCcon#uming tec$ni6ue# needed to identify underlying alloantibodie# in ca#e# of *arm autoimmune $emolytic anemia and antibodie# to $ig$Cpre2alence antigen#

!a%le .- 2otenti(l uses o= 3NA>"(sed (ss()s

To t)*e *(tients w,o ,(ve "een re+entl) tr(ns=used To identi=) ( =etus (t ris? =or ,emol)ti+ dise(se o= t,e new"orn To t)*e *(tients w,ose R16s (re +o(ted wit, immuno<lo"ulin @*ositive 3ATA To t)*e *(tients wit, AIHAB to sele+t (nti<en>ne<(tive R16s =or ("sor*> tion o= (uto(nti"odies w,en se(r+,in< =or underl)in< (llo(nti"odies To t)*e donors, in+ludin< m(ss s+reenin< =or (nti<en>ne<(tive donors, w,en (**ro*ri(te (ntiser( (re not re(dil) (v(il("le To t)*e donors =or use on (nti"od) identi=i+(tion *(nels w,en (ntiser( (re not (v(il("le To t)*e *(tients w,o ,(ve (n (nti<en t,(t is e0*ressed we(?l) on R16s To resolve "lood <rou* A, 1, (nd 3 dis+re*(n+ies To stud) unusu(l (nd novel serolo<i+ re(+tions

BAIHA C (utoimmune ,emol)ti+ (nemi(

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Modification# of cla##ic $emagglutination, *$ic$ inC crea#ed it# #en#iti2ity and #pecificity and reduced t$e time it ta4e# to perform t$e te#t, $a2e contributed to t$e #afe tran#fu#ion practice a# *e 4no* it today 0lt$oug$ -e#tC ern immunoblotting and %+!Cba#ed a##ay# $a2e led to an under#tanding of t$e function and #tructure of !B+ membrane component# carrying blood group#, $emagglutination remain# t$e *or4$or#e of immuno$ematology te#ting &o*e2er, de#pite all our ad2ance#, error# in identification and clerical error# are #till t$e big problem, and 0B( incompatibility remain# a primary Adsor%ed cau#e of pre2entable tran#fu#ionCrelated fataliC LE tie# ADK>0 0ppro:imately $alf of t$e error# occur *$en blood i# tran#fu#ed to t$e *rong patient Sample collection error, i e , dra*ing blood from t$e *rong patient or mi#labeling t$e #ample, i# al#o re#pon#ible for t$e blood being tran#fu#ed to t$e *rong patient >B &emagglutiC nation in tube# doe# not re6uire #op$i#ticated e6uipment .t i# #imple, ine:pen#i2e 7alt$oug$ antibodie# are becoming e:pen#i2e and tec$C nologi#t co#t# con#tantly ri#e8, #en#iti2e, #peC cific, and reproducible .t remain# t$e ba#ic met$od for detecting reaction# bet*een !B+# and antibodie# Ac+nowledgments . t$an4 Ste2e %ierce for $elpful #ugge#C tion# and !obert !atner for $elp in preparing t$e manu#cript

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IMMUNOHEMATOLOGY, Volume !, Num"er , ##$

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References B Mallory , Mile#tone# in .mmuno$ematology B9D>C 2009, .mmuno$ematology 2009F25?9KD 2 Boral '., &enry JB ;$e type and #creen? a #afe alterC nati2e and #upplement in #elected #urgical procedure# ;ran#fu#ion B9EEFBE?B9AKD A )riedman B0, (berman &0, +$ad*ic4 0!, "ingdon ". ;$e ma:imum #urgical blood order #c$edule and #urgical blood u#e in t$e 5nited State# ;ran#fu#ion B9E9FB9?AD0KE (berman &0, Barne# B0, )riedman B0 ;$e ri#4 of abC bre2iating t$e maNor cro##matc$ in urgent or ma##i2e tran#fu#ion ;ran#fu#ion B9EDFBD?BAEK>B Garratty G ;$e role of compatibility te#t# 7!eport of a meeting #pon#ored by t$e Bureau of Biologic# for t$e Blood %roduct# 0d2i#ory +ommittee8 ;ran#fu#ion B9D2F22?B99KE2 Garratty G 0bbre2iated pretran#fu#ion te#ting 7editoC rial8 ;ran#fu#ion B9D9F29?2BEKB9 Butc$ S&, Judd -J, Steiner E0, Stoe M, (berman &0 Electronic 2erification of donorCrecipient compatibility? t$e computer cro##matc$ ;ran#fu#ion B99>FA>?B05K9 Moore &+, Molli#on %' 5#e of a lo*CionicC#trengt$ medium in manual te#t# for antibody detection ;ran#C fu#ion B9E9FB9?29BK9 Bec4 M', %lapp )V, Sinor ';, !ac$el JM SolidCp$a#e tec$ni6ue# in blood tran#fu#ion #erology 7re2ie*8 +rit !e2 +lin 'ab Sci B9D9F22?ABEK>2 Nance SJ, Garratty G 0 ne* potentiator of red blood cell antigenCantibody reaction# 0m J +lin %at$ol B9DEFDE?9AAK5 'apierre 3, !igal ,, 0dam J, et al ;$e gel te#t? a ne* *ay to detect red cell antigenCantibody reaction# ;ran#fu#ion B990FA0?B09KBA Morton J0, %ic4le# MM ;$e proteolytic en/yme te#t for detecting incomplete antibodie# J +lin %at$ol B95BF>?BD9K99 Jud#on %0, 0n#tee ,J +omparati2e effect of tryp#in and c$ymotryp#in on blood group antigen# Med 'ab Sci B9EEFA>?BK9 ,aniel# G Effect of en/yme# on and c$emical modificaC tion# of $ig$Cfre6uency red cell antigen# .mmuno$eC matology B992FD?5AKE !eid ME, 'oma#C)ranci# + Blood group antigen# and antibodie#? a guide to clinical rele2ance and tec$nical tip# Ne* 3or4? Star Brig$t Boo4#, 200E "o$ler G, Mil#tein + +ontinuou# culture# of fu#ed cell# #ecreting antibody of predefined #pecificity Nature B9E5F259?>95KE Barn#table +J, Bodmer -), Bro*n G, et al %roduction of monoclonal antibodie# to group 0 eryt$rocyte#, &'0 and ot$er $uman cell #urface antigen#? ne* tool# for genetic analy#i# +ell B9EDFB>?9K20

> 5

9 E D 9 B0 BB B2 BA B> B5 B9 BE

BD +ra*ford ,&, Barlo* MJ, &arri#on J), -inger ', &ue$n# E! %roduction of $uman monoclonal antiC body to r$e#u# , antigen 'ancet B9DAFB?AD9KD B9 0n#tee ,J, %ar#on# S), Mallin#on G, Spring )0, Jud#on %0, Smyt$e J +$aracteri/ation of monoclonal antibodC ie# again#t eryt$rocyte #ialoglycoprotein# by #erological analy#i#, immunoblotting and flo* cytometry !e2 )r ;ran#fu# .mmuno$ematol B9DDFAB?ABEKA2 20 &uang ;J, !eid ME, &al2er#on G!, 3a/danba4$#$ " %roduction of recombinant murineC$uman c$imeric .gM and .gG antiCJ#b for u#e in t$e clinical laboratory ;ran#fu#ion 200AF>A?E5DK9> 2B Nance SJ, 0rndt %, Garratty G %redicting t$e clinical #ignificance of red cell alloantibodie# u#ing a monocyte monolayer a##ay ;ran#fu#ion B9DEF2E?>>9K52 22 Nance SJ, Nel#on JM, &oren#tein J, 0rndt %0, %latt ',, Garratty G Monocyte monolayer a##ay? an effiC cient nonin2a#i2e tec$ni6ue for predicting t$e #e2erity of $emolytic di#ea#e of t$e ne*born 0m J +lin %at$ol B9D9F92?D9K92 2A 'uca# G), &adley 0G, Nance SJ, Garratty G %redicting $emolytic di#ea#e of t$e ne*born? a compari#on of t$e monocyte monolayer a##ay and t$e c$emilumine#cence te#t ;ran#fu#ion B99AFAA?>D>KE 2> &unt JS, Bec4 M', -ood G- MonocyteCmediated eryt$rocyte de#truction? a comparati2e #tudy of current met$od# ;ran#fu#ion B9DBF2B?EA5KD 25 Nance SJ, Nel#on JM, 0rndt %0, 'am &+, Garratty G Ouantitation of fetalCmaternal $emorr$age by flo* cytometry? a #imple and accurate met$od 0m J +lin %at$ol B9D9F9B?2DDK92 29 Nance SJ, Garratty G 0pplication of flo* cytometry to immuno$ematology J .mmunol Met$ B9DEFB0B?B2EK AB 2E (ien ', Nance S, 0rndt %, Garratty G ,etermination of /ygo#ity u#ing flo* cytometric analy#i# of red cell antiC gen #trengt$ ;ran#fu#ion B9DDF2D?5>BK> 2D Garratty G, Nance SJ +orrelation bet*een in 2i2o $emoly#i# and t$e amount of red cellCbound .gG meaC #ured by flo* cytometry ;ran#fu#ion B990FA0?9BEK2B 29 !eid ME, Elli#or SS 0b#orption of *arm autoantibodC ie# u#ing glutaralde$ydeCtreated $uman red cell# 0m J Med ;ec$nol B9D2F>D?9E9KD> A0 Branc$ ,!, %et/ ', 0 ne* reagent 7PP0%8 $a2ing multiple application# in immuno$ematology 0m J +lin %at$ol B9D2FED?B9BKE AB !eid ME, ;oy %;+3 5#e of pre#er2ed autologou# red blood cell# to ab#orb *arm autoantibodie# from t$e #erum of patient# recei2ing blood tran#fu#ion t$erapy Vo: Sang B9D>F>9?A55K9 A2 'eger !M, Garratty G E2aluation of met$od# for deC tecting alloantibodie# underlying *arm autoantibodC ie# ;ran#fu#ion B999FA9?BBKB9

AA !eid ME, ;oy %;+3 Simplified met$od for reco2ery of autologou# red blood cell# from tran#fu#ed patient# 0m J +lin %at$ol B9DAFE9?A9>K9 A> Bro*n ,J 0 rapid met$od for $ar2e#ting autologou# red cell# from patient# *it$ $emoglobin S di#ea#e ;ran#fu#ion B9DDF2D?2BKA A5 'Mgdberg ', !eid ME, 'amont !E, Pelin#4i ; &uman blood group gene# 200>? c$romo#omal location# and cloning #trategie# ;ran#f Med !e2 2005FB9?>5K5E A9 !eid ME, Mo$anda# N !ed blood cell blood group antigen#? #tructure and function Semin &ematol 200>F>B?9AKBBE AE !eid ME 0pplication# of ,N0Cba#ed a##ay# in blood group antigen and antibody identification ;ran#fu#ion 200AF>A?BE>DK5E AD 'inden JV, %aul B, ,re##ler "% 0 report of B0> tran#fu#ion error# in Ne* 3or4 State ;ran#fu#ion B992FA2?90BK9 A9 S$ulman .0, "ent , 5nit placement error#? a potential ri#4 factor for 0B( and !$ incompatible blood tran#fuC #ion# 'ab Med B99BF22?B9>K9 >0 -illiam#on 'M, 'o*e S, 'o2e EM, et al Seriou# $a/C ard# of tran#fu#ion 7S&(;8 initiati2e? analy#i# of t$e fir#t t*o annual report# BMJ B999FAB9?B9KB9 >B Sa/ama " !eport# of A55 tran#fu#ionCa##ociated deat$#? B9E9 t$roug$ B9D5 ;ran#fu#ion B990FA0?5DAK90

Marion E !eid, %$,, ).BMS Editorial Board Immunohematology

Attention: State "lood "an+ Meeting Organi/ers (otice to Readers Immunohematology$ %ournal of &lood 'rou" (erology and )ducation$ i# printed on acidCfree paper .f you are planning a #tate meeting and *ould li4e copC ie# of Immunohematology for di#tribution, plea#e #end re6ue#t, > mont$# in ad2ance, to immunoQu#a redcro## org

6(se Re*ort

Anti 0pa1induced severe dela$ed hemol$tic transfusion reaction

R& 5os,), 1& 2(tel, (nd 7&S& H(rrison
"pa i# a lo*Cfre6uency antigen occurring in le## t$an 2 percent of t$e +auca#ian population Mild to moderate delayed $emolytic tran#fu#ion reaction# 7,&;!8 and $emolytic di#ea#e of t$e fetu# and ne*born attributable to antiC"pa $a2e been reported Se2ere o2ert ,&;! $a# not been reported *it$ antiC"pa 0 ca#e of a #eC 2ere ,&;! attributed to antiC"pa after multiple !B+ tran#fu#ion# i# being reported 0 52CyearCold +auca#ian *oman recei2ed mulC tiple unit# of !B+# for a lo*er ga#trointe#tinal bleed S$e *a# reC ferred to our in#titution for $epatic and renal failure, *$ic$ *a# #upported by laboratory finding# of pea4 ',&, bilirubin, B5N, and creatinine ele2ation# &emoglobin $ad dropped on ,ay B0 after tran#fu#ion ;$e ,0; and antibody #creen 70BS8 *ere negaC ti2e .nitial *or4up and #ub#e6uent 0BS *ere negati2e 0ntiC"p a *a# identified *$en an additional !B+ panel *a# te#ted (ne of t$e !B+ unit# tran#fu#ed *a# incompatible by anti$uman globuC lin 70&G8 cro##matc$ *it$ t$e patientH# pla#ma and typed po#iti2e for "pa ,&;! *a# confirmed after e:ten#i2e *or4up ;$e patient re#ponded to #upporti2e t$erapy and e:perienced an une2entful reco2ery ,&;! may not be con#idered *$en ,0; and 0BS are negati2e &o*e2er, correlation of recent tran#fu#ion *it$ #ign# and #ymptom# #$ould alert t$e clinician to entertain and in2e#tiC gate a ,&;! t$at #$ould include t$e 0&G cro##matc$ of all impliC cated !B+ unit# ;$e #e2erity of t$e reaction al#o rai#e# concern# a# to *$en and *$at antigen #pecificity #$ould be con#idered for inclu#ion in t$e antibody #creening cell# Immunohematology 4009?45)44#47

0 52CyearCold +auca#ian *oman pre#ented to t$e emerC gency room complaining of being lig$tC$eaded and $a2ing

"

pa 7"E' A, %enney8 i# one of AB antigen# in t$e "ell 7.SB; #ymbol, "E'8 blood group #y#tem ;$e "ell antigen#, encoded by *)L, located on c$romo#ome E6AA, appear to be eryt$roid #pecific and are found in t$e fetal li2er and in bone marro* cell# B "pa i# a lo*Cincidence antigen found in le## t$an 2 percent of +auca#ian# B,2 ;$e antigen i# re#i#tant to t$e effect# of en/yme treatment but i# #en#iti2e to treatment *it$ dit$iot$reitol and acid Mild to moderate delayed $emolytic tran#fu#ion reaction 7,&;!8 and mild to moderate $emolytic di#ea#e of t$e fetu# or ne*born 7&,)N8 $a2e been reported a# *ell a# a ca#e of $ydrop# fetali# attributed to antiC"pa A ;$e antibody i# an .gG >K9 Suppre##ion of eryt$ropoie#i# by antiC"pa $a# been reported a# t$e cau#e of decrea#ed $emoglobin in &,)N E !eport# of an o2ert ,&;! attributable to #e2eral antibodie# mi##ed in t$e antibody #creen and immediateC #pin cro##C matc$ mention antiC"pa a# one of t$e antibodie# D &o*e2er, t$ere $a2e been no reported ca#e# of #e2ere o2ert ,&;! a# a re#ult of antiC"p a a# per ME,'.NE #earc$ Case Report

rectal bleeding, nau#ea, *ea4ne##, and di//ine## !ectal e:C amination confirmed t$e rectal fi##ure# and bleeding ;$ere *ere no ot$er remar4able finding# noted on p$y#ical e:amC ination E+G #$o*ed #inu# tac$ycardia at B09 beat#<min S$e *a# admitted for furt$er *or4up and for !B+ tran#fuC #ion# %a#t $i#tory *a# negati2e for prior tran#fu#ion# %atient $a# an adult #on *$o *a# li#ted a# a contact per#on, and no ot$er pregnancy $i#tory *a# a2ailable S$e $ad left renal angiopla#ty #e2eral year# ago for left renal artery #teno#i# S$e $ad a $i#tory of rectal fi##ure# S$e i# a #mo4er 72 pac4# per day8 and drin4# occa#ionally S$e $a# a $i#tory of alC lergy to amitriptyline

Anti>5*(Dindu+ed 3HTR

)ig- , Hemo<lo"in @H"E <8dLA (nd ,em(to+rit @H+tE FA v(lues =or d() # to d() /% (re s,own&

)ig- . Al?(line *,os*,(t(se @Al? 2,osA, l(+t(te de,)dro<en(se @L3HA, (nd +re(tine *,os*,o?in(se @625A v(lues =or d() # to d() /. (re s,own&

! a%le ,- L("or(tor) d(t( =rom t,e re=errin< ,os*it(l

!ests Hemo<lo"in Hem(to+rit 916 2l(telets Reti+ulo+)tes 2T Glu+ose Al?(line *,os*,(t(se 1UN 6re(tinine AST ALT L3H 625 Tot(l "iliru"in 3ire+t "iliru"in A1O, 3 Anti"od) s+reen 3AT Urin(l)sis 1iliru"in Uro"ilino<en :ree ,emo<lo"in (ormal range Admission .&!D// <8dL %HFD.JF .&!D//&# 0 /#$8dL / #,###D .!#,###8KL #&$FD/&$F //&!D/.&G s H!D/## m<8dL %#D/%% U8L GD / m<8dL #&!D/&. m<8dL !D%$ U8L GD!H U8L %%%DH$$ U8L %!D %# U8L #& D/&% m<8dL #&#D#&. m<8dL I I I H&/ /$&H $&$ H J,### I /%&J / ! /%J /J #&J %/ /$ I JG #&% I O 3 *ositive Ne<(tive I I Ne<(tive L/ m<8dL Ne<(tive 3() / I I I I I I /. I I I I ! / . ! I I I I I I #atient results 3() G I I I I I I I #% /J /&# I I %$J% GH%G I I I I I I I 3() /# J&G H&$ I I I /%&! I // %H .& /H/ //% I I /&J I O 3 *ositive Ne<(tive I I Moder(te . m<8dL L(r<e . .H !&H ! $ /HJ G$#! I %&! .&G O 3 *ositive Ne<(tive Ne<(tive %$% !/ H& %#% / # /! I /J&% /H&/ I I I I 3() // /#& %/& I I .&/ /!& 3() / $&$ $&% I I I /J&/

H1sA<, H1+ (nti"od), H1s (nti"od), (nd ,e*(titis 6 (nti"od)I(ll nonre(+tive

tran#fu#ed 5rinaly#i# on ,ay BB #$o*ed e2idence of increa#ed free $emoglobin, bilirubin, and uroC bilinogen +omputed tomograp$ic #can and magnetic re#onance imC aging to rule out acute c$olecy#titi# re2ealed an enlarged gallbladder *it$ t$ic4ened *all and inflammaC tion of adNacent area#, reported a# #u#piciou# for c$olecy#titi# 'i2er, #pleen, and pancrea# *ere *it$in normal limit# ;$ere *a# al#o e2iC dence of atrop$ic left 4idney and $ypertrop$ic rig$t 4idney *it$ #eC 2ere #teno#i# of a #egment of t$e rig$t renal artery clo#e to it# origin ;$e patient recei2ed A additional unit# of !B+# bet*een ,ay# B0 and BB for t$e drop in $emoglobin (n t$e BAt$ day of $er $o#pital cour#e, #$e *a# admitted to t$e reC ferral $o#pital, our in#titution, for in2e#tigation of acute li2er and reC nal failure ,&;! *a# #u#pected, and a *or4up *a# ordered by t$e $ematologi#t %igment nep$ropaC t$y attributable to intra2a#cular $emoly#i# *a# con#idered a# t$e cau#e for t$e acute renal failure ;$e cau#e of t$e #e2ere $epatoto:C icity could not be a#certained

Materials and Methods 0t t$e referral $o#pital, 0B( and , typing# *ere performed u#ing t$e ALT C (l(nine (minotr(ns=er(seE AST C (s*(rt(te (minotr(ns=er(seE 1UN C "lood ure( nitro<enE (rt$o 0<B<, Monoclonal and !eC 625 C +re(tine *,os*,o?in(seE H1+ (nti"od) C ,e*(titis 1 +ore (nti"od)E H1s (nti"od) C ,e*(titis 1 sur=(+e (nti"od)E H1sA< C ,e*(titis 1 sur=(+e (nti<enE 2T C *rot,rom"in timeE 916 2er#e Grouping +ard 7(rt$oC C w,ite "lood +ell +ount& +linical ,iagno#tic#, .nc , !aritan, NJ8 0ffirC magen reagent !B+# 7pooled cell#8, 0dmi##ion &b *a# 9 B g<d' S$e *a# tran#fu#ed *it$ 70&G8 cro##matc$ for all !B+ unit# 5 unit# of typeC#pecific, leu4oreduced or *a#$ed 7a# per $o#pital policy8, immediateC#pin, cro##matc$Ccompatible !B+ during t$e cour#e of 2> $our# of admi##ion, *$ic$ rai#ed $er &b to B2 g<d' S$e remained $o#pitali/ed for furt$er e2aluation for ga#trointe#tinal bleed (n t$e B0t$ po#ttran#fu#ion day, $er &b dropped to D E g<d' and $er &ct *a# 29 9R &er reticulocyte count *a# > BR 7reference range, 0 9 to B 9R8 on ,ay BB ;$ere *a# no e2idence of conC tinued rectal bleed ;$ere *a# a gradual increa#e of #e2eral c$emi#try re#ult#, *$ic$ pea4ed on t$e B0t$ and BBt$ po#tC tran#fu#ion day# 7;able BF )ig# BK>8 ;$e patient appeared #e2erely Naundiced *it$ #ign# of acute li2er and renal failC ure, *$ic$ *a# #upported by $er laboratory 2alue# .n2e#tiC gation for a #u#pected ,&;! re2ealed a negati2e ,0; and a negati2e antibody #creen .n2e#tigation did not proceed to anti$uman globulin

0 DR, *ere u#ed for re2er#e typing, and antibody #creen *a# done by .gG gel card, 0 DR Surgi#creen 7Jo$n#on S Jo$n#on, Ne* Brun#*ic4, NJ8 0ntibody panel *a# performed u#ing 0 DR !e#ol2e %anel 0 7(rt$oC+linical ,iagno#tic#, .nc 8 and %anocell B9, by .mmucor, .nc 7Norcro##, G08 ;$e ,0; *a# performed u#ing antiC.gGC+Ad *it$ c$ec4 cell#, antiC.gG and c$ec4 cell#, and antiC+Ab<+Ad *it$ complement c$ec4 cell# 7.mmucor, .nc 8 !eagent# u#ed for p$enotyping *ere from .mmucor, .nc Elution *a# performed *it$ Gamma E'5C".; .. 7Gamma Biological#, .nc , &ou#ton, ;@8 follo*ing initial #aC line *a#$ 7)i#$er ,iagno#tic#, Middleton, V08 of patient cell# 0B( and , typing# and a t$reeCcell antibody #creen *ere performed by gel tec$ni6ue and read t$roug$ t$e M;S reader S0 7(rt$oC+linical ,iagno#tic#, .nc 8 ,0; *a# performed *it$ polyclonal 0&G, antiC.gG, and antiC+Ad by tube met$od and eluate panel by gel met$od u#ing (rt$o and .mmucor panel cell#

R& 5os,) et (l&

Results ;$e ,&;! in2e#tigation on t$e day of admi##ion at t$e referral $o#pital re2ealed a negati2e antibody #creen *it$ t$e t$reeCcell antibody #creen ;$e ,0; *a# negati2e 7inC cluding a B5Cminute incubation8 *it$ poly#pecific, .gG, and +Ab<+Ad 0&G 0t t$e referral $o#pital, te#t# *it$ a B9Ccell reagent !B+ panel 7.mmucor, .nc 8 re2ealed t$e pre#ence of antiC"pa 0ll ot$er clinically #ignificant antibodie# *ere ruled out Eluate prepared from ,0;Cnegati2e !B+# *a# negati2e again#t "p7aT8 !B+ on .mmucor %anocell B9 ;$e patient typed negati2e for "pa 0&G cro##matc$ *a# done from #ample# obtained from donor #egment# of t$e tran#C fu#ed !B+ unit# recei2ed from t$e blood #upplier (ne of t$e fi2e !B+ unit# tran#fu#ed on ,ay B of admi##ion *a# inC compatible *it$ t$e patientH# pla#ma and typed po#iti2e for "pa &aptoglobin *a# B mg<d' 7reference range, A>K 200 mg<d'8 0 diagno#i# of #e2ere ,&;! *it$ intra2a#cular $emoly#i# attributable to antiC"pa *a# confirmed 0# t$e patientH# renal and li2er function# impro2ed, #$e did not undergo dialy#i# or con#ideration for furt$er li2er or renal e2aluation ;$e patient *a# monitored and maintained on #upportC i2e t$erapy &er $o#pital cour#e *a# une2entful 0ll laboraC tory re#ult# returned to normal 2alue# 7)ig# BK >8 S$e *a# di#c$arged B0 day# after $er admi##ion to t$e referral $o#C pital ;able 2 pre#ent# t$e patientH# laboratory data on adC mi##ion to t$e referral $o#pital on ,ay BA
!a%le .- L("or(tor) d(t( on (dmission (t t,e re=err(l ,os*it(l, 3() /%
!est H(*to<lo"in @re=eren+e r(n<e %.D ## m<8dLA A1O, 3 @") Ort,o <elA Anti"od) s+reen @#&JF Sur<is+reenA 2(nel +ells, A 2(no+ell /H 5* t)*in< o= *(tientMs R16s
(

)ig- 2 Tot(l (nd dire+t "iliru"in v(lues =or d() # to d() # (re s,own&

)ig- 3 Al(nine (minotr(ns=er(se @ALTA (nd (s*(rt(te (minotr(ns> =er(se @ASTA v(lues =or d() # to d() # (re s,own&

Result / m<8dL O, 3 *ositive Ne<(tive Ne<(tive 2ositive @(nti>5*( identi=iedA Ne<(tive Ne<(tive Ne<(tive In+om*(ti"le, 5*@(NA 5*@(NA: /N ") tu"e (nd N ") <el te+,ni-ues

3ATIusin< *ol)+lon(l, I<G, (nd 6%"86%d AHG 2(nel wit, elu(te 6rossm(t+, wit, / o= ! units tr(ns> =used (t re=errin< ,os*it(l 5*( t)*in< o= in+om*(ti"le unit

Discussion "pa *a# fir#t de#cribed by 0llen and 'e*i# in B95E 2 ;$e "pa antigen i# a member of t$e "ell blood group #y#tem and i# carried on t$e "ell glycoprotein ;$e prototypical gene for t$e "ell protein family *a# cloned and c$aracteri/ed in t$e early B990# 9 0# di#cu##ed by 'ee and colleague#,9 t$e antigen# of t$e "ell blood group #y#tem re#ult from #ingle nucleotide c$ange# in t$e "ell protein Mo#t "ell antigen#

re#ide on t$e CCterminal domain of "ell in t$e #tructural #e6uence NCterminal to t$e /incCbinding catalytic motif, *$ic$ i# t$e maNor #ite for endot$elinCAKcon2erting en/yme acti2ity "ell antigen# are important in tran#fu#ion medicine o*ing to t$eir #trong immunogenicity, and t$e corre#pondC ing antibodie# are clinically #ignificant 9 0ntiC"pa $a# been implicated in mild to moderate &,)N and ,&;! Se2ere ,&;! a# pre#ented in t$i# ca#e $a# not been reported +linical #ign# and t$e laboratory 2alue# pre#enting on ,ay E *it$ pea4 laboratory 2alue# at ,ay# B0 and BB after tran#fuC #ion of a unit of !B+# po#iti2e for "pa #upport a diagno#i# in t$i# ca#e of a #e2ere ,&;! *it$ intra2a#cular $emolyC #i# attributable to antiC"pa ;$e cau#e of t$e primary "pa e:po#ure could not be determined from t$e patientH# $i#C tory 0&G cro##matc$ of all implicated !B+ unit# de#pite t$e negati2e ,0; or antibody #creen *ould $a2e po#iti2ely identified t$e incompatible "p7aT8 !B+ a# t$e implicated unit for t$e ,&;! ;$e patient under di#cu##ion e:perienced unu#ually #e2ere $epatoto:icity, and t$e rea#on# for t$i# remain unC clear? t$ere *a# no prior $i#tory of li2er di#ea#e Se2ere $emoly#i# *it$ re#ultant $ig$ le2el# of free $eme can cau#e unde#irable to:icity, leading to organ, ti##ue, and celluC lar inNury ;$e mec$ani#m of action i# t$roug$ free $eme t$at cataly/e# t$e o:idation, co2alent cro##lin4ing, and agC gregate formation of protein and it# degradation to #mall

peptide# .t al#o cataly/e# t$e formation of cytoto:ic lipid pero:ide 2ia lipid pero:idation and damage# ,N0 t$roug$ o:idati2e #tre## &eme, being a lipop$ilic molecule, interC calate# in t$e membrane and impair# lipid bilayer# and orC ganelle#, #uc$ a# mitoc$ondria and nuclei, and de#tabili/e# t$e cyto#4eleton .t al#o cau#e# endot$elial cell inNury, leadC ing to 2a#cular inflammation, and #timulate# t$e e:pre##ion of intracellular ad$e#ion molecule# 0# a proinflammatory molecule, $eme induce# inflammation t$at re#ult# in to:ic effect# on t$e 4idney, li2er, central ner2ou# #y#tem, and carC diac ti##ue B0 ;$e #e2ere $eme to:icity may al#o be attributC able to t$e mar4edly compromi#ed renal condition o*ing to t$e #e2ere #teno#i# of t$e rig$t renal artery ;$e #e2erity of t$e ,&;! in t$i# ca#e may *arrant conC #ideration for inclu#ion of clinically #ignificant lo*C fre6uency antigen# t$at may be mi##ed by current #creening cell# for detection of clinically #ignificant !B+ antibodie# &o*C e2er, t$e ri#4 of o2ert ,&;!# to lo*C incidence antigen# i# e#timated at B per 950,000 cro##matc$e# 5 ;$e calculation *a# ba#ed on report of probability of acute o2ert $emolytic tran#fu#ion reaction at B per 290,000 *it$ immediateC#pin cro##matc$e# of B A million negati2e antibody #creen# D 0# t$e ri#4 of o2ert ,&;! i# e:tremely #mall, t$e co#t benefit #$ould be con#idered for inclu#ion of lo*Cfre6uency anC tigen# #uc$ a# -ra, +*, and "pa in t$e antibody #creening cell# 5 -e concur *it$ t$e pre2iou# ob#er2ation 0&G p$a#e cro##matc$ mu#t be included in t$e in2e#tigation of any #u#pected ,&;! irre#pecti2e of a negati2e ,0; or negaC ti2e antibody #creen 0ppropriate and timely patient care to a2ert furt$er patient $arm depend# on a t$oroug$ in2e#tiC gation References B !obac4, J,, ed ;ec$nical Manual B9t$ ed Bet$e#da, M,? 0merican 0##ociation of Blood Ban4#, 200D 2 0llen )& Jr, 'e*i# SJ "pa 7%enney8, a ne* antigen in t$e "ell blood group #y#tem Vo: Sang B95EF2?DBKE

Smoleniec J, 0nder#on N, %oole G &ydrop# fetali# cau#ed by a blood group antibody u#ually undetected in routine #creening 0rc$ ,i# +$ild )etal Neonatal Ed B99>FEB?)2B9KE > %in4erton %&, +oo2adia 0S, Gold#tein J )re6uency of delayed $emolytic tran#fu#ion reaction# follo*ing anC tibody #creening and immediateC#pin cro##matc$ing ;ran#fu#ion B992FA2?DB>KBE 5 Garratty G &o* concerned #$ould *e be about mi##C ing antibodie# to lo* incidence antigen#U ;ran#fu#ion 200AF>A?D>>K>E 9 !eid ME, 'oma#C)ranci# + ;$e blood group antigen fact#boo4 San ,iego, +0? 0cademic %re##, B99E?BD2K > E ;u#on M, "oyal ", ,e#ai !, et al %robable #uppre##ion of fetal eryt$ropoie#i# by antiC"p 7ab#tract8 ;ran#fuC #ion 200EF>E7A Suppl8?B990 D S$ulman .0 ;$e ri#4 of an o2ert $emolytic tran#fu#ion reaction follo*ing t$e u#e of an immediate #pin cro##C matc$ 0rc$ %at$ol 'ab Med B990FBB>?>B2KB> 9 'ee S, Pamba# E,, Mar#$ -', !edman +M Molecular cloning and primary #tructure of "ell blood group proC tein %roc Natl 0cad Sci 5 S 0 B99BFDD?9A5AKE B0 "umar S, Bandyopad$yay 5 )ree $eme to:icity and it# deto:ification #y#tem# in $uman ;o:icol 'ett 2005FB5E?BE5KDD Ranie *oshy$ M# +corres"onding author,$ #irector$ &lood &an- and .ransfusion (er/ices$ and &hishma Patel$ (&&$ &lood &an- and .ransfusion (afety 0fficer$ #e"artment of Pathology and Laboratory Medicine$ N%M(1!M#N%$ C232$ !ni/ersity 4os"ital$ Newar-$ N% 352367 and %onathan (8 4arrison$ M#$ #e"artment of Medicine$ 4ematology$ Robert 9ood %ohnson Medical (chool:Pisc1New &runswic-$ New &runswic-$ N%8

Review

!he A"O %lood group s$stem revisited: a review and update

7&R& Storr) (nd M&L& Olsson
;$e antigen# of t$e 0B( #y#tem *ere t$e fir#t to be recogni/ed a# blood group# and actually t$e fir#t $uman genetic mar4er# 4no*n ;$eir pre#ence and t$e reali/ation of naturally occurring antibodC ie# to t$o#e antigen# lac4ing from t$e cell# made #en#e of t$e erratic failure of blood tran#fu#ion $it$erto and opened up t$e po##ibility of a #afe treatment practice in lifeCt$reatening blood lo## 0lt$oug$ initially apparently #imple, t$e 0B( #y#tem $a# come to gro* in comple:ity o2er t$e year# ;$e ma## of 4no*lC edge relating to carbo$ydrate c$emi#try, en/ymology, molecular genetic#, and #tructural and e2olutionary biology i# no* enormou# t$an4# to more t$an a century of re#earc$ u#ing 0B( a# a principal model ;$i# $a# pro2ided u# *it$ data to form a #olid platform of e2idenceCba#ed tran#fu#ion and tran#plantation medicine u#ed e2ery day in laboratorie# and clinic# around t$e globe ;$i# re2ie* aim# to #ummari/e 4ey finding# and recent progre## made to*ard furt$er under#tanding of t$i# #urpri#ingly polymorp$ic #y#tem Immunohematology 4009?45)48#596

Variation in 0 antigen e:pre##ion *a# al#o recogni/ed 2ery early in t$e t*entiet$ century 7re2ie*ed in !ace and SangerB08, and t$e 0 blood group *a# di2ided into 0B and 02 B,BB (t$er de#cription# of *ea4ened 0 antigen e:pre##ion follo*ed, and t$e 0 blood group *a# #ubdi2ided furt$er ba#ed on c$aracteri#tic reacti2ity *it$ $uman polyclonal anti#era, i e , #trengt$ of reacti2ity and pre#ence of mi:ed field agglutinationF pre#ence of antiC0 F and *$et$er 0 or B & blood group #ub#tance *a# pre#ent in t$e #ali2a of #ecretor #ubNect# 7;able B8 -ea4 form# of B antigen *ere al#o found but are typically more difficult to define #erologically into #pecific categorie# alt$oug$ #ome #ubgroup# 7e g , B 8 are el analogou# to t$eir 0 counterpart# 70el8 ;$e fre6uency of t$e common 0B( p$enotype# 70B , 02 , B, 0B B, 02 B, and (8 2arie# greatly among different populaC tion# B2,BA %opulation# *it$ a $ig$ fre6uency of 0 p$enotype are found mainly in Nort$ern and +entral Europe, and t$e
!a%le ,- Su"<rou*s o= AI(<<lutin(tion re(+tion *(tterns (d(*ted =rom te0t"oo?s

0e$ 4ords: 0B(, blood group, antigen, allele, genotype

$ere $a2e been many re2ie*# of t$e 0B( blood

group #y#tem *ritten t$roug$out t$e year#, co2ering difC ferent a#pect# of t$i# fa#cinating topic 0 limited #eC lection of #uc$ re2ie*# can be found in t$e reference li#t, particularly for reader# *$o *ant to focu# more on t$e di#C co2ery,B bioc$emi#try,2,A en/yme #tructure,> and molecular genetic# 5,9 (ur intention i# not to reproduce t$em but to follo* t$e guideline# of t$i# ne* #erie# of blood group #y#C tematic re2ie*# in Immunohematology to pro2ide a brief introduction to t$i# ama/ingly comple: blood group #y#tem 7istor$ ;$e di#co2ery of t$e 0B( blood group #y#tem range# from myt$ and fol4 legend all t$e *ay to t$e Nobel %ri/e "arl 'and#teiner, a Vienne#e pat$ologi#t, made t$e ob#er2ation t$at *$en $i# #erum and t$at of fi2e colleague# *ere mi:ed indi2idually *it$ t$eir #alineC#u#pended !B+#, agglutinaC tion *a# ob#er2ed *it$ #ome mi:ture# but not *it$ ot$er# &e reported t$i# a# a footnote to a paper publi#$ed in B900E follo*ed by a more compre$en#i2e paper in B90B D ;ran#laC tion# of bot$ paper# can be found in t$e re2ie* by +amp and Elli# B .n t$e#e early #tudie#, $e #$o*ed t$at t*o eac$ of t$e #i: #era di#criminated among t$ree blood group#? 0, B, and + 7later renamed ( from t$e German ohne, meaning

Su% group of A A/ A Aint A

%

Reactions5 with Anti A NNNN NNNN NNNN NN@NA #8N N #8N N N@NA #O #O #
O

Anti A6" NNNN NNNN NNNN NN@NAm= NN@NA N #8N N N@NA # # #

Anti A, NNNN # NN@NA # # # # # # NNNBB # #

Anti 7 # NNNN NNN NNNN NNNN NNNN NNNN NNNN NNNN NNNN NNNN NNNN

Su% stances in saliva8 A, H A, H A, H A, H H H A, H H H H A, H H

Anti A, in serum No Some> times No Some> times O=ten Some> times No Yes Yes YesBBB No Some> times

m=

A Aend Am A
=inn 0

A"(ntu A/(e
)

Ael

BA ne<(tive re(+tion is denoted ") #& 2ositive re(+tions (re denoted (s =rom N @we(? (<<lutin(tionA to NNNN @m(0im(l (<<lutin(tionA& BB3oli+,os "i=lorus onl)&
/

A1O "lood <rou* s)stem without8 ;$u#, 'and#teiner demon#trated t$at a per#onH# #erum contained antibodie# to t$e antigen7#8 lac4ing from t$eir !B+# ;$e fourt$ blood group, 0B, *a# de#cribed a year later by ,eca#tello and Sturli9 in four indi2idual# in a larger #tudy of A> $ealt$y #ubNect# and B2B patient#
BBBSerum re(+tivit) (<(inst "ot, A (nd A R16& P1lood <rou* A1O su"st(n+es in s(liv( (nd ot,er "od) =luids o= se+retors& O 3es*ite l(+? o= (<<lutin(tion, (nti>A +(n "e (dsor"ed to (nd eluted =rom +ells in t,is su"<rou*& m= C mi0ed =ield (<<lutin(tion&

02 p$enotype reac$e# it# pea4 among t$e 'app# in Nort$C ern Scandina2ia but i# 2ery rare in 0#ia ;$e B p$enotype i# mo#t fre6uent in +entral 0#ia and almo#t ab#ent in 0mC erindian# Blood group ( i# t$e mo#t fre6uent p$enotype in a global per#pecti2e, *it$ Nati2e 0merican .ndian# beC ing almo#t e:clu#i2ely blood group ( %art# of 0frica and 0u#tralia al#o #$o* $ig$ fre6uencie# of blood group ( ;$e rea#on for t$e difference# ob#er2ed among population# i# not fully under#tood alt$oug$ #e2eral t$eorie# $a2e ari#en ;$e concept of e2olutionary #election ba#ed on pat$ogenC dri2en blood group c$ange# *ill be di#cu##ed later 7#ee #ection on pat$ogen interaction#8 ;$e early importance of 0B( di2er#ity i# #upported by report# in *$ic$ t$e group 0Cdefining #ingle ba#e pair deletion at nucleotide po#ition 29B 7#ee #ection on molecular genetic#8 $a# been found in bot$ Neandertal peopleB> and ancient Egyptian mummie#,B5 #ugge#ting t$at #election pre##ure and #ur2i2al of t$e fitte#t *ere indeed early feature# during our coCe2olution *it$ pat$ogen# li4e malaria para#ite# and many ot$er# (omenclature ;$e 0B( #y#tem *a# t$e fir#t to be di#co2ered and $a# t$erefore been gi2en t$e number 00B in t$e official .nterC national Society of Blood ;ran#fu#ion 7.SB;8 terminology Nomenclature for t$e 0B( antigen# i# actually #traig$tforC *ard #ince t$e antigen #tatu# i# determined by t$e pre#C ence or ab#ence of #pecific carbo$ydrate molecule# ;$i# i# particularly true for t$e 0 and B antigen# but may be le## clear for t$e t*o ot$er antigen# 70,B and 0B8 gi2en official antigen #tatu# by t$e .SB; ;$e 0,B antigen i# t$oug$t to be an epitope not in2ol2ing t$e 0 2er#u# BKdifferentiating #urface#, but con#i#t# of a common recognition motif B9 found *$en eit$er t$e 0 or B antigen# are pre#ent ;$e deC bate #urrounding t$e real identity of t$e 0B antigen i# #till ongoing,BE,BD but t$e 0B p$enotype re2eal# many difference# compared *it$ 02 , bot$ 6uantitati2e and 6ualitati2e, #o t$e 6ue#tion i# 6uite comple: 7#ee #ection on bioc$emi#try8 ;able 2 #$o*# bot$ t$e numerical and traditional nomenC clature according to t$e .SB; -or4ing %arty on ;erminolC ogy for !ed +ell Surface 0ntigen# B9
!a%le .- A1O nomen+l(ture
S$stem IS1T num"er IS1T n(me ##/ A1O A1O/ @##/##/ A A A"O antigen notation A1O @##/## A 1 A1O% @##/##%A A,1 A1O. @##/##.A A/

db!B+ -eb #ite 7$ttp?<<*** ncbi nlm ni$ go2<proNect#< g2<rbc208 .n t$i# re2ie*, allele# *ill be referred to in t$e traditional *ay but *it$ db!B+ terminology gi2en in brac4C et#, e g , AB VA232W and 02 V032W .t can be #pecifically noted t$at it i# important for clarC ity and con#i#tency to u#e #ub#cript#, #uper#cript#, and italic# appropriately )or e:ample, 0B, 0B , and 0B mean t$e antigen, t$e p$enotype, and t$e allele, re#pecti2ely Inheritance and Molecular *enetics ;$e 0 and B antigen# are in$erited a# Mendelian c$arC acteri#tic# in a codominant auto#omal fa#$ion .n B90D, EpC #tein and (ttenberg2B *ere t$e fir#t to #ugge#t in a #$ort ca#e report t$at 0B( blood group# mig$t be in$erited ;$i# *a# later pro2ed by 2on ,ungern and &ir#/feld in B9B0 7tran#C lated by %o$lmann 228 .n fact, 0B( in$eritance *a# one of t$e fir#t genetic mar4er# to be u#ed in paternity te#ting and in foren#ic medicine 2A,2> 5nli4e t$e maNority of blood group#, t$e antigen# of t$e #i: currently 4no*n carbo$ydrate #y#tem# are not coded by gene# directly .n#tead, t$e#e blood group gene# encode glyco#yltran#fera#e# t$at in turn #ynt$e#i/e t$e oligo#acC c$aride epitope# 7)ig B8 ;$u#, t$e 0 and B antigen# are made by 0 and B glyco#yltran#fera#e, re#pecti2ely, encoded by t$e A&0 gene carried on t$e long arm of c$romo#ome 9 796A>8 0# *it$ many of t$e blood group gene#, t$e po#ition of t$e A&0 locu# *a# 4no*n for many year# before t$e gene *a# cloned 25 ;$e gene# encoding t$e 0C #ynt$e#i/ing AC'CNC acetylgalacto#aminyltran#fera#e and t$e BC#ynt$e#i/ing AC'CNCgalacto#aminyltran#fera#e *ere cloned by 3amamoC to and colleague# in B99029,2E after purification and partial amino acid #e6uencing of 0 tran#fera#e from lung ti##ue 2D %robing c,N0 librarie# obtained from $uman adenocarC cinoma cell line# of different 0B( type#, t$e main allele# *ere defined 29 ;$ey determined t$at t$e &C#pecific m!N0 differed from t$e AC#pecific gene by only E of B092 coding nucleotide#, of *$ic$ > re#ult in amino acid difference# in t$e en/yme product ;$e difference bet*een t$e AB VA232W and 0B V032W gene# *a# #$o*n to be a #ingle guano#ine 7G8 deletion, *$ic$ alter# and #e2erely truncate# t$e open reading frame 7(!)8 a# #$o*n in )igure 2 ;$e 02 p$enotype *a# #$o*n to depend on a cyto#ine deletion in t$e 5Q end of t$e gene, re#ulting in elongation of t$e (!) 29 ;$e organi/ation of t$e A&0 locu#A0,AB i# #$o*n in )igure A ;$e gene con#i#t#
)ig- , 2rin+i*(l
O H C H 2O H O O H H O A cN H O O O H O C H 3 O O H C H 3 O H O O H C H 2O H H O O O H O O H C H 2 O H O O H C H 2O H O

Blood group allele nomenclature including 0B( i# unC der con#ideration by a #ubcommittee of t$e aforementioned .SB; -or4ing %arty .n t$e ab#ence of an officially agreedC on terminology, #e2eral different 2ariant# $a2e e2ol2ed 7#ee ;able E in +$e#ter and (l##on98 ;ypically, allele# are reC ferred to by t$eir #erologic acti2ity and a number 0n unC

stru+ture o= t,e A, 1, (nd H oli<os(++,(> rides& T,e di==eren+e "etween t,e A (nd 1 stru+tures is ,i<,> li<,ted ") (rrows&

H O O H O H C H 2O H O B

HO O H

tt rr ii s a c c h a rr ii d e

tt rr ii s a c c h a rr ii d e

HO

official but often u#ed terminology i# found at t$e Blood Group 0ntigen Gene Mutation ,ataba#e, al#o 4no*n a# t$e

O C H 3

O H

O O H HO

O H

d ii s a c c h a rr ii d e

7&R& Storr) (nd M&L& Olsson of #e2en e:on# 7plu# an alternati2e e:on Ba located up#tream of e:on BA28, *it$ t$e maNority of t$e catalytic domain of t$e en/yme encoded by e:on E Since t$e groundbrea4ing cloning paper, 2B5 A&0 #eC 6uence entrie# $a2e been #ubmitted to t$e db!B+ -eb #ite20 7acce##ed on 0pril B5, 20098 and curated by t$e db!C B+ #taff and e:pert#, but ne* allele# are con#tantly being identified )igure > #$o*# a brea4do*n of t$e BDB allele# in t$e db!B+ categori/ed by t$eir a##ociation *it$ normal or altered p$enotype#? t$e#e include 95 different A allele#, >E & allele#, 5D 0 allele#, and BB IA&J allele# ;$e remainC ing A> #e6uence# li#ted in t$e current db!B+ con#i#t of 20 #e6uence# encompa##ing t$e 5Q noncoding region including t$e repetiti2e and polymorp$ic ++00; bo: binding facC tor<nuclear factor 3 7+B)<N)C38 motif and B> intronic or o2erlap #e6uence# (f t$e A allele#, 9 and BB encode norC mal 0B or 02 p$enotype# on !B+#, re#pecti2ely, *$erea# >D de#cribe mutated A allele# 7Awea-8 a##ociated *it$ different 2ariant# of *ea4 0 antigen e:pre##ion 7;able B8F t$e & alC lele# include 9 normal and AD *ea4 allele#F and BB allele#
H22/ !
A/

.HG " !# $ H2

G###%03 B%

/#H!#0
0

A 1

O O

$a2e been de#cribed t$at encode glyco#yltran#fera#e# caC pable of #ynt$e#i/ing ea#ily detectable le2el# of bot$ 0 and B antigen# ;$i# group include# allele# con2eying t$e t*o unu#ual p$enotype# ci#0B and B708 )iftyCeig$t allele# are predicted to gi2e ri#e to protein# *it$out en/ymatic acti2ity of *$ic$ >5 contain 29BdelG, t$e mutation t$at alter# t$e tran#lational (!) and predict# a #$ortened protein product *it$ no tran#fera#e acti2ity ;$i# large group of 0 allele# include# four principally important e2olutionary lineage#? 0B V032W, 0B2 V03;W, 0tlse3< or 027>9E;FABD;8 V03<W, and 0Bbantu V0=>W AA,A> Numerou# minor 2ariant# of t$e#e main allele#A5 a# *ell a# $ybrid 0 allele# combining A2 or & *it$ different 29BdelGCcontaining 0 #e6uence#A9 $a2e al#o been found, mo#t notably in indi2idual# of 0frican ance#try (f t$e reC maining BA InondeletionalJ allele#, A #uffer #imilar fate# to t$at cau#ed by 29BdelG becau#e t$ey contain non#en#e muC tation# re#ulting in altered (!)# cau#ed by nucleotide inC #ertion# 0not$er A $a2e non#en#e mutation# introducing immediate #top codon#, t$ereby truncating t$e (!) at t$e #ame codon *$ere t$ey occur )inally, E recorded nondeC letional 0 allele# are crippled by at lea#t one mi##en#e muC tation eac$, gi2ing ri#e to critical amino acid #ub#titution#, t$e mo#t famou# e:ample of *$ic$ i# D02GX0 re#ulting in 29D0rg )or a recent re2ie* about t$i# latter group of interC e#ting 0 allele# de#ignated 02 V036W, #ee 3a/er and (l##on AE -$at i# mo#t intriguing about t$e#e nondeletional 0 allele# i# t$at t$ey are all attributable to mutation# in A allele bac4C bone #e6uence# ;$i# $a# t*o main practical con#e6uence#? fir#t, 2irtually all A&0 genotyping met$od# *ill #ignal t$e
#0

)ig- . S+,em(ti+ re*resent(tion o= *redi+ted o*en re(din< =r(mes =or some +ommon ABO (lleles& 9,ite re+t(n<les re*resent tr(ns> non>A/ +onsensus @nonsenseA& Verti+(l "(rs indi+(te nu+leotide @ntA *ositions @<iven ("ove "(rsA o= mut(tions le(din< to (mino (+id +,(n<es& B indi+(tes B RB01S (llele is mut(ted (t nt G$H (nd J#%E O RO03S (llele (t nt J# &

$0

!3

"0

"& Unusual/weak Unusu(l8we(? phenotype *,enot)*e Common/expected phenotype 6ommo8e0*e+ted *,enot)*e 3& "$

Num"er o= (lleles

(ll ele s 30 o=
20

!0

!# ' !!

0 A t) B O AB

1lood 1 l o o d"lood < ro us*e+i=i+it) * s * e +i =i +i

)ig- 2 Or<(ni;(tion o= t,e ABO <ene& A: T,e seven e0ons (nd si0

introns (re not dr(wn to s+(le& T,e numer(ls ("ove "o0es re*resent t,e =irst (nd l(st nu+leotides @ntA o= t,e +odin< re<ion in e(+, e0on, (nd t,ose "elow "o0es s,ow t,e +orres*ondin< (mino (+id @(&(&A num"ers& T,e si;e o= e(+, intron is indi+(ted wit, ( t,in o"li-ue "(r& ": T,e ABO <ene dr(wn to s+(le @e0+e*t intron /AE e0ons (re "l(+? (nd introns <r()&

)ig- 3 Gr(*,i+ re*resent(tion s,owin< t,e num"er o= ABO (lleles +urrentl) listed in t,e d"R16 d(t("(se& T,e "l(+? "(rs re*resent (l> leles t,(t en+ode ( <l)+os)ltr(ns=er(se wit, norm(l (+tivit)E t,e w,ite "(rs re*resent (lleles en+odin< <l)+os)ltr(ns=er(ses t,(t ,(ve (ltered (+tivit) or s*e+i=i+it)& T,e A1 "(r in+ludes (lleles en+odin< <l)+os)l> tr(ns=er(ses +(*("le o= s)nt,esi;in< "ot, A (nd 1 (nti<ens, i&e&, +isA1 (nd 1@AA& T,e <rou* O "(r ,(s "een divided into t,e .! O (lleles t,(t +ont(in t,e mut(tion H/delG @"l(+?A (nd t,e /% Tnondeletion(lU (lleles wit,out it @w,iteA& T,e l(tter <rou* is o=ten (sso+i(ted wit, we(? e0*ression o= A (nti<en&

pre#ence of AB or A2 allele# unle## #pecifically de#igned to detect rare 0 allele#, *$ic$ *ill re#ult in t$e potentially cata#trop$ic prediction of group 0 in a group ( per#on Second, t$e p$enotype actually con2eyed by in$eritance of one of t$e#e #oCcalled 0 allele# i# not al*ay# ( but often *ea4 0 or (Cli4e but *it$out antiC0 pre#ent in pla#ma ;$e rea#on for t$i# i# currently unclear, but t$ere $a# recently been a #erie# of paper# in2e#tigating t$e #erologic pattern and mec$ani#m# be$ind t$i# intere#ting p$enomenon ADK>2 ;$ere i# currently no 0 allele de#cribed t$at i# ba#ed on a & #e6uence, but *e predict t$at *$en #uc$ an allele i# found, it *ill #$o* t$e oppo#ite #erology, i e , eit$er *ea4 B e:pre#C #ion or (Cli4e *it$out antiCB in pla#ma .t i# t$e molecular genetic# t$at ma4e t$i# #y#tem #o fa#C cinating becau#e mutation# ranging from #ingle nucleotide c$ange# to more comple: $ybrid gene formation# can alter t$e #pecificity of t$e en/yme, t$e efficacy of t$e en/yme, or bot$F c$ange# t$at, at t$e p$enotypic le2el, are manife#ted #imply by altered antigen e:pre##ion Good e:ample# are t$e 2ariou# molecular ba#e# of t$e 0: p$enotype, *$ic$ can eit$er re#ult from a #ingle mi##en#e mutation in e:on E of an AB VA232W allele or be ba#ed on different $ybrid#, for inC #tance bet*een t$e 5Q end of & and t$e AQ end of 0 allele# >A,>> ;$e BA p$enotype in t$e ;ai*ane#e population $a# al#o been #$o*n to re#ult from different molecular bac4ground#, one a mi##en#e mutation but more commonly, a principally intere#ting mutation t$at *a# t$e fir#t one #$o*n to affect #plicing of A&0 m!N0 and cau#e e:on #4ipping >5 .n adC dition to altered #pecificity or en/ymatic efficacy, aberrant intracellular traffic4ing of 0B( tran#fera#e may cau#e *ea4 #ubgroup p$enotype# >9 0# alluded to pre2iou#ly, t$i# added layer of comple:ity, in *$ic$ mutation# affect en/yme acti2ity and not t$e antiC gen directly, pro2ide# difficultie# in de#igning genotyping a##ay# t$at *ill detect rare 2ariant#, *$ic$ if mi#interpreted can $a2e #eriou# con#e6uence# in 0B( group determinaC tion >E ;$ere are problem# a##ociated *it$ all t$e more t$an A0 A&0 genotype #creening met$od# publi#$ed or commerC cially a2ailable #o far 7re2ie*ed in (l##on and +$e#ter>D8 ;$e 2a#t maNority i# only de#igned to determine bet*een t$ree and #i: of t$e common allele#, alt$oug$ additional allele# can often #urface if t$eir polymorp$i#m# interfere *it$ t$e detection #y#tem &o*e2er, 2irtually all met$od# *ill fail to predict t$e p$enotype of a #ample in t$e pre#C ence of mo#t 0<B #ubgroup allele#, rare nondeletional null allele#, ci#A& and &7A8 allele#, or $ybrid allele#, *$ic$ can lead to #eriou# con#e6uence# Becau#e t$i# i# particularly dangerou# if blood or tran#plant recipient# are typed 7a# #ugge#ted, e g , by %rocter et al >98 *e recently de2eloped and implemented an impro2ed A&0 genotype #creening met$od t$at addre##e# t$e#e problem# and can be u#ed in a clinical laboratory #etting >E .n #ummary, t$e comple: genetC ic# of 0B( i# a maNor c$allenge for A&0 genotyping effort#, not lea#t becau#e of t$e di#turbing fact t$at a certain allele can lead to more

cal p$enotype# can $a2e more t$an one molecular genetic bac4ground ;$e regulatory mec$ani#m of t$e A&0 gene $a# been in2e#tigated e:ten#i2ely 0n en$ancer element located apC pro:imately > 4bp up#tream of e:on B 50 *a# found to conC tain four >ACbp repeat# in all allele# e:cept AB VA232W and t$e infre6uent 02 V036W, *$ic$ $a2e only one copy 5B ;$i# may play a role in e:pre##ion 52 ;$e en$ancer region contain# a +B)<N)C3 binding #iteF mutation# in t$i# #ite decrea#e en$ancer acti2ity in a ga#tric cancer cell line,50 and alteraC tion# in t$i# region may e2en cau#e rare B #ubgroup p$enoC type# 5A &o*e2er, it *a# recently #$o*n t$at AB VA232W or A2 VA;32W tran#cript# are 2irtually undetectable in perip$eral blood *$erea# & and 0 7including 02 V036W8 m!N0 i# readC ily found 5>,55 ;$i# appear# to #pea4 again#t a critical role for +B) repeat# in eryt$roid A&0 regulation, but more *or4 i# re6uired ;$ere i# al#o an SpBCbinding #ite in t$e pro:imal promoter t$at may be important for eryt$roid A&0 regulaC tion 59 0lt$oug$ muc$ i# under#tood regarding t$e cau#e of *ea4 0<B antigen e:pre##ion on !B+# *$en it come# to inC $erited *ea4 0B( #ubgroup#,5,9 le## i# 4no*n about altered 0B( e:pre##ion in $ematologic di#order# Eryt$rocyte# lo#C ing 0, B, or & antigen $a2e been noted in patient# *it$ $eC t$an one p$enotype and #eemingly identiC

matologic malignancy, e#pecially in t$e myeloid lineage 5E,5D Very recently it *a# #ugge#ted t$at met$ylation of t$e A&0 pro:imal promoter i# t$e rea#on for #uc$ leu4emiaC a##ociated do*nregulation 59 !educed 0 and B antigen e:pre##ion in bladder and oral carcinoma# i# partially attributable to lo## of $etero/ygo#ity or $ypermet$ylation 90,9B )urt$ermore, urot$elial tumor ti##ue contain# decrea#ed amount# of 0<B antigen# t$at correlated to decrea#ed le2el# of 0B( m!N0 compared *it$ cell# from normal ti##ue 92 ;ran#ient depre#C #ion of 0 antigen# $a# al#o been ob#er2ed in #ome pregnant *omen,>> but t$e rea#on for t$i# i# #till un4no*n "iochemistr$ ;$e bioc$emi#try of t$e 0 and B antigen# *a# elucidatC ed by t$e a#toni#$ingly early and brilliant *or4 from t$e group# of Morgan and -at4in#, and "abat 7re2ie*ed by -at4in#2 and "abat9A8 ;$e 0, B, and & determinant# *ere $ypot$e#i/ed to re#ide on *aterC#oluble glycoprotein# able to in$ibit agglutination of !B+# by antibodie# or lectin# 0 precur#or #ub#tance, &, *a# $ypot$e#i/ed a# a building #tructure for 0 and B, and t$e term# 0- 7or 4-8 substance and anti-4 *ere introduced in B9>D 9> (*ing to difficultie# in obtaining #ufficient 6uantitie# of blood group acti2e material after e:traction from !B+#, mo#t of t$e early #tudie# *ere performed on o2arian cy#t or animal mucin, ric$ in #ecreted blood group #ub#tance# Before i#olaC tion and c$emical identification of t$e#e #ub#tance#, in$ibiC tion *it$ #imple #ugar# indicated NC acetylCdCgalacto#amine 7GalN0c8, dCgalacto#e 7Gal8, and lC fuco#e 7)uc8 a# t$e definC ing #ugar# in blood group# 0, B, and (, re#pecti2ely 95,99 .ndependent of t$e blood group of t$e indi2idual in2e#tigated, a #urpri#ingly #imilar compo#ition of carboC

$ydrate re#idue# 7mainly )uc, Gal, GalN0c and NCacetylC dCgluco#amine VGlcN0cW8 *a# found ;$i# *a# ta4en a# a #ign of large #imilar precur#or molecule# carrying #mall re#idue# t$at differentiate blood group# 9E ;$e minimal determinant #tructure# *ere #ub#e6uently #$o*n to be tri#acc$aride# a# #$o*n in )igure B ;$e important concept of precur#orCproduct relation#$ip bet*een & and 0<B *a# formulated,9E,9D and t$e critical role of nucleotideCbound #ugar# a# #ub#trate# in oligo#acc$aride #ynt$e#i# *a# appreC ciated 99 ;$e bio#ynt$etic pat$*ay of t$e 0B( blood group #tructure# i# a# outlined in )igure 5, and t$e pre#ence of 0 and B glyco#yltran#fera#e# *a# fir#t predictedE0 and t$en e:perimentally e#tabli#$ed EBKEA ;$u#, t$e 0 and B glyco#ylC tran#fera#e# u#e 5,%CGalN0c and 5,%CGal, re#pecti2ely, a# #ub#trate# Bot$ re6uire t$e & determinant a# acceptor ;$e ( protein i# nonfunctional, lea2ing t$e &Cdefining terminal )uc unaltered
V' U32 > G(INA+ UUUUUU (((((( )))))) ******** U32 ++++++++ aaaaaaaa lllllNNNNNNNN
++ aa lluuuu VV cccc >> -++++> (((( ,,,, G32 :u+ )))) **** G32 ++++ ((((

epit$elial cell# t$at line t$e lumen of t$e ga#trointe#tinal, re#piratory, and reproducti2e tract# a# *ell a# in #ali2ary gland# and #4in ;$i# *ide di#tribution i# a common feaC ture for many of t$e carbo$ydrate blood group#, *$ic$ $a# re#ulted in t$e term histo-blood grou" often being u#ed to reflect t$i# *ide di#tribution 0 and B antigen #ynt$e#i# occur# during normal glyco#ylation of protein# and lipid# in t$e Golgi compartment EE ;$e precur#or & #ub#tance i# #ynt$e#i/ed by one of t*o fuco#yltran#fera#e# depending on t$e acceptor #ub#trate u#ed ;$e F!.2 gene t$at encode# t$e 2C'Cfuco#yltran#fera#e 7'2)uc;B8 i# re#pon#ible mainly for t$e #ynt$e#i# of t$e & antigen on type 2 7and type >8 carC bo$ydrate precur#or# found on !B+# ED ;$e clo#ely related F!.; gene encode# a 2ery #imilar 2C'Cfuco#yltran#fera#e 7'2)uc;28 t$at i# e:pre##ed in epit$elial cell# and #ynt$eC #i/e# & antigen mainly on type B and type A c$ain# EE ;$e maNor precur#or type# pre#ent in different ti##ue# and #ecretion# are #$o*n in ;able A
!a%le 2- 2eri*,er(l +ore stru+tures (nd t,eir *rin+i*(l tissue distri"ution @modi=ied =rom 6l(usen (nd H(?omori %A
2eri*,er(l +ore t)*e T)*e / T)*e T)*e % T)*e . Stru+ture G(lV/W%Gl+NA+V/WR G(lV/W.Gl+NA+V/WR G(lV/W%G(lNA+'/WR G(lV/W%G(lNA+V/WR 3istri"ution Endoderm(l, se+retions, *l(sm( E+to> (nd mesoderm(l @e&<&, er)t,ro+)tesA O>lin?ed mu+in>t)*e, re*etitive A Gl)+oli*ids in ?idne)s @(nd er)t,ro+)tesA

+ a llN A c ' 3 + a ll V > -

G(INA+ ' %G(lV > R ' '2 :,,u+u

c

Gaa(lllVV + > >R > ' 2 , u c

H Ht rtaar(nnnss=e. G(lV > R e rr a s e r( s e

'

:u +

AAAAAA (((((( A tr(ns=er(se ssssss nnnnnn tttttt iiii AAAAAAAA tttttttt <<<<<< eeeeee ss rrrrrrrr aaaaaaaa nnnnnn nnnnnnnn ssssssss ........ eeeeeeee rrrrrrrr s e 1 tr(ns=er(se 1 (nti<en aaaaaaaa

A (nti<en

+ Ga (ll

22 2re+ursor rr ee ++ uu rr ss oo rr

HHHHHH (( nn tt ii << ee nn

H (nti<en

l''%3G++(lVa>ll RV >
'

'

UUUUUUUU (((((((( )))))))) ******** ++++++++ aaaaaaaa lllll

U23 > G(l

U32

, :uucc+

)ig- 9- S+,em(ti+ de*i+tion o= t,e "ios)nt,eti+ *(t,w()s =or +on> version o= H determin(nts to A or 1 determin(nts& R re*resents t,e +ore stru+ture& See te0t =or en;)me (""revi(tions&

0lt$oug$ t$e compo#ition of t$e 0 and B antigen# i# apparently #traig$tfor*ard, t$e bioc$emi#try be$ind t$e #$ared 0,B antigen recogni/ed by many group ( pla#ma# $a# only recently been elucidated e:perimentally Bo2in and $i# colleague#B9 #ynt$e#i/ed a deacetylated 0 tri#acc$aC ride #tructure and bound it to t$e precur#or in #uc$ a *ay a# to e:po#e *$at t$ey $ypot$e#i/ed *ould be t$e common 0,B epitope ;$ey *ere able to demon#trate binding of bot$ monoclonal and polyclonal antiC0,B to t$e #ynt$etic #trucC ture 0lt$oug$ it i# *ell 4no*n t$at t$ere are appro:imately fi2e time# fe*er 0 antigen# on 02 t$an on 0B !B+#, t$e unC derlying ba#i# for t$e 6ualitati2e difference# bet*een t$em i# le## *ell defined ;$e 02 tran#fera#e i# B0 time# le## efC ficient t$an t$e 0B tran#fera#e and $a# a different p& optiC mum and p. E>,E5 ;$e 02 en/yme i# al#o le## able to u#e c$ain# ot$er t$an type B or 2 carbo$ydrate precur#or# li4e t$e e:C tended type A 7repetiti2e 08 and type > 7globoC08 c$ain# on !B+ glycolipid# BE,E9 More recently, S2en##on et al BD $a2e produced #ome*$at contradictory data indicating t$at alC t$oug$ t$e 02 tran#fera#e can readily u#e & type A c$ain# to #ynt$e#i/e 0 antigen, t$e lo* le2el# of type > c$ain# remain uncon2erted ;$e 0B& #ugar# are found on glycolipid# 7appro:imateC ly B0R8 and glycoprotein# 7appro:imately

R C inner +ore stru+ture or lin?(<e&

.n t$e Bombay p$enotype 7($ 8, a #ilenced F!.2 gene i# pre#ent toget$er *it$ a #ilenced F!.; gene Becau#e & anC tigen i# t$e precur#or #ub#trate for bot$ 0 and B antigen#, neit$er antigen can be #ynt$e#i/ed *it$out '2)uc; acti2ity, independent of t$e A&0 genotype ;$e paraCBombay p$eC notype re#ult# from eit$er 7B8 a #ilenced F!.2 gene pre#ent toget$er *it$ an acti2e F!.; gene, *$ic$ permit# t$e #ynC t$e#i# of & type B 7and t$erefore 0<B antigen#8 t$at may be ad#orbed onto t$e !B+ from t$e pla#maF or 728 a mutated F!.2 gene in *$ic$ t$e encoded en/yme acti2ity i# greatly dimini#$ed, #o t$at 2ery lo* amount# of & antigen 7and 0<B antigen8 are produced .t may be pre#ent *it$ or *it$C out an acti2e F!.; gene .n bot$ ca#e#, & antigen 7and 0<B antigen8 i# 2ery *ea4ly e:pre##ed and i# often only detected by ad#orption and elution te#t# *it$ t$e appropriate blood group reagent# ;$e & blood group #y#tem 7.SB; 0BD8 *ill be t$e #ubNect of anot$er re2ie* later in t$i# Immunohematology #erie# ;$e 0 and B glyco#yltran#fera#e# are type .. membrane 90R8 on t$e !B+ a# *ell a# on many different ti##ue# and cell type#, including

protein# located in t$e Golgi compartment,E9,D0 alt$oug$ #oluble form# are found in pla#ma and ot$er body fluid# ;$e en/yme con#i#t# of a #$ort tran#membrane domain, a #tem region, and a catalytic domain t$at e:tend# into t$e Golgi lumen 7)ig 98 ;$e cry#tal #tructure elucidated by

)ig- : A: T,e to*olo<) o= t,e tr(ns=er(se is s,own (s ( Gol<i>lo+(l> i;ed, mem"r(ne>"ound en;)me wit, ( +)to*l(smi+ N>terminus (nd +(t(l)ti+ C>termin(l dom(in @modi=ied =rom 2(ulson (nd 6olle)G$A& " and C: T,e t,ree>dimension(l sur=(+e model ;"< w(s +re(ted wit, t,e 3ee* View Swiss 2d" Viewer version %&G, (nd t,e t,ree> dimension(l ri""on stru+ture ;C< w(s <ener(ted usin< SETOR (nd SetoRi""on @un*u"lis,edA& T,e verti+(l "(r to t,e le=t illustr(tes t,e (**ro0im(te e0on us(<e =or t,e di==erent <l)+os)ltr(ns=er(se dom(ins&

%atenaude and colleague#DB #$o*ed t$at t$e catalytic #ite i# di2ided into t*o domain#F t$e NCterminal domain recC ogni/e# t$e nucleotide #ugar donor #ub#trate 75,%CGal or 5,%CGalN0c8, *$erea# t$e acceptor #ub#trate i# $eld by t$e CCterminal domain ;$e ,@, motif 7,V, in t$e#e enC /yme#8 t$at #er2e# to capture Mn 2T, e##ential to t$e reacC tion becau#e of it# ability to bind t$e 5,% part of t$e donor #ub#trate, lie# bet*een t$e t*o domain# .n addition, t*o #oCcalled di#ordered loop# $a2e been identified by t$e cry#C tal #tructural #tudie# (ne i# located at t$e CCterminal of t$e en/yme ;$e ot$er di#ordered loop lie# clo#e to t$e catalytic #ite of t$e en/yme .t# role i# unclear >F $o*e2er, mutation# in t$i# region $a2e been #$o*n to reduce en/yme acti2ity and are often a##ociated *it$ *ea4 #ubgroup p$enotype# D2 Anti%odies in the S$stem 0ntiC0 and antiCB are naturally occurring antibodie# t$at are produced by immunocompetent indi2idual# from t$e age of appro:imately 9 mont$# ;$e *idely $eld dogma i# t$at t$e#e antibodie# are in fact mimic4ing antibodie# produced again#t terminal carbo$ydrate# on bacterial cell *all# a# a re#pon#e to our normal inte#tinal microbial flora, and t$at t$e#e glycotope# #$are #tructural $omology *it$ 0 and B antigen# DA .n a modern follo*Cup to t$i# original conC cept, t$ree c$ildren *it$ different congenital immune deC fect# *ere #tudied after apparent 0B( grouping di#crepanC cie# D> ;$e#e patient# 7age range, B E to D year#8 *ere limited to total parenteral nutrition and tube feeding ;$eir !B+# typed a# group 0, but eac$ c$ild lac4ed t$e e:pected antiCB by routine te#ting, alt$oug$ antiCB *a# *ea4ly detectable in t$e #erum of one of t$em after prolonged incubation at >Y+

;$e aut$or# concluded t$at t$e ab#ence of dietary e:po#ure to bacteria pre2ented t$e production of antiCB de#pite norC mal immunoglobulin le2el# in t$e patient#H #era !ecogniC tion of #elf pre2ent# an indi2idual from ma4ing antibodie# to antigen# #$ared by t$e bacteria and may al#o partially e:plain di#ea#e #u#ceptibility of one blood group o2er anC ot$er 7di#cu##ed briefly in t$e ne:t #ection8 0ntiC0 and antiCB are predominantly .gM antibodie# alt$oug$ .gG or .g0 component# are often found D5,D9 +la##C #*itc$ing to .gG doe# not occur unle## t$ere i# a I$yperimC muni/ingJ e2ent #uc$ a# an 0B(Cincompatible pregnancy or tran#fu#ion 0b#ence of t$e e:pected antibodie# occur# rarely, alt$oug$ antibody titer# 2ary con#iderably among indi2idual# and $a2e been #$o*n to dimini#$ *it$ age %aC tient# *$o $a2e immunoglobulin deficiencie# *ill al#o lac4 antiC0 or antiCB (t$er*i#e, mo#t often t$e ab#ence of an agglutinin in a $ealt$y per#on #$ould be ta4en a# an indiC cation t$at t$ere may be a *ea4 antigen or e2en 7micro8 c$imeri#m pre#ent, per$ap# detectable by ad#orption and elution or by flo* cytometry .ndi2idual# of t$e 02 and 02B p$enotype# a# *ell a# t$o#e *$o#e !B+# carry certain 0 #ubgroup# 7;able B8 can al#o produce antiC0B, generally reacti2e at room temperaC ture and belo* 0lt$oug$ 0B( antibodie# of .gG type can cro## t$e placenta, #e2ere 0B(Crelated $emolytic di#ea#e of t$e ne*born i# not common ;$e mec$ani#m# be$ind t$i# are di#cu##ed in more detail in t$e #ection on clinical con#e6uence# #athogen Interactions Bacteria, 2iru#e#, and para#ite# $a2e been propo#ed a# important dri2ing force# for t$e geograp$ic di#tribution of 0B( blood group p$enotype# becau#e different pat$ogen# demon#trate blood groupKidentical or Kcro##Creacti2e molC ecule# on t$eir #urface# ;$e#e are t$e probable target# for Iblood groupJ antibodie#, and t$eir e:i#tence i# t$e leadC ing $ypot$e#i# a# to *$y *e ma4e naturally occurring anC tibodie# again#t t$e carbo$ydrate blood group# *e lac4 .n addition, many pat$ogen# #$o* #electi2e binding to blood group carbo$ydrate moietie# 2ia lectin# 7re2ie*ed by GarC rattyDE8 More recent but per$ap# anecdotal e2idence for t$i# t$eory *a# pro2ided after #e2ere $emolytic tran#fu#ion reaction# in t*o group B patient# recei2ing ap$ere#i# plateC let# from t$e #ame group 0 platelet donor DD ;$e donor $ad donated regularly for a period of 20 year#, during *$ic$ time no ad2er#e effect# of tran#fu#ion $ad been ob#er2ed, but $ad recently begun to #upplement $i# diet *it$ $ig$C do#e probiotic# and $i# antiCB titer *a# #$o*n to be greater t$an D000 .n$ibition #tudie# performed *it$ pla#ma from random group 0 donor# and #olubili/ed probiotic tablet# demon#trated a reduction in titer, $inting at a role for 0B( antibodie# in neutrali/ing pat$ogen# ;$i# line of t$in4ing i# #upported furt$er by data from #tudie# on 2iral glyco#yC lation in $o#t cell# &.V cultured in 2itro *it$ perip$eral blood mononuclear cell# 7%BM+8 from donor# of different

0B( group# demon#trated #pecific neutrali/ation *it$ antiC0 of t$o#e i#olate# gro*n in group 0 %BM+# but not t$o#e cultured *it$ group B or group ( cell# D9 Mea#le# 2iC ru#, *$en cocultured in a #y#tem e:pre##ing 0B& glyco#ylC tran#fera#e# 7to mimic an in 2i2o en2ironment8, e:pre##ed 0 or B epitope#, or not, according to t$e en/yme# e:pre##ed Viral particle# could t$en be neutrali/ed by normal polyC clonal antiC0 or antiCB #era in t$e pre#ence of complement if t$e corre#ponding glycan# *ere pre#ent 90 +on2er#ely, t$e 0 and B 7and &8 antigen# are al#o u#ed a# receptor# for pat$ogen in2a#ion by attac$ment to $o#t cell# a# mentioned pre2iou#ly, #o t$e e6uilibrium bet*een in2a#ion and e2aC #ion i# a fine balance on bot$ #ide# )urt$ermore, gro*ing e2idence for a leading role of Plasmodium falci"arum a# t$e maNor force #$aping t$e $uC man genome including t$e di#tribution of t$e blood group# $a# emerged 9B,92 ;$e para#iteCinduced !B+ #urface protein pfEM%B i# 4no*n to bind to t$e 0 antigen tri#acc$aride, 9A and it $a# been #$o*n t$at t$e #e2erity, including mortality, of malarial di#ea#e i# #ignificantly lo*er in group ( c$ildren t$an in ot$er group#, mainly t$roug$ t$e mec$ani#m of reC duced ro#etting 9>,95 .t i# t$e focu# on pediatric di#ea#e t$at i# t$oug$t to ma4e t$i# pat$ogen particularly effecti2e in e:erting a #election pre##ure on our genome ;$e general t$eme $ere i# t$e concept of $erd immuC nity, i e , t$e fact t$at difference# in t$e population *ill 4eep at lea#t a fraction of all indi2idual# protected from mo#t if not all pat$ogen# for $umanity to #ur2i2e 0B( difference# a# part of our innate immunity appear to be one of t$e betC ter e:ample# of t$i# idea 99 Clinical Significance (f all antibodie# to !B+ blood group antigen#, antiC0 and antiCB are arguably t$e mo#t clinically important (n t$e ot$er $and antiC0B and antiC& are 2ery #eldom found to correlate *it$ $emolytic ad2er#e e2ent# but often #$o* lo*er t$ermal optima Before t$e di#co2ery of 0B(, tran#C fu#ion bet*een $uman# $ad been attempted *it$ mi:ed #ucce## .n #ome ca#e#, t$e patient #ur2i2ed and got betC ter .n ot$er# t$e patient died rapidly, *$ic$ *e no* reC ali/e *a# attributable to rapid intra2a#cular $emoly#i# of 0B(Cincompatible !B+# 7re2ie*ed by Molli#on et al 9E8 .t $a# been reported t$at tran#fu#ion of a# little a# A0 m' of 0B(Cmi#matc$ed blood can re#ult in a rapid fatal inC tra2a#cular tran#fu#ion reaction 7re2ie*ed in .##itt and 0n#tee9D8 ;oget$er *it$ tran#fu#ionCrelated acute lung inNury 7;!0'.8 and bacterial contamination of blood comC ponent#, 0B( incompatibility i# #till one of t$e main ri#4# for maNor morbidity and mortality a##ociated *it$ tran#fuC #ion#, after erroneou# tran#fu#ion# 99,B00 ;$e late#t ),0 reC port on tran#fu#ionCa##ociated fatalitie# 7found at $ttp?<< *** fda go2<cber<blood<fatal0D $tm8 #$o*# t$at blood group incompatibility *a# Nudged a# t$e cau#e of deat$ in AE percent of all ca#e# during 200D, *it$ ;!0'. at A5 perC cent 0mong t$e $emolytic fatalitie# 0B( *a# t$e cau#e in

59 percent Surpri#ingly, $o*e2er, many report# #$o* t$at appro:imately 50 percent of patient# *$o are inad2ertently tran#fu#ed *it$ a maNor 0B(Cmi#matc$ed unit of blood tolC erate t$e blood *it$out any apparent #ign# of a tran#fu#ion reaction B0B ;$e mec$ani#m# underlying t$e ability of #ome indi2idual# to tolerate 0B(Cmi#matc$ed blood are not *ell under#tood but are 2ery intere#ting a# identification of re#i#tance mar4er# could be e:ploited in tran#plantation t$erapy ,e#pite our relati2e #op$i#tication in pro2iding apC propriately 0B(Cmatc$ed blood for patient#, t$ere i# recent clinical e2idence t$at e2en t$e concept of 0B(Ccompatible 7a# oppo#ed to 0B(Cidentical8 product# may not be a# #afe a# it *ould appear 0 #tudy t$at follo*ed t$e po#ttran#fuC #ion mortality among more t$an D9,000 patient# recei2ing pla#ma #$o*ed t$at e:po#ure to 0B(Ccompatible but nonC 0B(Cidentical pla#ma *a# a##ociated *it$ an increa#ed ri#4 of deat$ B02 -$et$er t$i# i# a##ociated *it$ immune comC ple:e# bet*een antiC0<B and #oluble 0<B antigen in 0B pla#ma, for in#tance, remain# to be #tudied )urt$ermore, report# of t$e u#age of platelet concentrate# in cardiac #urgery $a# al#o demon#trated le## fa2orable outcome# in t$o#e patient# recei2ing 0B(Cmi#matc$ed product# B0A ;$e aut$or# $ypot$e#i/ed t$at t$e formation of immune comC ple:e# may trigger cellular and inflammatory c$ange# t$at ad2er#ely affect patient outcome &emolytic di#ea#e of t$e fetu# and ne*born 7&,)N8 a# a re#ult of 0B( incompatibility bet*een mot$er and baby i# a relati2ely common e2ent in group ( mot$er# carrying a group 0 or group B fetu# &o*e2er, t$e di#ea#e i# generally mild and rarely re6uire# treatment, mo#t often by p$otoC t$erapy,9E alt$oug$ in$ibition of antibodie# by admini#traC tion of #oluble 0 or B tri#acc$aride# $a# been u#ed #ucce##C fully B0> Mild &,)N i# a con#e6uence of t$e comparati2ely lo* le2el# of .gG 0B( antibodie# 7*$ic$ are often mainly .gG2 or .gG>8 capable of cro##ing t$e placenta and al#o i# related to t$e immaturity of t$e glyco#ylated #tructure# on fetal !B+# .n addition, 0B& antigen# are pre#ent on many ot$er cell type# #o t$e antibody concentration on !B+# i# limited and t$e ,0; often only *ea4ly po#iti2e ;$e clinical #ignificance of antiC0 and antiCB e:tend# beyond tran#fu#ion medicine and i# important in bot$ #olid organ and $ematopoietic tran#plantation 0lt$oug$ 0B(C mi#matc$ed $ematopoietic #tem cell tran#plantation i# #tandard practice *it$ a fa2orable outcome in mo#t ca#e#, tran#plantation of 0B(Cincompatible #olid organ# $a# been e#tabli#$ed only relati2ely recently *it$ moderately #ucC ce##ful outcome B05 +$ildren younger t$an A year# of age $a2e been #$o*n to tolerate mi#matc$ed organ# better, and -e#t and colleague# $a2e demon#trated good po#ttran#C plant #ur2i2al in infant# undergoing 0B(C incompatible $eart tran#plant#,B09 #$o*ing t$at t$e relati2ely immature BCcell re#pon#e in t$e#e patient# can be e:ploited B0E .n a #tudy of >9 patient# undergoing 0B(C mi#matc$ed renal tran#plant#, ;obian et al B0D demon#trated t$at t$erapeuC tic ap$ere#i# to reduce antiC 0 and antiCB titer# to le## t$an

B9 toget$er *it$ #tandard immuno#uppre##ion protocol# re#ult# in #ucce##ful and #table engraftment %rogre## continue# in t$i# field, dri2en by a #$ortage of appropriate organ# for tran#plant 3a/er and ;riul/iB09 conclude t$at immune $emoly#i# remain# a maNor complication in 0B(C mi#matc$ed tran#plantation of #olid organ# and to a le##er e:tent $ematopoietic progenitor cell# &o*e2er, pa##enger lymp$ocyte #yndrome attributable to 0B( or ot$er blood group antibodie# can no* often be ameliorated by monoC clonal antibody t$erapy, once clinician# reali/e t$e probC lem Summar$ and )uture #erspectives ,e#pite t$e relati2e #implicity of t$e 0 and B antigen#, per$ap# e#pecially con#idering t$e minor bioc$emical difC ference bet*een t$em, t$e 0B( blood group #y#tem remain# one of t$e mo#t intere#ting, bot$ clinically and #cientifiC cally, di2iding t$e *orldH# population including patient# and donor# into four group# irre#pecti2e of origin or creed )igure E #ummari/e# t$e four principal le2el# at *$ic$ t$e 0B( #y#tem can be con#idered and #$o*# $o* immuno$eC matologi#t# $a2e been able to e:ploit t$e #teadily increa#ing 4no*ledge of t$i# #y#tem by de2i#ing te#t# ta4ing ad2anC tage of eac$ of t$e different le2el# .t al#o #$o*# #ome of t$e natural con#e6uence# generated and t$eir relation to t$e microbe# #urrounding u#
An(l)ti+An(l)ti+ mod(lmod(l ii tiesties

Anal$tic modalities

(atural conse&uences N(tur(lN(tur(l

+onse+onse -+enetic le3el /(NA7 m-NA 1

Genot)*in< +enotypin+eno typin00

)olymorphic population

5n2ym5n2ym iicc actiacti 33ityity

5n2yme le3el
@<l)+os)ltr(ns=er(seA /0lyco/0lyco ssyltrans.erase1yltran

6ounter(+tin< en;)mes @e0o<l)+osid(sesA develo*ed Counteractin0Counteractin0 ") "(+teri( en2ymesen2ymes 6ell sur=(+e re+e*tor v(ri(tion CellCell sur.acesur.ace Neutr(li;(tion ") se+reted (nti<ens
receptorreceptor 3ariation3ariation Neutrali2ationNeutrali2ation 4y4y

En;)mi+ (+tivit)

:orw(rd ,orward,orward t)*in< Adsor*tion8elution typin0typin0 Adsorption/Adsorp :low +)tomer) tion/ in,i"ition elutionelution S(liv(
,low

+lycocon8u0ate le3el /car4ohydrate anti0ens1

Reverse t)*in< -e3erse-e3erse Titr(tion typin0typin0

6itration6itration

9mmunolo0ical le3el /anti4odies 1

Neutr(li;(tiom ") immuno<lo"ulins Neutrali2ationNeutrali2atio n 4y4y

)ig- = 2rin+i*les o= t,e A1O s)stem (t =our mole+ul(r levels (nd t,eir modes o= inter(+tion (re s+,em(ti+(ll) re*resented ") (rrows in "l(+?& On t,e le=t side, t,e l("or(tor) (n(l)ti+(l mod(lities +ur> rentl) e0*loited (t e(+, level (re listedE t,e ri<,t side s,ows some o= t,e inn(te me+,(nisms used "etween ,ost (nd *(t,o<en&

0 *$ole array of 0B(Crelated re#earc$ and ot$er proNC ect# i# currently in progre## E2en if a #urpri#ing number of A&0 allele# $a# been di#co2ered already, no doubt t$ere are more to come .SB; i# currently *or4ing to facilitate communication and reporting by introducing an official alC lele nomenclature 0lt$oug$ A&0 genotyping cannot yet be u#ed a# a #tandCalone analy#i# to #upport clinical deci#ion#, impro2ement of t$e current #tatu# i# $ig$ly de#irable for it# u#e a# an independent addition to #erology in t$e referC ence laboratory ;oget$er *it$ colleague# acro## Europe,

*e recently introduced t$e fir#t microarrayCba#ed 0B( typC ing #y#tem t$at ta4e# t$e fir#t #tep# to*ard t$i# goal on a $ig$er t$roug$put #y#tem BB0 Effort# to rene* met$od# for #erologic typing are al#o ongoing )or in#tance, t$e young field of microfluidic# $old# promi#e for alternati2e blood grouping tec$nology being more rapid, u#ing #maller 2olC ume# of reactant#, and being applicable to broader te#ting platform# BBB ;$e temptation to create 0B(Cuni2er#al blood for tran#fu#ion purpo#e# $a# 4ept #cienti#t# bu#y #ince t$e early B9D0# *$en t$e fir#t #ucce##ful report of deliberate tran#fu#ion *it$ modified !B+# acro## t$e 0B( barrier *a# publi#$ed BB2 %rogre## from t$o#e early day#, u#ing a poorly effecti2e BCcon2erting e:oglyco#ida#e from green coffee bean#, $a# continued *it$ t$e aim# of eliminating 0B(C a##ociated $emolytic tran#fu#ion reaction# and #implifyC ing blood logi#tic# and in2entory management Not only $a# t$e proce## ta4en important #tride# to*ard becoming a reality *it$ bot$ 0C and BCdegrading en/yme# recombiC nantly a2ailable and nece##ary clinical trial# in progre## or being de#igned, but t$e proNect $a# al#o broug$t *it$ it t$e #cientifically e:citing di#co2ery of a large ne* cla## of bacC terially deri2ed e:oglyco#ida#e en/yme# un4no*n $it$erto and *it$out clear $omology or re#emblance to any ot$er group of molecule# BBA,BB> .t i# un4no*n at t$i# point *$y #o many different bacterial #pecie# $a2e de2eloped t$e#e blood groupKcon2erting en/yme# Speculation include# t$at it *ould #imply be a mean# of dige#ting potential nutrient #acc$aride#, but it al#o may be yet anot$er *ay for microbe# to ma4e #ure t$ey are able to attac$ to t$e $o#t cell #urface, e2en if t$e $i#toCblood group of t$e current $o#t $appen# not to fit t$e bacterial lectin# initially .t i# actually 6uite li4ely t$at yet ot$er glyco#ida#e #pecificitie# *ill be found in t$i# e:tended ar#enal of ne*ly di#co2ered en/yme# 0 recently e:ploited e:ample i# t$e Gal 'AGal 7al#o 4no*n a# t$e #traig$t B, fuco#eCle## B, or Galili antigen8 Cdegrading en/yme #ubfamily of galacto#ida#e# t$at can, for in#tance, be u#ed to degrade :enograft antigenicity in pig tendon# for u#e in 4nee #urgery BB5 )inally, it i# ea#y to ma4e t$e mi#ta4e of #itting bac4 and loo4ing at t$e 0B( #y#tem a# clo#e to complete *$en it come# to 4no*ledge and di#co2ery -e predict t$at bot$ t$e antigenic di2er#ity and t$e *ay *e loo4 at antibody #pecificitie# in t$i# and related #y#tem# *ill c$ange dramatC ically during t$e ne:t fe* year# ba#ed on recent and future finding# made po##ible by ne* tec$nologie# 0B( $a# for a long time #er2ed a# a great model for genetic#, en/ymology, and bioc$emi#try t$an4# to our deep under#tanding of t$e interindi2idual 2ariation in t$i# #y#tem, and t$ere i# not$C ing to #ugge#t t$at it *ill #top no* *$en $ig$Ct$roug$put genetic# and glycotope array# are $ere to $elp u# (n t$e contrary, it #$ould be e:pected t$at t$ere are #till more #urC pri#e# *aiting around t$e corner

Ac+nowledgments Some of t$e content and figure# in t$i# re2ie* $a2e been modified from t$e doctoral t$e#e# of M ' ( 7Molecular GeC netic Studie# of t$e Blood Group 0B( 'ocu# in ManF 'und 5ni2er#ity, B99E8 and ,r Ba$ram &o##einiCMaaf 7Genetic +$aracteri#ation of &uman 0B( Blood Group Variant# *it$ a )ocu# on Subgroup# and &ybrid 0llele#F 'und 5ni2er#ity, 200E8 References B +amp )!, Elli# )! Selected contribution# to t$e literaC ture of blood group# and immunology )ort "no:, "3? 5S 0rmy Medical !e#earc$ 'aboratory, B999 2 -at4in# -M Bioc$emi#try and genetic# of t$e 0B(, 'e*i# and % blood group #y#tem# .n? &arri# &, &ir#c$$orn ", ed# 0d2ance# in $uman genetic# Ne* 3or4? %lenum %re##, B9D0?BKBA9 A +lau#en &, &a4omori S 0B& and related $i#toCblood group antigen#F immunoc$emical difference# in carrier i#otype# and t$eir di#tribution Vo: Sang B9D9F59?BK 20 > 3a/er M&, %alcic MM ;$e importance of di#ordered loop# in 0B( glyco#yltran#fera#e# ;ran#fu# Med !e2 2005FB9?2B0KB9 5 3amamoto ) Molecular genetic# of 0B( Vo: Sang 2000FED?9BKB0A 9 +$e#ter M0, (l##on M' ;$e 0B( blood group gene? a locu# of con#iderable genetic di2er#ity ;ran#fu# Med !e2 200BFB5?BEEK200 E 'and#teiner " Pur "enntni# der antifermentati2en, lyti#c$en und agglutinierenden -ir4ungen de# Blut#eC rum# und der 'ymp$e Pbl Ba4t B900F2E?A5EK92 D 'and#teiner " Zber 0gglutination#er#c$einungen norC malen Men#c$lic$en Blute# -ien "lin -oc$en#c$r B90BFB>?BBA2K> 9 ,eca#tello 0, Sturli 0 5eber die i#oagglutinine im geC #under und 4ran4er men#c$en Munc$ Med -oc$enC #c$rift B902F>9?B090K5 B0 !ace !!, Sanger ! Blood group# in man 9t$ ed (:C ford, 5"? Blac4*ell Scientific %ublication#, B9E5 BB 2on ,ungern E, &ir/#feld ' 5ber die gruppen#C pe/ifi#c$e #tru4turen de# blute# ... .mmun )or#c$ 2B9BFD?529K92 B2 Mourant 0E, "ope 0+, ,omanie*#4a " ;$e di#tribuC tion of $uman blood group# and ot$er polymorp$i#m# Ne* 3or4? (:ford 5ni2er#ity %re##, B9E9 BA !oyc$oud$uri 0", Nei M &uman polymorp$ic gene# *orld di#tribution (:ford? (:ford 5ni2er#ity %re##, B9DD B> 'alue/aC)o: +, Gigli E, de la !a#illa M, )ortea J, !o#a# 0, Bertranpetit J, "rau#e J Genetic c$aracteri/ation of t$e 0B( blood group in Neandertal# BM+ E2ol Biol 200DFD?A>2 B5 +rainic ", ,urigon M, (riol ! 0B( ti##ue antigen# of Egyptian mummie# )oren#ic Sci .nt B9D9F>A?BBAK2>

B9 "orc$agina E3, %oc$ec$ue2a ;V, (bu4$o2a %S, )ormano2#4y 00, .mberty 0, !ieben !, Bo2in NV ,e#ign of t$e blood group 0B glycotope GlycoconN J 2005F22?B2EKAA BE +lau#en &, 'e2ery SB, ,abel#teen E, &a4omori S Blood group 0B& antigen#? a ne* #erie# of blood group 0Ca##ociated #tructure# 7genetic regulation and ti##ue di#tribution8 ;ran#plant %roc B9DEFB9?>>0DKB2 BD S2en##on ', !ydberg ', de Matto# '+, &enry SM Blood group 0 and 0 re2i#ited? an immunoc$emical analy#i# Vo: Sang 2009F99?59K9B B9 ,aniel# G', )letc$er 0, Garratty G, et al Blood group terminology 200>? from t$e .nternational Society of Blood ;ran#fu#ion committee on terminology for red cell #urface antigen# Vo: Sang 200>FDE?A0>KB9 20 Blumenfeld ((, %atnai4 S" 0llelic gene# of blood group antigen#? a #ource of $uman mutation# and cSC N%# documented in t$e Blood Group 0ntigen Gene Mutation ,ataba#e &um Mutat 200>F2A?DKB9 2B Ep#tein 00, (ttenberg ! Simple met$od of performing #erum reaction# %roc N 3 %at$ol Soc B90DFD?BBEK2A 22 2on ,ungern E, &ir#/feld ' +oncerning $eredC ity of group #pecific #tructure# of blood ;ran#fu#ion B992F2?E0K2 2A Bern#tein ) Pu#ammenfa##ande betrac$tungen [ber die erblic$en Blut#tru4turen de# Men#c$en P .ndu4t 0b#tamm u Vererb'e$re B925FAE?2AEKE0 2> +ro* J) )eli: Bern#tein and t$e fir#t $uman mar4er locu# Genetic# B99AFBAA?>KE 25 )ergu#onCSmit$ M0, 0it4en ,0, ;urleau +, de Grouc$y J 'ocali#ation of t$e $uman 0B(? NpCB? 0"CB lin4age group by regional a##ignment of 0"CB to 96A> &um Genet B9E9FA>?A5K>A 29 3amamoto ), +lau#en &, -$ite ;, Mar4en J, &a4omori S Molecular genetic ba#i# of t$e $i#toCblood group 0B( #y#tem Nature B990FA>5?229KAA 2E 3amamoto ), Mar4en J, ;#uNi ;, -$ite ;, +lau#en &, &a4omori S +loning and c$aracteri/ation of ,N0 complementary to $uman 5,%CGalN0c?)ucCalp$aBK 2Gal alp$aBKAGalN0c tran#fera#e 7$i#toCblood group 0 tran#fera#e8 m!N0 J Biol +$em B990F295?BB>9K5B 2D +lau#en &, -$ite ;, ;a4io ", et al .#olation to $omoC geneity and partial c$aracteri/ation of a $i#toCblood group 0 defined )ucCalp$aBK2Gal alp$aBKACNCacetylC galacto#aminyltran#fera#e from $uman lung ti##ue J Biol +$em B990F295?BBA9K>5 29 3amamoto ), McNeill %,, &a4omori S &uman $i#toC blood group 02 tran#fera#e coded by 02 allele, one of t$e 0 #ubtype#, i# c$aracteri/ed by a #ingle ba#e deletion in t$e coding #e6uence, *$ic$ re#ult# in an additional domain at t$e carbo:yl terminal Bioc$em Biop$y# !e# +ommun B992FBDE?A99KE> A0 3amamoto ), McNeill %,, &a4omori S Genomic orgaC ni/ation of $uman $i#toCblood group 0B( gene# GlyC cobiology B995F5?5BKD

AB Bennett E%, Steffen#en !, +lau#en &, -eg$ui# ,(, 2an "e##el 0G Genomic cloning of t$e $uman $i#toCblood group 0B( locu# Bioc$em Biop$y# !e# +ommun B995F209?ABDK25 A2 "ominato 3, &ata 3, ;a4i/a*a &, et al 0lternati2e promoter identified bet*een a $ypermet$ylated upC #tream region of repetiti2e element# and a +pG i#land in $uman 0B( $i#toCblood group gene# J Biol +$em 2002F2EE?AE9A9K>D AA &o##einiCMaaf B, Smart E, +$e#ter M0, (l##on M' ;$e 0bantu p$enotype in t$e 0B( blood group #y#tem i# due to a #pliceC#ite mutation in a $ybrid bet*een a ne* 02Cli4e allelic lineage and t$e A; allele Vo: Sang 2005FDD?259K9> A> +alafell ), !oubinet ), !amire/CSoriano 0, Saitou N, Bertranpetit J, Blanc$er 0 E2olutionary dynamic# of t$e $uman 0B( gene &um Genet 200DFB2>?B2AKA5 A5 !oubinet ), "ermarrec N, ,e#piau S, 0poil %0, ,ugC ouNon JM, Blanc$er 0 Molecular polymorp$i#m of ( allele# in fi2e population# of different et$nic origin# .mmunogenetic# 200BF5A?95KB0> A9 (l##on M', Guerreiro J), Pago M0, +$e#ter M0 MoC lecular analy#i# of t$e ( allele# at t$e blood group 0B( locu# in population# of different et$nic origin re2eal# no2el cro##ingCo2er e2ent# and point mutation# BioC c$em Biop$y# !e# +ommun B99EF2A>?EE9KD2 AE 3a/er M&, (l##on M' ;$e 0; allele? 6ue#tioning t$e p$enotypic definition of an A&0 allele .mmuno$emaC tology 200DF2>?BADK>E AD &o##einiCMaaf B, .r#$aid NM, &ellberg 0, et al Ne* and unu#ual ( allele# at t$e 0B( locu# are implicated in une:pected blood group p$enotype# ;ran#fu#ion 2005F>5?E0KDB A9 Selt#am 0, ,a# G+, -agner )), Bla#c/y4 ! NondeleC tional 0B(\( allele# e:pre## *ea4 blood group 0 p$eC notype# ;ran#fu#ion 2005F>5?A59K95 >0 'ee &J, Barry +&, Bori#o2a SN, et al Structural ba#i# for t$e inacti2ity of $uman blood group (2 glyco#ylC tran#fera#e J Biol +$em 2005F2D0?525K9 >B -agner )), Bla#c/y4 !, Selt#am 0 Nondeletional 0B(\( allele# fre6uently cau#e blood donor typing problem# ;ran#fu#ion 2005F>5?BAABK> >2 3a/er M&, &ult 0", &ellberg 0, &o##einiCMaaf B, %alcic MM, (l##on M' .n2e#tigation into 0 antigen e:pre#C #ion on (2 $etero/ygou# group (Clabeled red blood cell unit# ;ran#fu#ion 200DF>D?B950KE >A (l##on M', +$e#ter M0 &eterogeneity of t$e blood group A: allele? genetic recombination of common alC lele# can re#ult in t$e A: p$enotype ;ran#fu# Med B99DFD?2ABKD >> (l##on M', .r#$aid NM, &o##einiCMaaf B, et al GeC nomic analy#i# of clinical #ample# *it$ #erologic 0B( blood grouping di#crepancie#? identification of B5 no2el 0 and B #ubgroup allele# Blood 200BF9D?B5D5K

>5 3u '+, ;*u 3+, +$ou M', +$ang +3, -u +3, 'in M Molecular genetic analy#i# for t$e B7A8 allele Blood 2002FB00?B>90K2 >9 Selt#am 0, Gruger ,, Ju#t B, et al 0berrant intracelluC lar traffic4ing of a 2ariant B glyco#yltran#fera#e ;ran#C fu#ion 200DF>D?BD9DK905 >E &o##einiCMaaf B, &ellberg 0, +$e#ter M0, (l##on M' 0n e:ten#i2e %+!C0S% #trategy for clinical 0B( blood group genotyping t$at a2oid# potential error# cau#ed by null, #ubgroup and $ybrid allele# ;ran#fu#ion 200EF>E?2BB0K25 >D (l##on M', +$e#ter M0 %olymorp$i#m and recombiC nation e2ent# at t$e 0B( locu#? a maNor c$allenge for genomic 0B( blood grouping #trategie# ;ran#fu# Med 200BFBB?295KABA >9 %rocter J, +ra*ford J, Bunce M, -el#$ ". 0 rapid molecC ular met$od 7polymera#e c$ain reaction *it$ #e6uenceC #pecific primer#8 to genotype for 0B( blood group and #ecretor #tatu# and it# potential for organ tran#plant# ;i##ue 0ntigen# B99EF50?>E5KDA Vpubli#$ed erratum appear# in ;i##ue 0ntigen# B99DF5B?AB9W 50 "ominato 3, ;#uc$iya ;, &ata N, ;a4i/a*a &, 3amaC moto ) ;ran#cription of $uman 0B( $i#toCblood group gene# i# dependent upon binding of tran#cription facC tor +B)<N)C3 to mini#atellite #e6uence J Biol +$em B99EF2E2?25D90KD 5B .r#$aid NM, +$e#ter M0, (l##on M' 0lleleCrelated 2ariation in mini#atellite repeat# in2ol2ed in t$e tranC #cription of t$e blood group 0B( gene ;ran#fu# Med B999F9?2B9K29 52 3u '+, +$ang +3, ;*u 3+, 'in M &uman $i#toCblood group 0B( glyco#yltran#fera#e gene#? different en$ancC er #tructure# *it$ different tran#criptional acti2itie# Bioc$em Biop$y# !e# +ommun 2000F2EA?>59K99 5A Selt#am 0, -agner )), Gr[ger ,, Gupta +,, BadeC,oC eding +, Bla#c/y4 ! -ea4 blood group B p$enotype# may be cau#ed by 2ariation# in t$e ++00;Cbinding facC tor<N)C3 en$ancer region of t$e 0B( gene ;ran#fuC #ion 200EF>E?2AA0K5 5> ;*u 3+, &#ie$ +3, 3u '+ E:pre##ion of t$e $i#toC blood group B gene predominate# in 0BCgenotype cell# ;ran#fu#ion 2009F>9?B9DDK99 9A

55 ;$ure##on B, +$e#ter M0, Storry J!, (l##on M' A&0 tran#cript le2el# in perip$eral blood and eryt$ropoietic culture #$o* different alleleCrelated pattern# indepenC dent of t$e +B)<N)C3 en$ancer motif and multiple no2el alleleC#pecific 2ariation# in t$e 5QC and AQC noncodC ing region# ;ran#fu#ion 200DF>D?>9AK50> 59 &ata 3, "ominato 3, 3amamoto )., ;a4i/a*a & +$arC acteri/ation of t$e $uman 0B( gene promoter in eryt$C roid cell lineage Vo: Sang 2002FD2?A9K>9 5E Bianco ;, )armer BJ, Sage !E, ,obro2ic 0 'o## of red cell 0, B, and & antigen# i# fre6uent in myeloid maligC nancie# Blood 200BF9E?A9AAK9

5D &o#oi E, &iro#e M, &amano S, "uroda 3 ,etection of $i#toCblood group 0B( m!N0 in $uman c$ronic myC eloid leu4emia cell line# u#ing re2er#e tran#criptionC polymera#e c$ain reaction 7!;C%+!8 +ancer 'ett B99DFBAA?B9BK9 59 BiancoCMiotto ;, &u##ey ,J, ,ay ;", (H"eefe ,S, ,oC bro2ic 0 ,N0 met$ylation of t$e 0B( promoter underC lie# lo## of 0B( allelic e:pre##ion in a #ignificant proporC tion of leu4emic patient# %'oS (NE 2009F>?e>EDD 90 +$i$ara 3, Sugano ", "obaya#$i 0, et al 'o## of blood group 0 antigen e:pre##ion in bladder cancer cau#ed by allelic lo## and<or met$ylation of t$e 0B( gene 'ab .n2e#t 2005FD5?D95K90E 9B ,abel#teen E, Gao S 0B( bloodCgroup antigen# in oral cancer J ,ent !e# 2005FD>?2BKD 92 (rntoft ;), Meldgaard %, %eder#en B, -olf & ;$e blood group 0B( gene tran#cript i# do*nCregulated in $uman bladder tumor# and gro*t$C#timulated urot$eC lial cell line# +ancer !e# B999F59?B0ABK9 9A "abat E0 Blood group #ub#tance# ;$eir c$emi#try and immuno$i#toc$emi#try Ne* 3or4? 0cademic %re##, B959 9> Morgan -;, -at4in# -M ;$e detection of a product of t$e blood group ( gene and t$e relation#$ip of t$e #oCcalled (C#ub#tance to t$e agglutinate# 0 and B Br J E:p %at$ol B9>DF29?B59KEA 95 Morgan -;, -at4in# -M ;$e in$ibition of t$e $aeC magglutinin# in plant #eed# by $uman blood group #ubC #tance# and #imple #ugar# Br J E:p %at$ol B95AFA>?9>K B0A 99 -at4in# -M, Morgan -; .n$ibition by #imple #ugC ar# of en/yme# *$ic$ decompo#e t$e bloodCgroup #ubC #tance# Nature B955FBE5?9E9KE 9E -at4in# -M, Morgan -; %o##ible genetical pat$*ay# for t$e bio#ynt$e#i# of blood group mucopoly#acc$aC ride# Vo: Sang B959F>?9EKBB9 9D +eppellini ! %$y#iological genetic# of $uman blood group factor# .n? -ol#ten$olme GE-, (H+onnor +M, ed# +iba )oundation #ympo#ium on bioc$emi#try of $uman genetic# 'ondon? +$urc$ill, B959?2>2K9B 99 'eloir ') Nucleo#ide dip$o#p$ate #ugar# and #acc$aC ride #ynt$e#i# Bioc$em J B99>F9B?BKD E0 -at4in# -M GeneCen/yme relation#$ip# of t$e 0, B, & and 'e blood group gene# 7ab#tract8 ;ran#fu#ion B99EFE?A9E EB &earn VM, Smit$ PG, -at4in# -M 0n aCNCacetylC,C galacto#aminyltran#fera#e a##ociated *it$ t$e $uman bloodCgroup 0 c$aracter Bioc$em J B99DFB09?AB5KBE E2 !ace +, Piderman ,, -at4in# -M 0n alp$aCdC galactoC #yltran#fera#e a##ociated *it$ t$e bloodCgroup B c$arC acter Bioc$em J B99DFB0E?EAAK5 EA Sc$en4elCBrunner &, ;uppy & En/yme# from $uman ga#tric muco#a conferring bloodCgroup 0 and B #peciC

E> Sc$ac$ter &, Mic$ael# M0, ;illey +0, +roo4#ton M+, +roo4#ton J& Oualitati2e difference# in t$e NCacetylC dC galacto#aminyltran#fera#e# produced by $uman 0B and 02 gene# %roc Natl 0cad Sci 5 S 0 B9EAFE0?220K > E5 ;opping M,, -at4in# -M .#olectric point# of t$e $uC man blood group 0CB, 0C2 and B geneC a##ociated glyC co#yltran#fera#e# in o2arian cy#t fluid# and #erum BioC c$em Biop$y# !e# +ommun B9E5F9>?D9K99 E9 +lau#en &, 'e2ery SB, Nudelman E, ;#uc$iya S, &a4oC mori S !epetiti2e 0 epitope 7type A c$ain 08 defined by blood group 0BC#pecific monoclonal antibody ;&C B? c$emical ba#i# of 6ualitati2e 0B and 02 di#tinction %roc Natl 0cad Sci 5 S 0 B9D5FD2?BB99K20A EE Var4i 0, +umming# !, E#4o J, )ree/e &, &art G, Mart$ J E##ential# of glycobiology +old Spring &arbor, N3? +old Spring &arbor 'aboratory %re##, B999 ED (riol !, +andelier JJ, Mollicone ! Molecular genetic# of & Vo: Sang 2000FED7Suppl 28?B05KD E9 %aul#on J+, +olley "J Glyco#yltran#fera#e# Structure, locali/ation, and control of cell typeC#pecific glyco#ylaC tion J Biol +$em B9D9F29>?BE9B5KBD D0 +lau#en &, Bennett E%, ,abel#teen E +arbo$ydrate# of t$e cell #urface? molecular a#pect# of glyco#yltran#C fera#e# and t$eir gene# 0%M.S Suppl B992F2E?9KBE DB %atenaude S., Seto N(, Bori#o2a SN, et al ;$e #trucC tural ba#i# for #pecificity in $uman 0B(7&8 blood group bio#ynt$e#i# Nat Struct Biol 2002F9?9D5K90 D2 &o##einiCMaaf B, 'ett# J0, %er##on M, et al Structural ba#i# for red cell p$enotypic c$ange# in ne*ly identiC fied, naturally occurring #ubgroup mutant# of t$e $uC man blood group B glyco#yltran#fera#e ;ran#fu#ion 200EF>E?D9>KE5 DA Springer G), -illiam#on %, !eadler B' Blood group acti2e gramCnegati2e bacteria and $ig$er plant# 0nn N 3 0cad Sci B992F9E?B0>KB0 D> +ooling '-, Sit*ala ", ,a4e '!, Judd -J, ,a2enport ! 0B( typing di#crepancie# in c$ildren re6uiring longC term nutritional #upport? it i# t$e gut after all] ;ran#fuC #ion 200EF>E?B00 D5 "un4el &G, )udenberg &, (2ary P &ig$ molecular *eig$t antibodie# 0nn N3 0cad Sci B990FD9?999CEA D9 "un4el &G, !oc4ey J& V2 0 and ot$er immunoglobuC lin# in i#olated antiC0 antibodie# %roc Soc E:p Biol Med B99AFBBA?2ED DE Garratty G Blood group antigen# a# tumor mar4er#, para#itic<bacterial<2iral receptor#, and t$eir a##ociaC tion *it$ immunologically important protein# .mmuC nol .n2e#t B995F2>?2BAKA2 ficitie# upon eryt$rocyte# Eur J Bioc$em B9E0FBE?2BDK 22

DD ,anielCJo$n#on J, 'eeCStro4a 0, Sc$ec$terly +, et al %robioticCa##ociated $ig$Ctiter antiCB in a group 0 platelet donor a# a cau#e of #e2ere $emolytic tran#fuC #ion reaction# ;ran#fu#ion 200DF>DS7Suppl 28?2900

D9 0rendrup M, &an#en JE, +lau#en &, Niel#en +, Mat$C ie#en '!, Niel#en J( 0ntibody to $i#toCblood group 0 antigen neutrali/e# &.V produced by lymp$ocyte# from blood group 0 donor# but not from blood group B or ( donor# 0.,S B99BF5?>>BK> 90 %reece 0), Stra$an "M, ,e2itt J, 3amamoto ), Gu#taf#C #on " E:pre##ion of 0B( or related antigenic carbo$yC drate# on 2iral en2elope# lead# to neutrali/ation in t$e pre#ence of #erum containing #pecific natural antibodC ie# and complement Blood 2002F99?2>EEKD2 9B +#erti +M, ,/i4 -& ;$e 0B( blood group #y#C tem and Plasmodium falci"arum malaria Blood 200EFBB0?2250KD 92 5ne4e +J Plasmodium falci"arum malaria and 0B( blood group? i# t$ere any relation#$ipU %ara#itol !e# 200EFB00?E59K95 9A +$en O, &eddini 0, Barragan 0, )ernande/ V, %earce S), -a$lgren M ;$e #emicon#er2ed $ead #tructure of Plasmodium falci"arum eryt$rocyte membrane proC tein B mediate# binding to multiple independent $o#t receptor# J E:p Med 2000FB92?BKB0 9> 'o#certale# M%, (*en# S, (H,onnell J, Bunn J, Bo#c$C +apblanc$ @, Brabin BJ 0B( blood group p$enotype# and Plasmodium falci"arum malaria? unloc4ing a pi2C otal mec$ani#m 0d2 %ara#itol 200EF95?BK50 95 !o*e J0, &andel .G, ;$era M0, et al Blood group ( protect# again#t #e2ere Plasmodium falci"arum maC laria t$roug$ t$e mec$ani#m of reduced ro#etting %roc Natl 0cad Sci 5 S 0 200EFB0>?BE>EBK9 99 Gagneu: %, Var4i 0 E2olutionary con#ideration# in reC lating oligo#acc$aride di2er#ity to biological function Glycobiology B999F9?E>EK55 9E Molli#on %', Engelfriet +%, +ontrera# M Blood tran#C fu#ion in clinical medicine B0t$ ed 'ondon? Blac4*ell Scientific, B99E 9D .##itt %,, 0n#tee ,J 0pplied blood group #erology >t$ ed Miami? Montgomery Scientific %ublication#, B99D 99 Sa/ama " !eport# of A55 tran#fu#ionCa##ociated deat$#? B9E9 t$roug$ B9D5 ;ran#fu#ion B990FA0?5DAK90 B00 Stain#by ,, Jone# &, 0#$er ,, et al Seriou# $a/ard# of tran#C fu#ion? a decade of $emo2igilance in t$e 5" ;ran#fu# Med !e2 2009F20?2EAKD2 B0B 'inden JV, -agner ", Voyto2ic$ 0E, S$ee$an J ;ran#C fu#ion error# in Ne* 3or4 State? an analy#i# of B0 year#H e:perience ;ran#fu#ion 2000F>0?B20EKBA B02 S$an*ell 0, 0nder##on ;M, !o#tgaard ", et al %o#tC tran#C fu#ion mortality among recipient# of 0B(C compatible but nonCidentical pla#ma Vo: Sang 2009F99?AB9K2A B0A Blumberg N, &eal JM, &ic4# G' Jr, !i#$er -& 0##oC ciation of 0B(Cmi#matc$ed platelet tran#fu#ion# *it$ morbidity and mortality in cardiac #urgery ;ran#fu#ion 200BF>B?E90KA

B0> !omano E', Soyano 0, Montano !), et al ;reatment of 0B( $emolytic di#ea#e *it$ #ynt$etic blood group tri#acC c$aride# Vo: Sang B99>F99?B9>K9 B05 !ydberg ' 0B(Cincompatibility in #olid organ tran#planC tation ;ran#fu# Med 200BFBB?A25K>2 B09 -e#t 'J, %olloc4CBar/i2 SM, ,ipc$and 0., et al 0B(C inC compatible $eart tran#plantation in infant# N Engl J Med 200BFA>>?E9AKD00 B0E -e#t 'J BCcell tolerance follo*ing 0B(CincompatC ible infant $eart tran#plantation ;ran#plantation 2009FDB?A0BKE B0D ;obian 00, S$irey !S, Montgomery !0, ;i#c$ ,J, Ne## %M, "ing "E ;$erapeutic pla#ma e:c$ange reduce# 0B( titer# to permit 0B(Cincompatible renal tran#plantation ;ran#fu#ion 2009 )eb 9 VEpub a$ead of printW B09 3a/er M&, ;riul/i ,J .mmune $emoly#i# follo*ing 0B(C mi#matc$ed #tem cell or #olid organ tran#plantation +urr (pin &ematol 200EFB>?99>KE0 BB0 02ent N,, Martine/ 0, )legel -0, et al ;$e BloodGen proNect? to*ard ma##C#cale compre$en#i2e genotyping of blood donor# in t$e European 5nion and beyond ;ran#fu#ion 200EF>E7Suppl8?>0SK9S BBB "line ;!, !unyon M", %ot$ia*ala M, .#magilo2 !) 0B(, , blood typing and #ubtyping u#ing plugCba#ed microfluidic# 0nal +$em 200DFD0?9B90KE BB2 Gold#tein J, Si2iglia G, &ur#t !, 'enny ', !eic$ ' Group B eryt$rocyte# en/ymatically con2erted to group ( #ur2i2e normally in 0, B, and ( indi2idual# Science B9D2F2B5?B9DKE0 BBA 'iu O%, Sul/enbac$er G, 3uan &, et al Bacterial glyC co#ida#e# for t$e production of uni2er#al red blood cell# Nat Biotec$nol 200EF25?>5>K9> BB> (l##on M', +lau#en & Modifying t$e red cell #urface? to*ard# an 0B(Cuni2er#al blood #upply Br J &aematol 200DFB>0?AKB2 BB5 'iu O%, 3uan &, Bennett E%, et al .dentification of a G&BB0 #ubfamily of alp$a B,ACgalacto#ida#e#? no2el enC /yme# for remo2al of t$e alp$a AGal :enotran#plantaC tion antigen J Biol +$em 200DF2DA?D5>5K5> %ill R8 (torry$ Ph#$ FI&M( +corres"onding author,$ Coordinator$ ("ecial (erology$ #e"artment of Clinical Immunology and .ransfusion Medicine$ !ni/ersity and Regional Laboratories$ and Martin L8 0lsson$ M#$ Ph#$ #i/ision of 4aematology and .ransfusion Medicine$ #e"artment of Laboratory Medicine$ Lund !ni/ersity$ Lund$ (weden8

6(se Re*ort

Clinical evaluation for l$mphoproliferative disease prompted %$ finding of IgM warm autoanti I! in two cases
R&M& Le<er, :& Lowder, M&6& 3un<o, 9& 6,en, H&M& M(son, (nd G& G(rr(tt)
0ntiC.; i# an unu#ual #pecificity originally de#cribed a# a naturally occurring cold agglutinin ;$e antibody react# #trongly *it$ cord !B+#, *ea4ly *it$ adult . !B+#, and mo#t *ea4ly *it$ t$e rare adult i !B+# .gG antiC.; in patient# *it$ $emolytic anemia $a# been a##ociated *it$ &odg4inH# lymp$oma ,ifficultie# in blood grouping te#t# and t$e pre#ence of a *arm reacti2e agglutinin in #ample# from t*o patient# *it$ $emolytic anemia led to furt$er #erologic #tudie# and t$e identification of antiC.; .n bot$ ca#e#, t$e antiC.; *a# a rarely encountered .gM *arm reacti2e agglutiC ninF in one ca#e, t$e .gG component *a# al#o antiC.;, *$erea# in t$e #econd ca#e t$e .gG antibody *a# broadly reacti2e ;$e unC u#ual #erologic finding of antiC.; prompted furt$er clinical e2aluC ation for lymp$oproliferati2e di#ea#e in t$e#e t*o patient# Immunohematology 4009?45)60#646

0e$ 4ords: .gM *arm autoantibody, autoantiC.;, $emolytic anemia

ntiC.; *a# originally de#cribed a# a benign, naturally occurring, .gM cold agglutinin in Melane#ian#B and later in Vene/uela .ndian# 2 ;$e antiC.; agglutinin did not demon#trate cla##ical . or i #pecificity but reacted #trongly *it$ cord !B+#, *ea4ly *it$ normal adult . !B+#, and mo#t *ea4ly *it$ t$e rare adult i !B+# .t *a# t$oug$t t$e agglutinin recogni/ed a tran#ition #tate of i to ., t$u# t$e de#ignation .; 7; for tran#ition8 B Sub#e6uent data do not #upport t$i# $ypot$e#i#F .; i# e:pre##ed nearly a# *ell or a# *ell on fetal !B+# ranging in age from BB to B9 *ee4# a# on cord !B+# A ;$e bioc$emical #tructure of .; i# #till unclear ;$e fir#t four e:ample# of .gG antiC.; *ere in #era of patient# *it$ autoimmune $emolytic anemia 70.&08 and &odg4inH# lymp$oma A,> (t$er# reported a #imilar a##ociaC tion 5 &afleig$ et al 9 found t$ree e:ample# of .gG autoantiC .; in patient# *$o did not $a2e &odg4inH# di#ea#e or 0.&0 (ne e:ample of .gM *arm antiC.; and one .gM cold plu# .gG antiC.; in patient# *it$ 0.&0 *ere not a##ociated *it$ &odg4inH# di#ea#e, but one of t$e ca#e# *a# a##ociated *it$ nonC&odg4inH# lymp$oma E,D -e report an unu#ual AEY+ reacti2e .gM agglutinin plu# an .gG antiC. ;9 and a AEY+ reC acti2e .gM agglutinating antiC.; plu# broadly reacti2e .gG autoantibody in t*o patient# *it$ $emolytic anemia *$o *ere #ub#e6uently e2aluated for lymp$oproliferati2e di#C ea#e o*ing to t$e #pecificity of t$e antibodie# reported

Case Reports Case 1 0 99CyearCold &i#panic *oman pre#ented *it$ pancyC topenia 7-B+ ^ 2 A _ B09<'F &b ^ 9 9 g<d'F &ct ^ B9 BRF platelet# ^ 9>,000<`'8, #plenomegaly but no lymp$adeC nopat$y, and $emolytic anemia 7#p$erocyto#i#F ',& ^ 9E2 5<' Vnormal A55K9A0WF total bilirubin ^ 2 D mg<d' Vnormal 0 BKB 2WF direct bilirubin ^ 0 E mg<d' Vnormal 0K0 >W8 ;$e direct antiglobulin te#t 7,0;8 *a# po#iti2e 'ymp$oma *a# not #u#pected until after t$e antiC.; *a# identified +omputC ed tomograp$y 7+;8 #can# #$o*ed e2idence of large lymC p$oid infiltrate# compo#ed of a mi:ture of #mall and large lymp$ocyte# Bilateral bone marro* a#piration #$o*ed inC crea#ed lymp$ocyte# but *a# not diagno#tic of lymp$oma ;$e patient *a# empirically treated *it$ #teroid# and $ad impro2ed $emoglobin and #en#e of *ellC being Steroid# *ere tapered ;*o and a $alf mont$# later t$e patient reC turned for a #plenectomy, *$ic$ *a# pat$ologically negaC ti2e for lymp$oma Section# #$o*ed lymp$oid $yperpla#ia *it$ a benign p$enotype con#i#ting of ; and B cell# *it$ no aberrant e:pre##ion of +,5, +,2A, or bclC2 Serologic #tudC ie# at t$at time #$o*ed #imilar reacti2ity of antiC.; ;$ree mont$# later, t$e patient e:$ibited mild t$rombocytopenia *it$ #lig$tly ele2ated ',& 0 repeat bone marro* #$o*ed lymp$ocyto#i# #ugge#ti2e of lo*Cgrade BCcell lymp$oproC liferati2e di#ea#e 0 year later, after ritu:imab and ot$er c$emot$erapy, t$e bone marro* #$o*ed atypical lymp$oid infiltrate# ;$e infiltrate# *ere compo#ed primarily of #mall mature lymp$ocyte# *it$ occa#ional larger lymp$ocyte# noted, mo#t li4ely repre#enting a lymp$oproliferati2e di#C order )lo* cytometry #$o*ed an entire BCcell population t$at did not e:pre## +,20 'e## t$an A year# after original pre#entation, t$e patient *a# tran#fu#ionCdependant and diagno#ed *it$ apla#tic anemia S$e *a# di#c$arged to $o#C pice care *it$ endC #tage li2er di#ea#e, lymp$oproliferati2e di#order, and $emolytic anemia Case 2 0 pre2iou#ly $ealt$y B9CyearCold "orean man pre#ented to t$e emergency room *it$ in#idiou# on#et of fatigue, #$ortC ne## of breat$, dy#pnea on e:ertion, and pallor 'aboratory data re2ealed t$rombocytopenia and $emolytic anemia?

-B+ ^ 9 D _ B09<'F &b ^ > 9 g<d'F &ct ^ B2RF platelet# ^ 20,000<`'F #p$erocyte# on t$e perip$eral #mearF total bilirubin ^ 2 9 mg<d'F direct bilirubin ^ 0 > mg<d'F and ',& ^ 5A9 5<' ;$e $aptoglobin *a# le## t$an 5 D mg< d' ;$ere *a# no #plenomegaly or lymp$adenopat$y ;$e ,0; *a# po#iti2e 0n autoantiC.; agglutinin plu# a broadly reacti2e .gG autoantibody *ere identified 0fter a fe* day# on pul#e de:amet$a#one 7,ecadron8 t$erapy t$e $emogloC bin impro2ed only mildly, and t$e patient *a# #tarted on a >Cday cour#e of .V.G *it$ reco2ery of $i# $emoglobin to 9 A g<d' Becau#e of t$e a##ociation of lymp$oma *it$ anC tiC.; t$e patient under*ent +; #can#, bone marro* biop#y, and po#itron emi##ion tomograp$y ;$ere *a# no e2idence of malignancy or lymp$oproliferati2e proce## ,uring t$e period of a year, t$e patient $ad multiple relap#e# of t$e $emolytic anemia 7but not t$rombocytopenia8, nece##iC tating furt$er treatment *it$ #teroid# !itu:imab, gi2en for t$e $emolytic proce##, $ad no #u#tained benefit ;$e patient under*ent a #plenectomy, and bot$ t$e $emogloC bin and platelet count remain normal ;$ere $a# been no e2idence of &odg4inH# di#ea#e, lymp$oma, or ot$er maligC nancy in #e2eral year# of follo*Cup

Materials and Methods ;$e ,0; *a# performed *it$ antiC$uman .gG 7(rt$o +linical ,iagno#tic#, !aritan, NJ8 and antiC$uman +A 7inC $ou#e reagent8 0 9R bo2ine albumin control *a# te#ted Case 2 in parallel ;$e inC$ou#e antiC+A *a# prepared by inNectC ;$e ,0; on ,;;Ctreated !B+# *a# >T *it$ antiC.gG ing rabbit# *it$ purified protein# and #tandardi/ed a# and antiC+AF t$e 9R albumin control *a# nonreacti2e .n pre2iou#ly de#cribed B0 Before te#ting, t$e patient#H !B+# t$e initial titer and t$ermal amplitude #tudie#, an agglutinin *ere treated *it$ 0 0B M dit$iot$reitol 7,;;8 to brea4 reC acted at AEY+ *it$ cord !B+#F adult . !B+# did not .gM bond# t$at cau#e #pontaneou# agglutination BB Eluate# react at *ere prepared from t$e patient#H !B+# u#ing a AEY+ or A0Y+ ;itration re#ult# *it$ adult ., cord i, and commercial acid elution 4it 7Gamma EluC"it .., Gamma adult i !B+# are #$o*n in ;able B Sufficient autologou# Biological#, &ou#ton, ;@8F cold '.SS *a# #ub#tituted for !B+# *ere not a2ailable ,;; treatment of t$e patientH# t$e 4it *a#$ #olution B2 #erum aboli#$ed agglutination *it$ cord !B+#F $o*e2er, )or immunoglobulin cla##ification, #ample# *ere dilution# of ,;;C treated #erum te#ted again#t adult . and treatC ed *it$ 0 0B M ,;; ;$e agglutinin titer and cord !B+# did not #$o* a difference in reaction #trengt$ of t$ermal amC plitude *a# determined at AEY+ t$e .gG component ;$u#, an .gM antiC.; plu# a broadly 7pre*armed8, A0Y+, 22Y+, and >Y+ *it$ group ( adult ., reacti2e .gG antibody *a# demon#trated in t$e #erum ;$e cord, and adult i !B+#,B0 and for +a#e B, *it$ ,;;Ctreated eluate contained an .gG anC tibody #ugge#ti2e of antiC.; autologou# !B+S ;$e te#t# at eac$ temperature *ere #et 7titer<#core 2er#u# adult . !B+# *a# A2<>2 and 2er#u# cord up #eparately 7i e , u#ing #epaC rate #et# of dilution#8 to !B+# *a# B2D<558 .n t$e 0.&0 #erum #creen, untreated eliminate potential carryo2er of agglutination %atient#H !B+# *ere *ea4ly agglutinated at #era *ere al#o te#ted by a pre2iou#C ly de#cribed #erum 22Y+ and *ea4ly #en#iti/ed at AEY+F en/ymeCtreated !B+# #creen met$odB0 u#ed to c$aracteri/e antibodie# in 0.&0 *ere agglutinated and $emoly/ed at bot$ temperature# Briefly, #erum Discussion *a# te#ted *it$ and *it$out !a%le ,- Titer (nd t,erm(l (m*litude o= two e0(m*les o= (nti>IT acidification and t$e addition of fre#$ normal #erum a# a #ource of complement, again#t untreated and en/ymeCtreated !B+# at AEY+ 7pre*armed8 and 20Y+ 0gglutination re#ult# *ere graded and #cored a# preC 2iou#ly de#cribed B0

Results Case 1 ;$e ,0; on ,;;Ctreated !B+# *a# AT *it$ antiC.gG and antiC+AF t$e 9R albumin control *a# nonreacti2e ;$e initial titer and t$ermal amplitude #tudie# #$o*ed a AEY+ agglutinin t$at reacted to a $ig$er titer *it$ cord !B+# t$an *it$ adult . !B+# ;itration re#ult# *it$ adult ., cord i, and adult i !B+# 7to determine #pecificity8 are #$o*n in ;able B 0nomalou# re#ult# 7une:plained $ig$ titer8 *ere obtained *it$ ,;;Ctreated autologou# !B+#? titer# of 5B2 at AEY+, B02> at A0Y+, 20>D at 22Y+, and D000 at >Y+ 0n apparent antiC. *a# detected at >Y+ 7adult . !B+ titer of 259, cord !B+ titer of 9>8 0n acid eluate prepared from t$e patientH# !B+# reacted more #trongly *it$ cord !B+# t$an *it$ adult . !B+# at AEY+ 0fter treatment *it$ ,;;, t$e patientH# #eC rum and t$e eluate did not agglutinate cord !B+#, but reC acted BT and >T, re#pecti2ely, at t$e antiglobulin te#t *it$ antiC.gG ;$e dilution control 7for t$e aboli#$ed agglutiC nation8 reacted Aa to >T *it$ t$e #erum and Ba T *it$ t$e eluate ;$u#, .gM plu# .gG antiC .; *a# demon#trated in bot$ t$e #erum and t$e eluate .n t$e 0.&0 #erum #creen, agglutination *a# ob#er2ed at 22Y+ and AEY+ #imilar to t$at in t$e titration and t$ermal amplitude #tudie#F a $emoly#in *a# al#o ob#er2ed *it$ en/ymeCtreated !B+# at bot$ temC perature#, but *it$out a clear preference for eit$er temperC ature

R"CS 2=>C Adult I / @.A 6ord i Adult i

Case , titer ;score< at: 2?>C / @HA ..>C @//A !H @HJA @/#A 3>C !H @GJA H. @!HA NTB 2=>C # H. @!.A #

Case . titer ;score< at: 2?>C # H. @! A>/ J @H#A / @.A ..>C / @.A H. @.$A / @!A 3>C J @ JA % @.JA NT

BNT C not tested

% @%GA / J @H/A / @HA @/#A

R&M& Le<er et (l&

.gM *arm autoagglutinin# reacti2e at AEY+ are an unu#ual #ubcategory of *arm autoimmune $emolytic aneC mia B0,BA ;ypically, t$e patientH# !B+# are #pontaneou#ly agglutinated, re6uiring treatment *it$ a #ulf$ydryl reagent #uc$ a# ,;; to re#ol2e 0B( and !$ typing and to interpret t$e ,0; ;$e t*o ca#e# pre#ented $ere *ere referred to t$e immuno$ematology re#earc$ laboratory for furt$er diagC no#tic te#ting and c$aracteri/ation of t$e agglutinin *$en t$e#e c$aracteri#tic# *ere noted by our reference laboraC tory .n bot$ ca#e# t$e *arm agglutinin demon#trated . ; #pecificity Bot$ of our ca#e# al#o demon#trated an .gG auC toantibody componentF in +a#e B, t$e .gG autoantibody *a# antiC.; -e $a2e no e:planation for t$e $ig$ titer# obtained afC ter ,;;Ctreatment of t$e group ( autologou# !B+# in +a#e B ;$i# may indicate t$at t$e patientH# !B+# $ad greatly increa#ed .; e:pre##ion -$en group ( untreated, ,;;C treated, and ficinCtreated cord !B+# *ere te#ted in parallel *it$ dilution# of t$i# patientH# antiC.; and anot$er #ample of antiC.;, no en$ancement of reacti2ity *a# ob#er2ed *it$ ,;; treatment *$erea# reacti2ity *it$ ficinCtreated !B+# *a# increa#ed a# e:pected by t$ree to four dilution# 7data not #$o*n8 ;$u#, t$e ,;; treatment #$ould not $a2e afC fected t$e autologou# !B+ te#t re#ult# ;$e pre2iou# #ample of *arm .gM antiC.; a##ociated *it$ 0.&0 did not agglutiC nate t$at patientH# untreated autologou# !B+# at AEY+ 7t$e optimal temperature of reacti2ity8 E 0ntiC.; i# an unu#ual #pecificity and may not e2en be #u#pected unle## dilution# of t$e #era are te#ted *it$ cord i and adult i !B+# in parallel *it$ adult . !B+# .n our ca#e#, additional titration# to identify t$e #pecificity *ere only pur#ued after t$e initial increa#ed reacti2ity *it$ cord !B+# *a# ob#er2ed E:ample# of antiC.; $a2e been reported to be .gM cold agglutinin# or .gG antibodie# optimally reacti2e at AEY+ -e are only a*are of one reported e:ample of .gM *arm antiC.;, and t$at ca#e *a# not a##ociated *it$ &odgC 4inH# di#ea#e or lymp$oma E .n more t$an 20 year#, *e $a2e encountered only t*o ot$er e:ample# of .gM *arm reacti2e antiC.;F neit$er $ad an .gG component, but bot$ *ere a#C #ociated *it$ a $i#tory of lymp$oma before t$e #erologic *or4up ,etermining t$e #pecificity of autoantibodie# i# typicalC ly of academic intere#t only .n general, #erologic re#ult# do not nece##arily prompt a clinical e2aluation for lymp$oma .n bot$ of t$e#e ca#e#, t$e unu#ual !B+ antibody and t$e $i#toric a##ociation of t$i# #pecificity *it$ lymp$oma, toC get$er *it$ t$e pre#enting finding# of 0.&0, led to t$e lymC p$oma *or4up )or patient# *$o do not progre## to lymC p$oma, one mig$t #peculate t$at ritu:imab 7antiC+,208 gi2en for t$e 0.&0 could $a2e eradicated a malignant clone of B cell#

References B Boot$ %B, Jen4in# -J, Mar#$ -' 0ntiC.;? a ne* anC tibody of t$e . blood group #y#tem occurring in certain Melane#ian #era Br J &aematol B999FB2?A>BK> 2 'ayri##e P, 'ayri##e M &ig$ incidence cold autoagC glutinin# of antiC.; #pecificity in 3anomama .ndian# of Vene/uela Vo: Sang B99DFB>?A99KD2 A Garratty G, %et/ ',, -aller#tein !(, )udenberg && 0utoimmune $emolytic anemia in &odg4inH# di#ea#e a##ociated *it$ antiC.; ;ran#fu#ion B9E>FB>?229KAB V+orrection note? ;ran#fu#ion B9E>FB>?9A0 W > Garratty G, &afleig$ B, ,al/iel J, %et/ ', 0n .gG anC tiC.; detected in a +auca#ian 0merican ;ran#fu#ion B9E2FB2?A25K9 5 'e2ine 0M, ;$ornton %, )orman SJ, et al %o#iti2e +oomb# te#t in &odg4inH# di#ea#e? #ignificance and imC plication# Blood B9D0F55?90EKBB 9 &afleig$ EB, -ell# !), Grumet )+ Non$emolytic .gG antiC.; ;ran#fu#ion B9EDFBD?592KE E )reedman J, Ne*land# M, Jo$n#on +0 -arm .gM antiC.; cau#ing autoimmune $aemolytic anaemia Vo: Sang B9EEFA2?BA5K>2 D )reedman J, +$eng '), Murray ,, Myer# ! 0n unu#ual autoimmune $emolytic anemia in a patient *it$ immuC nobla#tic #arcoma 0m J &ematol B9DAFB>?BE5KD> 9 'eger !M, Nguyen N, Garratty G, 'o*der ), )eldman N 0n unu#ual .gM *arm T .gG autoantiC.; a##ociated *it$ lymp$oma, pancytopenia and $emolytic anemia 7ab#tract8 ;ran#fu#ion 200AF>A?B000 B0 %et/ ',, Garratty G .mmune $emolytic anemia# 2nd ed %$iladelp$ia? +$urc$ill 'i2ing#tone, 200> BB !eid ME 0utoagglutination di#per#al utili/ing #ulp$yC dryl compound# ;ran#fu#ion B9EDFBD?A5AK5 B2 'eger !M, 0rndt %0, +ie#iel#4i ,J, Garratty G )al#eC po#iti2e eluate reacti2ity due to t$e lo*Cionic *a#$ #oC lution u#ed *it$ commercial acidCelution 4it# ;ran#fuC #ion B99DFAD?595KE2 BA 0rndt %0, 'eger !M, Garratty G Serologic finding# in autoimmune $emolytic anemia a##ociated *it$ imC munoglobulin M *arm autoantibodie# ;ran#fu#ion 2009F>9?2A5K>2 Regina M8 Leger$ M(?A$ M.+A(CP,(&&$ Research Associ- ate$ American Red Cross &lood (er/ices$ (outhern Califor- nia$ 233 Red Cross Circle$ Pomona$ CA <25@A7 Frederic- Lowder$ CL($M.+A(CP,(&&$ 0li/e iew-!CLA Medical Center$ (ylmar$ CA7 Maria C8 #ungo$ M#$ Assistant Clini- cal Professor$ #a/id 'effen (chool of Medicine at !CLA$ 4arbor-!CLA Medical Center$ .orrance$ CA7 9ei" Chen$ M#$ 4arbor-!CLA Medical Center$ .orrance$ CA7 4olli M8 Mason$ M#$ Assistant Clinical Professor of Pathol- ogy$ #a/id 'effen (chool of Medicine at !CLA$ #irector of .ransfusion Medicine and (erology$ 4arbor-!CLA Medical Center$ .orrance$ CA7 and 'eorge 'arratty$ Ph#$ FRCPath$ (cientific #irector$ American Red Cross &lood (er/ices$ (outhern

R&M& Le<er et (l& California$ Pomona$ CA8

Ori<in(l Re*ort

Southeast Asian ovaloc$tosis is associated with increased e@pression of Duff$ antigen receptor for chemo+ines ;DARC<
I&7& 9oolle), 2& Hut+,inson, 7&6& Reeder, 7&9& 5(;ur(, (nd A& 6ortXs
;$e ,uffy antigen receptor for c$emo4ine# 7,0!+ or )y glycoC protein8 carrie# antigen# t$at are important in blood tran#fu#ion and i# t$e main receptor u#ed by Plasmodium /i/ax to in2ade reticulocyte# Sout$ea#t 0#ian o2alocyto#i# 7S0(8 re#ult# from an alteration in !B+ membrane protein band A and i# t$oug$t to mitigate #u#ceptibility to falciparum malaria E:pre##ion of #ome !B+ antigen# i# #uppre##ed by S0(, and *e $ypot$e#i/ed t$at S0( may al#o reduce )y e:pre##ion, potentially leading to reduced #u#ceptibility to 2i2a: malaria Blood #ample# *ere collected from indi2idual# li2ing in t$e Madang %ro2ince of %apua Ne* Guinea Sample# *ere a##ayed u#ing a flo* cytometry a##ay for e:pre#C #ion of )y on t$e #urface of !B+ and reticulocyte# by mea#uring t$e attac$ment of a p$ycoeryt$rinClabeled )y9 antibody !eticuC locyte# *ere detected u#ing t$ia/ole orange ;$e pre#ence of t$e S0( mutation *a# confirmed by %+! ;$ere *a# a #mall 7appro:iC mately B0R8 but #tati#tically #ignificant 7p^0 0>9, MannC-$itney ! te#t8 increa#e in )y e:pre##ion on S0( !B+ compared *it$ !B+ from indi2idual# *it$out t$i# polymorp$i#m? mean )y e:pre#C #ion 7mean fluore#cence inten#ity VM).W8 *a# B0 B2 b B 22 for S0( $etero/ygote# 2er#u# an M). of D 95 b B B for indi2idual# *it$out S0( )or reticulocyte# t$e M). 2alue# *ere 2E 9B b B9 B2 for S0( $etero/ygote# and B9 >E b A DB for control# S0( i# a##ociated *it$ increa#ed and not decrea#ed )y9 e:pre##ion #o t$at #u#ceptibility to P8 /i/ax infection i# unli4ely to be affected Immunohematology 4009?45)63#666

!B+ morp$ology A S0( i# *ide#pread in #e2eral populaC tion# of %apua Ne* Guinea 7%NG8, *$ere it# pre2alence correlate# *it$ malaria endemicity and altitude > .n t$e#e population#, $omo/ygo#ity i# apparently incompatible *it$ full de2elopment of t$e fetu# ina#muc$ a# no per#on# $oC mo/ygou# for t$e band A mutation $a2e yet been de#cribed, but $etero/ygo#ity confer# #trong protection again#t cereC bral malaria 5,9 0lt$oug$ early #tudie# $ad #ugge#ted t$at t$e S0( trait may afford #ome protection again#t /i/ax or falci"arum "arasitemia,EK9 ot$er #tudie# did not #upport t$i# $ypot$e#i# B0 ;$e mec$ani#m of protection again#t cerebral malaria i# not completely under#tood,BB,B2 but t$e #pecific protection again#t cerebral malaria #ugge#t# t$at it may operate by mean# of alteration# in #e6ue#tration of inC fected !B+ &o*e2er, S0( confer# limited or no protection again#t placental malaria, *$ic$ i# al#o lin4ed to #e6ue#traC tion of infected !B+# BA,B> .ndi2idual# *$o#e !B+# are negati2e for e:pre##ion of ,uffy antigen# illu#trate $omo/ygote ad2antage for 2i2a: malaria in t$at t$eir !B+# are completely refractory to inC 2a#ion by Plasmodium /i/ax B5 &i#toric #erologic data #ugC ge#t e:pre##ion of #ome antigen# on $uman !B+# *a# #upC pre##ed by t$e S0( trait, but e:pre##ion of ,uffy antigen# did not appear #uppre##ed a# determined by t$e le## #en#iC ti2e #erologic in#trument# a2ailable at t$at time B9 .n t$o#e #tudie#, antibodie# of 2arying #pecificitie# *ere placed in tube# u#ing #erial dilution, and re#ult# *ere read macroC #copically *it$ t$e aid of an eyepiece u#ing a #tandardC i/ed #coring #y#tem .n t$i# #tudy, *e u#ed molecular and cytometric tec$ni6ue# to diagno#e S0( and to ree:amine *$et$er t$ere *a# a difference in e:pre##ion of ,uffy anC tigen receptor for c$emo4ine# 7,0!+8 bet*een S0( and control indi2idual# in t$e conte:t of po##ible differential #u#ceptibility to infection *it$ different Plasmodium #peC cie# Materials and Methods Blood *a# collected by 2enipuncture in +%, anticoagC ulant or by finger pric4 u#ing a B, Microtainer 7Becton ,ic4in#on, San Jo#e, +08 *it$ E,;0 anticoagulant from $ealt$y 2olunteer# from t*o 2illage#, Sempi and Bemlon, on t$e nort$ coa#t of t$e Madang %ro2ince, %NG (ral inC formed con#ent *a# obtained after appro2al for t$e #tudy by t$e Medical !e#earc$ 0d2i#ory +ommittee of t$e %NG

0e$ 4ords: ,uffy, Sout$ea#t 0#ian o2alocyto#i#, antigen e:pre##ion

n B9>9 &aldane propo#ed t$at malaria $ad a dramatic influence on t$e $uman genome, by #electing for geC netic polymorp$i#m# t$at *ere 4no*n or #u#pected to protect again#t malaria B 0lt$oug$ #ome of t$e#e polymorC p$i#m# can be detrimental *$en indi2idual# are $omo/yC gou#, e g , #ic4le cell anemia, t$eir apparent #election in $uC man population# li2ing in malariaCendemic area# i# e2idence t$at t$ey offer #ome protection again#t deat$ from malaria, an infectiou# di#ea#e t$at continue# to 4ill more t$an B milC lion per#on# annually 2 +ritical to t$i# t$eory i# t$e concept of $etero/ygote ad2antage ;$at i#, carriage of t$e mutant gene on one member of a c$romo#omal pair i# beneficial *$erea# $omo/ygo#ity i# deleteriou# 0n e:treme e:ample of $etero/ygote ad2antage in Melane#ian population# i# Sout$ea#t 0#ian o2alocyto#i# 7S0(8, a $ereditary form of o2alocyto#i# t$at i# cau#ed by a 2ECba#e pair deletion in t$e gene encoding t$e maNor integral !B+ membrane protein band A 70EB, S'+>0B8, leading to a di#tincti2e c$ange in

I&7& 9oolle) et (l&

Mini#try of &ealt$ 0fter collection, #ample# *ere 4ept on ice or refrigerated at >Y+ -it$in B *ee4, flo* cytometric #tudie# *ere underta4en *it$ antibody to )y9 74indly proC 2ided by Jo$n Barn*ell, +,+, 0tlanta, G08 ;$i# i# a mou#e monoclonal antibody t$at attac$e# to t$e fir#t e:tracellular domain of t$e )y glycoprotein, in an area t$oug$t to corC re#pond to t$e binding #ite of P8 /i/ax mero/oite# BE,BD ;$e antibody *a# conNugated directly to a p$ycoeryt$rin 7%E8 label 7%ro/yme, San 'eandro, +08 according to t$e manuC facturerH# in#truction# 0 5C`' ali6uot of blood *a# *a#$ed t$ree time# in 50 `' of %BS and pelleted !B+# *ere incuC bated *it$ 50 `' of a B in 50 dilution of )y9 antibody for B5 minute# at AEY+ +ell# *ere t$en *a#$ed t*ice in %BS and re#u#pended in t$ia/ole orange 7;(8 #olution according to t$e manufacturerH# #pecification# 7Becton ,ic4in#on8 ;$e #ample# *ere analy/ed on a flo* cytometer 7MoC)lo, ,aC 4o+ytomation, )ort +ollin#, +(8 e6uipped *it$ a E0Cm- airCcooled argon ion la#er at >DD nm ;( fluore#cence *a# read *it$ a 525C nm bandpa## optical filter and %E fluore#C cence *it$ a 5E0Cnm bandpa## filter +ompen#ation *a# applied, and negati2e fluore#cence #ignal# *ere adNu#ted until t$ey *ere ort$ogonal )or*ardC#catter, #ideC#catter, and fluore#cence data *ere analy/ed 0 count of 5000 ;(C po#iti2e cell# *a# ta4en per #ample ;$i# *a# appro:imately B to 2 percent of t$e total number of cell# a##ayed for eac$ indi2idual Bead# of 4no*n immunofluore#cence 7.mmuC noCBrite, +oulter, %uerto !ico8 *ere u#ed to #tandardi/e e:periment# underta4en at different time# ,etection of t$e S0( mutation *a# underta4en u#ing pre2iou#ly de#cribed %+! met$od# B9 E:perienced micro#copi#t# from t$e %NG .n#titute of Medical !e#earc$ performed lig$t micro#copic in#pection of Giem#aC#tained blood film# for malaria paraC #ite# Stati#tical analy#i# *a# underta4en by u#ing S%SS 7Stat2ie* > 5B, 0bacu# +oncept#, Ber4eley, +08 -e $a2e u#ed nonparametric te#ting becau#e *e do not $a2e e2iC dence for normal di#tribution of ,0!+ abundance in t$e #urface of S0( eryt$rocyte# Results Sample# from B9 S0( $etero/ygote# and 20 nonCS0( donor# *ere e:amined Mean age of donor# did not difC fer #ignificantly bet*een t$e t*o group# 7mean age, 29 A2 b BA E0 year# for S0( $etero/ygote# 2er#u# 29 9B b BB D0 year# for nonCS0( indi2idual#8 )our indi2idual# $ad maC laria infection ba#ed on in#pection of blood #mear# (ne S0( and one nonCS0( indi2idual $ad Plasmodium malari- ae, and t*o nonCS0( donor# $ad Plasmodium falci"arum S0( !B+ #$o*ed increa#ed e:pre##ion of )y glycoprotein relati2e to nonCS0( !B+ a# mea#ured by binding of t$e )y9 monoclonal antibody 7;able B8 ;$e le2el of )y9 antigen *a# al#o $ig$er in S0( reticulocyte# compared *it$ control reticulocyte#, but t$e difference *a# not #tati#tically #igC nificant 7;able B8 Sub#e6uent analy#i# of t$e data did not #ugge#t t$e difference# *ere cau#ed by a #y#temic bia# atC tributable to #e:, 2illage of origin, or met$od of obtaining blood 7data not #$o*n8
H.

!a%le ,- Me(n =luores+en+e intensit) @Y st(nd(rd devi(tionA o= :)H (nti"od) "indin< to er)t,ro+)tes (nd reti+ulo+)tes
All Su%Aects ;Reticuloc$tes< SAO ,etero;)<otes @N C /$A Non>SAO individu(ls @N C #A 2 v(lue =or di==eren+e @M(nn> 9,itne) U testA G&H/ Y /$&/ /H&.G Y %&J/ #&H! All Su%Aects ;Er$throc$tes< /#&/ Y /& J&$! Y /&/ #&#.JG

Discussion ;$e main finding of t$i# #tudy *a# t$at t$e S0( trait doe# not re#ult in reduced e:pre##ion of )y antigen .n fact, *e ob#er2ed a B0 percent increa#e 7p^0 0>98 in )y antigen e:pre##ion by S0( !B+# *$en compared *it$ !B+# from nonCS0( indi2idual# from t$e #ame area ;$i# difference *a# #ignificant *$en e:pre##ion by all !B+ population# *a# e2aluated but not *$en only S0( reticulocyte# *ere compared *it$ nonCS0( reticulocyte# 7alt$oug$ a #ugge#C ti2e trend e:i#ted8 0# anticipated, reticulocyte e:pre##ion of )y9 antigen e:ceeded !B+ e:pre##ion 20 ;$e rea#on# for t$e increa#ed !B+ )y9 antigen e:pre##ion in S0( are unC clear at pre#ent, but it may reflect eit$er a decrea#ed rate of lo## of )y9 antigen from t$e #urface of S0( !B+ relati2e to control !B+, per$ap# in relation to t$e increa#ed rigidity of t$e S0( cell *all, or difference# in t$e #urface area of o2aloC cyte# 2er#u# nonCS0( !B+ Becau#e t$ere *a# only a #mall increa#e in )y9 antigen e:pre##ion on S0( !B+ and t$ere *a# no #tati#tically #ignificant increa#e in t$e reticulocyte #ubpopulation, *$ic$ i# t$e only #ubpopulation #u#ceptible to infection by P8 /i/ax, it i# unli4ely t$at t$i# alteration afC fect# #u#ceptibility to t$i# para#ite, alt$oug$ t$ere i# ot$er in 2itro e2idence t$at alteration# in number# of )y antigen# e:pre##ed may alter t$at #u#ceptibility 2B .t i# not #urpri#ing t$at t$e difference in )y le2el# *a# not #$o*n in t$e paper of Boot$ et al B9 becau#e t$ey *ere u#ing le## #en#iti2e #eC rologic met$od# or becau#e )y9 antigen i# more a2ailable or more e:pre##ed in S0( o2alocyto#i# o2er t$e antigen# te#ted in t$e pre2iou# #tudy &o*e2er, t$eir finding# *it$ re#pect to ot$er antigen#, including !$ polypeptide#, $a2e #ub#e6uently been confirmed by molecular tec$ni6ue# 22 )y antigen negati2ity cau#ed by $omo/ygo#ity for a proC moter mutation t$at #ilence# tran#cription of t$e FB gene2A i# ob#er2ed in many et$nic group# in #ubCSa$aran 0frica, and pre#umably account# for t$e relati2e lac4 of 2i2a: maC laria in t$i# part of t$e *orld ;$e apparently independent emergence of $etero/ygo#ity for t$i# #ame promoter mutaC tion $a# al#o been de#cribed in t$e -o#era area of %NG, *$ere S0( i# rare or none:i#tent ;$ere i# a need for furt$er e2aluation of *$et$er ot$er common !B+ polymorp$i#m# affect )y antigen e:pre##ion, e#pecially t$o#e t$at are a#C #ociated *it$ c$ange# in !B+ #$ape and #urface area )or e:ample, 'Ct$ala##emia i# common in %NG, and in many area#, including t$e Madang %ro2ince, nearly all indi2idual# $a2e t$e typical 'Cglobin mutation #een in Melane#ian# 2> .t
IMMUNOHEMATOLOGY, Volume !, Num"er , ##$

SAO (nd 3AR6

#eem# unli4ely t$at t$i# common polymorp$i#m *ould act a# a confounding factor in our #tudy on t$e ground# of bioC logic plau#ibility, lo* li4eli$ood of lin4age di#e6uilibrium, and 2ery $ig$ pre2alence in t$e region 7a##uming t$erefore more or le## e6ual di#tribution bet*een S0( and control indi2idual# *it$in t$e population #tudied8 )inally, it *ill be important to determine *$et$er en2ironmental 2ariC able# e:tant in malariaCendemic population# mig$t c$ange )y antigen e:pre##ion 0not$er e:ample *ould be iron defiC ciency, *$ic$ i# pre2alent in %NG and many ot$er malariaC endemic region# of t$e *orld ;$ere i# e2idence t$at t$e S0( trait affect# #e2eral #tep# of t$e biologic cycle of P8 falci"arum t$at may be rele2ant for t$e #electi2e ad2antage conferred by t$i# trait again#t malaria .n particular, S0( !B+# are partly re#i#tant to inC 2a#ion in culture by mero/oite# of Plasmodium -nowlesi and #e2eral line# of P8 falci"arum,25,29 and t$e S0( trait al#o re#ult# in altered ad$e#ion of infected !B+# to +,A9 0# *it$ 0B(,2E it i# li4ely t$at t$e e2olutionary pre##ure e:C erted by #ur2i2al *it$ S0( i# related to #ur2i2al of c$ildren from cerebral malaria before reproducti2e age 0lt$oug$ )y e:pre##ion probably affect# P8 /i/ax infection,2D t$i# e2oluC tionary pre##ure i# almo#t certainly cau#ed by P8 falci"arum t$roug$ it# relation#$ip to !B+ ad$e#ion Ac+nowledgment ;$i# #tudy *a# funded in part by a +o2ance )ello*#$ip from t$e !oyal 0u#trala#ian +ollege of %$y#ician# 7. - 8 References B &aldane JBS ,i#ea#e and e2olution !ic Sci Suppl 0 B9>9FB9?9DKE9 2 Maitland ", BeNon %, Ne*ton +! Malaria +urr (pin .nfect ,i# 200AFB9?AD9K95 A Jarolim %, %ale4 J, 0mato ,, et al ,eletion in eryt$roC cyte band A gene in malariaCre#i#tant Sout$ea#t 0#ian o2alocyto#i# %roc Natl 0cad Sci 5 S 0 B99BFDD?BB022K 9 > Mgone +S, "o4i G, %aniu MM, et al (ccurrence of t$e eryt$rocyte band A 7A)28 gene deletion in relation to malaria endemicity in %apua Ne* Guinea ;ran# ! Soc ;rop Med &yg B999F90?22DKAB 5 Genton B, alC3aman ), Mgone +S, et al (2alocyto#i# 9 and cerebral malaria Nature B995FAED?59>K5 0llen SJ, (H,onnell 0, 0le:ander N,, et al %re2ention of cerebral malaria in c$ildren in %apua Ne* Guinea by Sout$ea#t 0#ian o2alocyto#i# band A 0m J ;rop Med &yg B999F90?B059K90 )o*4e# )J, Mic$on %, %illing ', et al &o#t eryt$rocyte polymorp$i#m# and e:po#ure to Plasmodium falci"arum in %apua Ne* Guinea Malar J 200DFE?B +attani J0, Gib#on ),, 0lper# M%, +rane GG &erediC tary o2alocyto#i# and reduced #u#ceptibility to malarC ia in %apua Ne* Guinea ;ran# ! Soc ;rop Med &yg B9DEFDB?E05K9

9 B0 BB

B2

BA

B> B5 B9

BE

BD

B9

20

SerNeant#on S, Bry#on ", 0mato ,, Babona , Malaria and $ereditary o2alocyto#i# &um Genet B9EEFAE?B9BK E )oo '+, !e4$raN V, +$iang G', Ma4 J- (2alocyto#i# protect# again#t #e2ere malaria para#itemia in t$e MaC layan aborigine# 0m J ;rop Med &yg B992F>E?2EBK5 +orte# 0, Benet 0, +oo4e BM, Barn*ell J-, !eeder J+ 0bility of Plasmodium falci"arum to in2ade Sout$ea#t 0#ian o2alocyte# 2arie# bet*een para#ite line# Blood 200>FB0>?299BK9 +orte# 0, Mellombo M, Mgone +S, Bec4 &%, !eeder J+, +oo4e BM 0d$e#ion of Plasmodium falci"arum K infected red blood cell# to +,A9 under flo* i# en$anced by t$e cerebral malariaCprotecti2e trait Sout$CEa#t 0#ian o2alocyto#i# Mol Bioc$em %ara#itol 2005FB>2?252KE (H,onnell 0, !ai4o 0, +legg JB, -eat$erall ,J, 0llen SJ Sout$ea#t 0#ian o2alocyto#i# and pregnancy in a malariaCendemic region of %apua Ne* Guinea 0m J ;rop Med &yg 200EFE9?9ABKA Benet 0, "$ong ;3, 5ra 0, et al %lacental malaria in *omen *it$ Sout$CEa#t 0#ian o2alocyto#i# 0m J ;rop Med &yg 2009FE5?59EK90> Miller '&, Ma#on SJ, +lyde ,), et al ;$e re#i#tance factor to Plasmodium /i/ax in blac4# ;$e ,uffy blood group genotype, )y)y N Engl J Med B9E9F295?A02K> Boot$ %B, SerNeant#on S, -oodfield ,G, 0mato , SeC lecti2e depre##ion of blood group antigen# a##ociated *it$ $ereditary o2alocyto#i# among Melane#ian# Vo: Sang B9EEFA2?99KBB0 Nic$ol# ME, !uben#tein %, Barn*ell J, et al 0 ne* $uC man ,uffy blood group #pecificity defined by a murine monoclonal antibody .mmunogenetic# and a##ociation *it$ #u#ceptibility to Plasmodium /i/ax J E:p Med B9DEFB99?EE9KD5 -a#nio*4#a ", Blanc$ard ,, Jan2ier ,, et al .dentifiC cation of t$e )y9 epitope recogni#ed by t*o monoclonal antibodie# in t$e NCterminal e:tracellular portion of t$e ,uffy antigen receptor for c$emo4ine# Mol .mC munol B999FAA?9BEK2A Jarolim %, %ale4 J, 0mato ,, et al ,eletion in eryt$roC cyte band A gene in malariaCre#i#tant Sout$ea#t 0#ian o2alocyto#i# %roc Natl 0cad Sci 5 S 0 B99BFDD?BB022K 9 -oolley .J, &otmire "0, Sram4o#4i !M, Pimmerman %0, "a/ura J- ,ifferential e:pre##ion of t$e ,uffy antigen receptor for c$emo4ine# according to !B+ age and )3 genotype ;ran#fu#ion 2000F>0?9>9K5A

E D

2B Mic$on %, -oolley ., -ood EM, "a#ten# -, PimmerC man %0, 0dam# J& ,uffyCnull promoter $etero/ygo#iC ty reduce# ,0!+ e:pre##ion and abrogate# ad$e#ion of t$e P8 /i/ax ligand re6uired for bloodC#tage infection )EBS 'ett 200BF>95?BBBKB>

I&7& 9oolle) et (l&

22 Bec4mann !, Smyt$e JS, 0n#tee ,J, ;anner MJ +oe:C pre##ion of band A mutant# and !$ polypeptide#? difC ferential effect# of band A on t$e e:pre##ion of t$e !$ comple: containing , polypeptide and t$e !$ comple: containing +cEe polypeptide Blood 200BF9E?2>99K 505 2A ;ournamille +, +olin 3, +artron J%, 'e Van "im + ,i#C ruption of a G0;0 motif in t$e ,uffy gene promoter aboli#$e# eryt$roid gene e:pre##ion in ,uffyCnegati2e indi2idual# Nat Genet B995FB0?22>KD 2> +oc4burn .0, Mac4innon MJ, (H,onnell 0, et al 0 $uman complement receptor B polymorp$i#m t$at reC duce# Plasmodium falci"arum ro#etting confer# protecC tion again#t #e2ere malaria %roc Natl 0cad Sci 5 S 0 200>FB0B?2E2KE 25 "id#on +, 'amont G, Saul 0, Nur#e G; (2alocytic eryt$rocyte# from Melane#ian# are re#i#tant to in2a#ion by malaria para#ite# in culture %roc Natl 0cad Sci 5 S 0 B9DBFED?5D29KA2 29 &adley ;, Saul 0, 'amont G, &ud#on ,E, Miller '&, "id#on + !e#i#tance of Melane#ian elliptocyte# 7o2aloC cyte#8 to in2a#ion by Plasmodium -nowlesi and Plasmodium falci"arum malaria para#ite# in 2itro J +lin .n2e#t B9DAFEB?ED0K2

2E +#erti +M, ,/i4 -& ;$e 0B( blood group #y#C tem and Plasmodium falci"arum malaria Blood 200EFBB0?2250KD 2D "a#e$agen 'J, Mueller ., "iniboro B, et al !educed Plasmodium /i/ax eryt$rocyte infection in %NG ,uffyC negati2e $etero/ygote# %'oS (NE 200EF2?eAA9 Ian %8 9oolley +corres"onding author,$ #e"artment of Infectious #iseases$ Monash Medical Centre and Monash !ni/ersity$ Clayton$ ictoria$ Australia$ Paul 4utchinson$ Centre for Inflammatory #iseases$ Monash Medical Centre$ Clayton$ ictoria$ Australia$ %ohn C8 Reeder$ Pa"ua New 'uinea Institute of Medical Research$ 'oro-a$ Pa"ua New 'uinea +current affiliationC &urnet Institute$ Prah- ran$ ictoria$ Australia,$ %ames 98 *aDura$ Center for 'lobal 4ealth E #iseases$ Case 9estern Reser/e !ni/er- sity$ Cle/eland$ 0hio$ !(A$ and Alfred CortFs$ Pa"ua New 'uinea Institute of Medical Research$ Madang$ Pa"ua New 'uinea +current affiliationC ICR)A and Institute for Research in &iomedicine$ &arcelona$ ("ain,8

Manuscripts ;$e editorial #taff of Immunohematology *elcome# manu#cript# pertaining to blood group #erology and educaC tion for con#ideration for publication -e are e#pecially intere#ted in ca#e report#, paper# on platelet and *$ite cell #erology, #cientific article# co2ering original in2e#tigation#, and paper# on ne* met$od# for u#e in t$e blood ban4 ,eadline# for receipt of manu#cript# for con#ideration for t$e Marc$, June, September, and ,ecember i##ue# are t$e fir#t *ee4# in No2ember, )ebruary, May, and 0ugu#t, re#pecti2ely )or in#truction# for #cientific article#, ca#e report# and re2ie* article#, #ee .n#truction# for 0ut$or# in e2ery i##ue of Immunohematology or on t$e -eb at *** redcro## org<immuno$ematology .nclude fa: and p$one number# and eCmail addre## *it$ all article# and corre#pondence ECmail all manu#cript# to immunoQu#a redcro## org

HH

IMMUNOHEMATOLOGY, Volume !, Num"er , ##$

Review

Sic+le cell disease: a review

S&3& Rose==B ic4le cell di#ea#e 7S+,8 i# de#cribed a# t$e fir#t identiC fied ImolecularJ di#ea#e #ince it# manife#tation# #tem from a #ub#titution of 2aline for glutamic acid in t$e #tructure of t$e V c$ain $emoglobin molecule B 0# a re#ult of t$i# c$ange, !B+# form c$aracteri#tic I#ic4leJ #$ape# and t$e #urface of t$e#e !B+# attract eac$ ot$er, polymeri/ing *$en in a lo* o:ygen en2ironment ;$i# #eemingly I#mallJ 2ariation in t$e #tructure of t$e !B+ cau#ing polymeri/ation lead# to manife#tation# #uc$ a# c$ronic occlu#ion of blood 2e##el# 72a#oCocclu#ion8, reduced blood flo* to 2ital organ# 7i#c$emia8, and alteration# of t$e immune #y#tem .n adC dition, t$e abnormal #ic4le cell# are prematurely remo2ed from circulation, re#ulting in $emolytic anemia ;ran#fuC #ion i# a 2ital component of t$e treatment of #ome of t$e complication# of S+, .t i# al#o a modality u#ed to pre2ent #ome of t$e#e complication# from occurring %atient# *it$ S+, are uni6ue becau#e t$o#e *$o are tran#fu#ed u#ually re6uire c$ronic tran#fu#ion, re#ulting in e:po#ure to many different blood donor# o2er t$e cour#e of treatment .n addition, mo#t patient# *it$ S+, in t$e 5nited State# are 0frican 0merican, and mo#t donor# are +auca#ian from -e#tern European de#cent 0# a re#ult of t$i# difference, patient# *it$ S+, are e:po#ed to !B+ antigen# t$at t$ey lac4, putting t$em at ri#4 for forming alloantibodie#, deC fined a# !B+ alloimmuni/ation 2 ;$erefore, it i# important to under#tand t$e i##ue# in2ol2ed in t$e #afe and effecti2e tran#fu#ion of patient# *it$ S+, i# found *orld*ide, it i# mo#t

Defining 7emoglo%inopathies &emoglobin 7&gb8 i# made up of iron 7$eme8 and > globin c$ain# ;$e type of globin c$ain# determine# t$e type of $emoglobin 7#ee ;able B8 A Since S+, i# c$aracteri/ed by t$e pre#ence of an abnorC mal or 2ariant $emoglobin, $emoglobin S, it i# c$aracteri/ed a# a $emoglobinopat$y ;$e compo#ition of $emoglobin for patient# *it$ $omo/ygou# SS i# pre#ented in ;able 2 ;$ere are a 2ariety of ot$er abnormal $emoglobin# t$at may be pre#ent *it$ or *it$out &gb S ;$e type of $emoC globin a per#on $a# i# ba#ed on pattern# of in$eritance .f eac$ parent contribute# $emoglobin S, t$e c$ild can in$erit t*o copie# and i# de#ignated a# &gb SS, or i# $omo/ygou# for $emoglobin S .f a c$ild only in$erit# one copy from one parent and a copy of normal $emoglobin, &gb 0, t$ey are de#ignated a# &gb 0S, or $etero/ygou# ;$e#e indi2idual# are u#ually a#ymptomatic, and only de2elop manife#tation# under rare circum#tance#, *$ere t$ey become $ypo:ic, #uc$ a# at $ig$ altitude# ;$erefore, not e2ery per#on *it$ an abnormal $emoglobin de2elop# or e:$ibit# #ign# and #ymptom# 0lt$oug$ &gb S

7emoglo%in H<" A H<" A H<" :

Composition 'V 'Z

#ercent ;B< $HD$J /&!D%&! L/

commonly found in *e#tern 0frica 0bout one in e2ery >00K 500 0frican 0merican#, or D0,000, $a# S+, 0bout 9000 0frican 0merican#, or one in B2, $a2e #ic4le cell trait > (n t$e ot$er $and, patient# *$o $a2e manife#tation# of t$eir #ic4le $emoglobin are con#idered to $a2e S+, ;$i# include# patient# *$o are $omo/ygou# for &gb SS, a# deC #cribed pre2iou#ly .n addition, #ome patient# *$o in$erit &gb S from one parent and anot$er abnormal $emoglobin from t$e ot$er parent can al#o $a2e S+, +ommon e:amC ple# are de#ignated a# &gb S+ and SVC t$ala##emia ;$e#e indi2idual# can $a2e a milder clinical cour#e t$an t$at of indi2idual# *$o are $omo/ygou# for &gb S Since !B+# *it$ &gb S are abnormal, t$ey are remo2ed from circulation in t$e #pleen more rapidly t$an normal !B+# ;$i# lead# to a reduced life in t$e circulation of B9K 20 day# in compari#on to B20 day# for normal !B+# 5 ;$e premature de#truction of !B+#, *it$ t$e accompanying decrea#e in $emoglobin, i# cla##ified a# a $emolytic anemia
!a%le ,- 6om*osition o= norm(l (dult ,emo<lo"in

!a%le .- Hemo<lo"in SS @>' V SA

7emoglo%in H<" S H<" A H<" : #ercent ;B< J# D.&! / #

!$pical La%orator$ )indings in Sic+le Cell Disease %atient# *it$ S+, are commonly diagno#ed after ne*C born #creening .n t$e pa#t, young c$ildren pre#ented *it$ painful #*elling# of t$e feet and $and#, a con#e6uence of 2a#oCocclu#ion 7#ee di#cu##ion on +linical Manife#tation# of ,i#ea#e8 Many patient# *it$ S+, $a2e anemia, *it$ $emoglobin le2el# bet*een 9 and D g<d' +$aracteri#tic #ic4le #$aped cell# are #een on perip$eral #mear 7)ig B8 %atient# do not al*ay# $a2e #ymptomatic anemia becau#e t$e body comC pen#ate# for t$e perip$eral !B+ de#truction by increa#ing t$e rate of !B+ production 7eryt$ropoie#i#8 in t$e bone marC ro* +on#e6uently, t$e bone marro* contain# an increa#e in t$e number of !B+ precur#or# 0# a re#ult, immature

BRe*rinted wit, *ermission o= t,e 6olle<e o= Ameri+(n 2(t,olo<ists&

S&3& Rose==

precur#or#, #ugge#ti2e of reticulocyte#, are relea#ed from t$e marro* prematurely ;$erefore, t$e perip$eral #mear *ill al#o #$o* t$e#e immature !B+#, *$ic$ are larger t$an mature !B+# and $a2e a #lig$tly blue color #ince t$ey are not fully $emoglobini/ed A ;$e term reticulocyte# *ill be u#ed in t$i# education acti2ity, and refer# to t$e#e !B+#

)ig- , T,e (rrowed +ell is ( +l(ssi+ e0(m*le o= ( si+?le +ell& Anot,> er si+?le +ell is lo+(ted in t,e u**er le=t +orner& T,ere is ( nu+le(ted red "lood +ell in t,e lower ri<,t +orner& T,e l(r<e +ell in t,e +enter is ( *ol)+,rom(to*,ili+ red +ell or reti+ulo+)te& @Sour+e: :i<ure HE>. & In: Gl(ss) E:, ed& 6olor Atl(s o= Hem(tolo<)& Nort,=ield, IL: 6olle<e o= Ameri+(n 2(t,olo<ists, /$$J:$G&A

0not$er con#e6uence of t$e $ig$ rate of $emoly#i# and eryt$ropoie#i#, or increa#ed !B+ turno2er, i# t$e accumulaC tion of unconNugated or indirect bilirubin 0# a re#ult, #ome patient# *ill $a2e yello*ing of t$e *$ite of t$e eye#, #cleral icteru#, and #4in, or Naundice ;$e increa#e in bilirubin al#o put# patient# at increa#ed ri#4 for gall#tone#, and t$e paC tient may $a2e to $a2e t$eir gallbladder remo2ed ;able A li#t# t$e common laboratory finding# in S+, and t$eir etiologie# Early diagno#i# i# e##ential in order to treat and e2en pre2ent #ome of t$e complication# of S+, .n t$e pa#t, appro:imately 25R of c$ildren bet*een t$e age# of four mont$# and fi2e year# *it$ S+, died of pneumonia ;$e u#e of prop$ylactic penicillin in c$ildren *it$ S+, in t$e #etting of compre$en#i2e care reduced t$e ri#4 of deat$ in c$ild$ood to le## t$an AR 9KD ;$erefore, in order to be able
!a%le 2- 6ommon l("or(tor) =indin<s in si+?le +ell dise(se La%orator$ value Etiolog$
Low ,emo<lo"in (nd ,em(to+rit Hi<, me(n +ellul(r volume @M6VA Hi<, w,ite "lood +ell @916A +ount Hi<, *l(telet +ount Hi<, l(+t(te de,)dro<en(se @L3HA Low ,(*to<lo"in Hi<, tot(l (nd indire+t "iliru"in Hi<, (l?(line *,os*,(t(se until *u"ert) HJ Hemol)sis Reti+ulo+)tes In=l(mm(tion (nd in+re(sed m(rrow *rodu+tion In+re(sed m(rrow *rodu+tion Hemol)sis Hemol)sis Hemol)sis Elev(ted "one m(rrow (+tivit)

to refer t$e#e patient# to #peciali#t# and pro2ide #tateCofC t$eCart patient care, identification of c$ildren *it$ S+, at birt$ i# an important public $ealt$ inter2ention Screening can be done in t$e neonatal period u#ing fetal ,N0 during pregnancy, or more commonly, performing ,N0 analy#i# #oon after birt$ %renatal te#ting can be done bet*een B>K B9 *ee4# of ge#tation in pregnancie# *$ere t$ere i# a c$ance t$at t$e baby *ill in$erit &gb S from bot$ parent# B,A,> More commonly, ne*born infant# are #creened t$roug$ mandatory program# re6uired by mo#t #tate#, #oon after birt$ B,A,> Se2eral met$od# e:i#t for detecting abnormal $eC moglobin# ;$e#e include? c &ig$ performance li6uid c$romatograp$y 7&%'+8L +on#idered one of t$e be#t met$od# to be able to detect abnormal $emoglobin# and to be able to differentiate t$em from normal $emoglobin &%'+ u#e# reaction# in column# of reagent# ;$i# tec$ni6ue al#o mea#ure# t$e 6uantity of t$e 2ariou# $emoglobin# c &emoglobin electrop$ore#i#LSeparate# different $eC moglobin# according to t$eir c$aracteri#tic migration acro## a gel of eit$er cellulo#e acetate at an al4aline p& or citrate agar at an acid p&, ba#ed on c$arge ;$e different type# of $emoglobin *ill migrate at different rate#, occupying a c$aracteri#tic po#ition on t$e gel c .#oelectric focu#ingL.f furt$er #eparation i# nece##ary, t$en i#oelectric focu#ing can be performed 0n electric current i# pa##ed t$roug$ t$e gel t$at $a# area# of difC ferent p& ;$e identity of t$e $emoglobin can be made by it# pattern of migration c Solubility te#tL;a4ing ad2antage of t$e fact t$at reC duced &gb S i# in#oluble in certain #olution#, a #imple #olubility te#t can be u#ed to detect t$e pre#ence of &gb S 0fter ly#i#, !B+# are reduced by #odium $ydro#ulfite .f &gb S i# pre#ent, t$e #olution *ill be turbidF if not pre#ent, t$en t$e $emoglobin remain# in #olution and t$e #u#pen#ion i# clear Since t$i# te#t re6uire# a certain amount of *$ole blood, it i# not routinely u#ed for ne*C born #creening Note t$at t$i# te#t *ill Nu#t detect t$e pre#ence of &gb S, #o patient# *$o $a2e #ic4le cell trait 7$etero/ygou# for &gb S8 *ill al#o be po#iti2e -$en performing patient te#ting, it i# al*ay# important to follo* t$e pac4age in#ert and en#ure t$at proficiency te#tC ing i# performed in compliance *it$ t$e +linical 'aboratory .mpro2ement 0mendment# of B9DD 7+'.08 +'.0 regulaC tion# re6uire t$at laboratorie# enroll in a +enter# for MediC care and Medicaid Ser2ice# 7+MS8 appro2ed proficiency te#ting 7%;8 program for all regulated te#t# t$at t$e laboraC tory perform# Clinical Manifestations of Sic+le Cell Disease ;$e function of a normal !B+ i# dependent upon it# ability to flo* freely t$roug$ blood 2e##el# and to be fle:ible enoug$ to mo2e in and out of 2e##el# and ti##ue *$ere o:ygen deli2ery occur# ,ue to t$e rigidity of t$e #ic4le !B+, t$e#e propertie# are lo#t .ntere#tingly, *$en a patient *it$ S+, $a# a $ig$er percentage of $emoglobin ),
IMMUNOHEMATOLOGY, Volume !, Num"er , ##$

t$e cour#e of t$eir

A review o= to*i+s in S63

IMMUNOHEMATOLOGY, Volume !, Num"er , ##$

H$

di#ea#e i# milder and t$eir life e:pectancy i# longer ;$i# i# probably t$e re#ult of t$e lo*er percentage of &gb S in t$e#e patient#, and t$at !B+# *it$ &gb ) do not form polymer# 9 ;$e#e c$ronic p$y#iologic c$ange# can lead to problem# in all organ #y#tem#F $eart, lung#, and 4idney# S+, can be #een a# a di#ea#e ba#ed on 2a#oCocclu#ion 7V(+8, c$ronic $emolytic anemia, and immunologic impairment 0cclusi/e #isease ;$ere are a 2ariety of *ay# by *$ic$ #ic4le cell# cau#e ob#truction (ne minor mec$ani#m i# *$ereby irre2er#ibly #ic4led cell# ob#truct #mall capillarie# More commonly, #ic4le cell# are trapped in #mall 2enule# and capillarie# B,B0 ;$e proce## of #ic4ling and occlu#ion in2ol2e# a comple: inC teraction bet*een c$emical mediator#, a# *ell a# element# ot$er t$an t$e !B+ it#elf ;$ere i# increa#ing under#tanding t$at t$e *all# of blood 2e##el# are in2ol2ed ;$ere appear# to be increa#ed ad$erence of #ic4le cell# to t$e 2a#cular *all#, due to propertie# of t$e !B+#, a# *ell a# c$ange# in t$e enC dot$elial cell# of blood 2e##el# ;$e lipid bilayer of !B+# i# di#rupted in #ic4le cell#, cau#ing t$eir early remo2al from circulation 0dditionally, c$ange# in t$eir interaction# *it$ ot$er cell# *it$in t$e blood #tream, #uc$ a# #tic4y *$ite blood cell# 7-B+#8 and acti2ated platelet#, contribute to 2a#oCocclu#ion B0,BB ;$e#e c$ange# can al#o cau#e t$e actiC 2ation of coagulation, leading to an increa#ed ri#4 of deep 2enou# t$rombo#i# B0,B2 Va#oCocclu#ion manife#t# it#elf a# one of t$e mo#t comC mon finding# in a patient *it$ S+,, pain cri#i# %rior to routine #creening of ne*born#, c$ildren *ere commonly diagno#ed *it$ S+, prior to t$e age of t*o, *it$ occluC #ion in t$e $and# and feet pre#enting a# painful #*elling, or dactyliti# >,5 ;$i# *ould not occur until #i: mont$# of age becau#e t$e $ig$er le2el of fetal $emoglobin prior to #i: mont$# i# protecti2e Mo#t patient# *ill often $a2e #e2ere pain due to occlu#ion of blood flo* to bone#, bone marro*, mu#cle#, or organ#, and in t$eir arm#, leg#, bac4, abdomen, and c$e#t ;reatment con#i#t# of analge#ia 7many patient# *it$ S+, re6uire c$ronic medication8 and $ydration, #ince de$ydrated !B+# are more li4ely to #ic4le ;$e cau#e of criC #i# can 2ary bet*een patient# and bet*een epi#ode# in t$e #ame patient, but may be related to infection, e:treme# of temperature, medication, or any ot$er p$y#iologic c$ange# (cclu#ion i# al#o a##ociated *it$ bony infarct# leading to o#teonecro#i#, #4in ulcer#, organ occlu#ion 7including t$e #pleen, re#ulting in functional a#plenia or auto#plenectoC my8, acute c$e#t #yndrome, and cerebro2a#cular accident# or #tro4e# (tro-e Stro4e in any patient i# a de2a#tating e2ent, *it$ apC pro:imately BB percent of patient# *it$ &gb SS $a2ing a #tro4e by t$e age of 20 BA 0# blood 2e##el# become occluded, t$eir diameter get# #maller and t$e rate of blood flo* inC crea#e#, t$ereby increa#ing t$e ri#4 of #tro4e 5#ing a type of ultra#ound, tran#cranial ,oppler 7;+,8, to mea#ure

blood flo* t$roug$ t$e internal carotid and middle cerebral arterie# of t$e brain, a #tudy found t$at one could predict patient# at ri#4 for a fir#t #tro4e B> +$ronic tran#fu#ion t$erC apy $a# been u#ed #ucce##fully to pre2ent primary #tro4e and t$en #ub#e6uent #tro4e 7#ee ;reatment of Sic4le +ell ,i#ea#e8 B5,B9 Acute Chest (yndrome 0cute c$e#t #yndrome 70+S8 i# t$e leading cau#e of deat$ in adult# *it$ S+, and a maNor cau#e of morbidity in patient# of all age# .t i# c$aracteri/ed by t$e on#et of *or#ening re#piratory #tatu#, fe2er, and ne* infiltrate on c$e#t :Cray ;$e inciting e2ent can be re#piratory infectionF $o*e2er, #ince a maNority of ca#e# of acute c$e#t #yndrome in adult# follo* pain cri#i#, it i# belie2ed t$at an embolu# of fatty ti##ue from t$e bone marro* 7t$e #ite of t$e initial 2a#oCocclu#ion8 into t$e lung# i# t$e culprit %atient# need en$anced o:ygenation, #o #upplemental o:ygen i# adminC i#tered ;ran#fu#ion i# an e##ential component in t$e treatC ment of acute c$e#t #yndrome, a# *ill be di#cu##ed in more detail later BE (f intere#t, t$ere are many in2e#tigator# loo4ing at t$e role of inflammatory c$emical# in t$e pat$op$y#iology of S+,, a# *ell a# t$eir potential for de2eloping ne* treatC ment# )or e:ample, t$ere i# a reduction in le2el# of an adC $e#ion molecule 7V+0MCB8 in patient# *it$ S+, on c$ronic tran#fu#ion protocol# BD ;$erefore, c$ronic tran#fu#ion proC tocol# mig$t pre2ent 2a#oCocclu#ion 0not$er recent #tudy found t$at t$e increa#e# in t$e inflammatory mediator, #ecretory p$o#p$olipa#e 02 , can predict acute c$e#t #ynC drome ;ran#fu#ing *$en le2el# are ele2ated can pre2ent acute c$e#t #yndrome B9 4emolytic Anemia ;$e abnormal #$ape and #urface of #ic4le cell# re#ult in t$eir #$ortened life #pan in t$e circulation and lead to t$e c$aracteri#tic anemia 0# !B+# are cycled t$roug$ t$e #pleen, t$e #ite of t$eir ultimate de#truction, t$ey al#o inNure t$e ti##ue of t$e #pleen ;$eir rigidity impair# t$eir ability to flo* #moot$ly t$roug$ t$e #inu#oid#, and t$eir #$arp edge# cau#e t$em to be #tuc4, and to damage #plenic ti##ue .n c$ildren under t$e age of fi2e, blood can pool in t$e #pleen, *$ic$ become# a #ite of #e6ue#tration of !B+# -$en t$i# occur#, t$e c$ild $a# a painful, enlarged #pleen accompaC nied by a drop in $emoglobin Splenic #e6ue#tration can be lifeCt$reatening #ince t$ere i# al#o a drop in blood 2olume in t$e 2a#culature, or $ypo2olemia ;ran#fu#ion management i# e##ential in t$e#e ca#e# Many of t$e#e patient# e2entuC ally need to $a2e t$eir #pleen remo2ed 0# a patient get# older, t$e damage to t$e #pleen i# c$ronic, and t$e #pleen actually become# #maller, e2entually #$ri2eling and lo#ing function B,>,5 .n order to 4eep up *it$ t$i# c$ronic de#truction, t$e body attempt# to compen#ate by increa#ing !B+ producC tion ;$i# c$ronic $emoly#i# may al#o create an inflammaC tory #tate B,B0,BB 0l#o, t$e free $emoglobin t$at i# relea#ed

from $emoly/ed !B+# cau#e# additional damage to t$e linC ing of blood 2e##el# B0,BA ;$e marro* i# 2ery acti2e, a# e2iC denced by immature !B+# or reticulocyte# in t$e perip$eral blood 0# t$e marro* increa#e# production of !B+#, plateC let and -B+ production al#o increa#e# 0# a con#e6uence of increa#ed eryt$ropoie#i#, many patient# do not #uffer from #ign# and #ymptom# of anemia, e2en t$oug$ t$ey may $a2e a lo* $emoglobin 0# long a# t$e indi2idual can continue to compen#ate, t$e anemia doe# not pre#ent a problem -$en t$e marro* cannot 4eep up *it$ production 7i e , a lac4 of folic acid8, or $a# it# production impaired by 2iral illC ne##, #uc$ a# par2o2iru# BCB9, an apla#tic cri#i# may occur %ar2o2iru# BCB9 i# a common c$ild$ood 2iru# re#pon#ible for )ift$H# ,i#ea#e ;$i# di#ea#e cau#e# a ra#$, t$e cla##ic I#lappedCc$ee4J appearance, and $ig$ fe2er# %ar2o2iru# can #uppre## bone marro* production by de#troying t$e !B+ precur#or cell# in t$e bone marro* .n t$e#e ca#e# of #e2ere anemia, tran#fu#ion t$erapy i# nece##ary 5 Immunologic and Infectious Manifestations ;$e #pleen can be affected in S+, due to occlu#i2e forcC e#, but it i# al#o damaged by t$e pointed, infle:ible #ic4le cell# t$at tra2el t$roug$ it and are #tuc4 ;$e #pleen i# an important immunologic organ, $elping to fig$t infection# *it$ encap#ulated organi#m# 7 (8 "neumoniae$ 48 influ- enDae, and N8 meningitidis8 ;$erefore, it i# important to recogni/e c$ildren *it$ S+, and immuni/e t$em 0# #tated earlier, t$e u#e of prop$ylactic penicillin $a# been found to reduce deat$ in c$ildren 9,20 0ll infection# #$ould be treated aggre##i2ely !reatment of Sic+le Cell Disease %re2ention of early complication#, #uc$ a# infection, i# important in t$e o2erall treatment plan for patient# *it$ S+, 0# more i# being learned about t$e ba#ic mec$ani#m# of t$e di#ea#e, ne* treatment# are being de2eloped 0nalC ge#ic#, including opioid#, are a main#tay of treatment for people #uffering *it$ pain cri#i# .n addition, it i# imporC tant to gi2e patient# *it$ S+, 2itamin#, #uc$ a# folic acid, *$ic$ are e##ential to t$e production of !B+# &ydration i# al#o 4ey, #ince !B+# #ic4le *$en de$ydrated .n addition, $ydration impro2e# t$e 2i#co#ity of t$e patientH# blood and allo*# t$e !B+# to mo2e more ea#ily 0# $emoglobin ri#e#, t$e 2i#co#ity of t$e blood#tream increa#e# and t$ere i# an increa#ed ri#4 of occlu#i2e di#order#, a# *ell a# an increa#ed ri#4 of pain cri#i# 2B ;$ere i# no data to #$o* t$at tran#fuC #ion #$ould be part of t$e routine treatment for cri#i# 5,20 ;$e role of nitric o:ide i# al#o being in2e#tigated a# a t$eraC peutic modality, #ince nitric o:ide play# an important role in t$e p$y#iology of !B+# B,> %atient# of all age# *$o $a2e $ig$er concentration# of &gb ) $a2e milder di#ea#e and lo*er mortality t$an patient# *it$ lo*er le2el# of &gb ) .ncrea#ing t$e proC duction of &gb ) #eem# li4e a rea#onable t$erapeutic inC ter2ention .n t$e laboratory, &gb ) $a# been #$o*n to

interfere *it$ t$e polymeri/ation of deo:ygenated &gb S

;$e c$emot$erapeutic agent, $ydro:yurea 7&58, increa#e# t$e amount of &gb ) t$at i# made by t$e bone marro* !B+# *it$ &gb ) lac4 t$e V c$ain, *$ic$ i# re#pon#ible for t$e #ic4ling #een in &gb S !B+# ;$erefore, t$e#e !B+# do not #ic4le, nor can t$ey polymeri/e ;$i# i# one of t$e mec$ani#m# con#idered to be re#pon#ible for t$e impro2ed outcome# .n addition, &5 $a# been found to reduce -B+ production, t$ereby reducing t$e number of circulating inC flammatory cell#, capable of ad$ering to blood 2e##el *all# %latelet count# al#o drop and t$i# may in$ibit one of t$e factor# re#pon#ible for 2a#oCocclu#ion &5 al#o influence# nitric o:ide metaboli#m Nitric o:ide lead# to t$e dilation of blood 2e##el# and #eem# to reduce t$e ad$e#ion bet*een !B+# and blood 2e##el *all# 22 &5 $a# been found to reduce mortality due to an inducC tion of &gb ) and a reduction in 2a#oCocclu#i2e e2ent# .n addition, it reduce# t$e incidence of acute c$e#t #yndrome, tran#fu#ion re6uirement#, epi#ode# of $o#pitali/ation, pain cri#i#, and reduce# blood flo* t$roug$ intracranial blood 2e##el#, a# mea#ured by tran#cranial ,oppler in c$ilC dren 22K2> +urrently, t$ere i# contro2er#y about *$et$er or not &5 can be u#ed to pre2ent repeat #tro4e# a# effecti2ely a# c$ronic tran#fu#ion in c$ildren BA,2>,25 Since &5 i# a c$eC mot$erapeutic agent, t$ere i# concern t$at it *ill $a2e long term #ide effect# .t i# not u#ed in *omen *$o are pregC nant or planning to become pregnant .n addition, #ome patient# $a2e to di#continue t$erapy becau#e t$eir -B+ count become# too lo* ;$e effect# of $ydro:yurea are not immediate, generally ta4ing a fe* mont$# to be effecti2e 2A ;$erefore, it doe# not pro2ide rapid re#pon#e during acute illne## Bone marro* tran#plant, perip$eral blood #tem cell tran#plant, and umbilical cord blood tran#plant are all #trategie# t$at can cure S+, ,ue to t$e morbidity and mortality #econdary to tran#plant, it i# important to careC fully c$oo#e patient# *it$ #e2ere di#ea#e *it$ a $ig$ ri#4 of morbidity and mortality, #uc$ a# t$o#e *it$ recurrent #tro4e# ;$erefore, trial# $a2e centered on treating c$ildren or young adult#, and t$ere are #ome encouraging re#ult# 5nfortunately, one impediment i# t$e lo* a2ailability of matc$ed #ibling donor# 29K2D .ransfusion Management ;ran#fu#ion t$erapy #$ould only be initiated in patient# *it$ #ign# and #ymptom# of anemia 0# mentioned, mo#t patient# *it$ S+,, t$oug$ anemic, do not generally $a2e daily #ign# and #ymptom# of anemia ;$erefore, !B+ tran#C fu#ion #$ould only be u#ed for #pecific indication# !B+ tran#fu#ion, *$en nece##ary in patient# *it$ S+,, pro2ide# #ome additional benefit# -$ile increa#ing t$e patientH# $eC moglobin, tran#fu#ion dilute# t$e &gb S *it$ &gb 0 ;$e !B+# *it$ &gb 0 $a2e longer #ur2i2al t$an t$e !B+# *it$ &gb S and neit$er #ic4le nor polymeri/e .n addition, tran#C fu#ion *ill #uppre## t$e patientH# o*n eryt$ropoie#i#, or !B+ production 0# a con#e6uence, t$ey *ill produce le## of t$eir o*n &gb S !B+# >,5,29

;$e deci#ion to tran#fu#e #$ould ta4e into account t$e 4no*n benefit# in t$e face of ri#4# 0ll blood product# are capable of tran#mitting certain infectiou# di#ea#e# and cau#ing tran#fu#ion reaction# .n addition, t$e recipient i# e:po#ed to certain inflammatory mediator# t$at accumuC late in tran#fu#ed blood and to foreign antigen# from t$e donor E:po#ure to foreign !B+ antigen# $a# important imC plication# for patient# *it$ #ic4le cell di#ea#e !B+# can be tran#fu#ed a# a #imple tran#fu#ion or 2ia e:c$ange tran#fu#ion 7eryt$rocytop$ere#i#8 5,29 ,uring #imple tran#fu#ion, one or t*o unit# of !B+# are tran#fu#ed t$roug$ a perip$eral .V E:c$ange tran#fu#ion i# u#ually performed u#ing an automated mac$ine t$at i# de#igned to remo2e *$ole blood from t$e patient, #eparate into it# 2ariC ou# component#, and t$en di#card t$e patientH# &gb S !B+# !B+# from t$e blood ban4 are t$en u#ed a# replacement ;ypically, an !B+ e:c$ange e:c$ange# one to t*o !B+ 2olC ume# 7total blood 2olume _ $ematocrit ^ B blood 2olume8 0 larger bore, #tiffC*alled central 2enou# cat$eter i# u#ually re6uired due to t$e flo* re6uirement# of t$e automated inC #trument .n t$e ab#ence of automated e6uipment, manual e:c$ange tran#fu#ion can be done ;$i# i# not optimal, #ince t$i# can create blood pre##ure and 2olume c$ange# during t$e alternating remo2al of *$ole blood t$roug$ a perip$eral 2ein *it$ #ub#e6uent reinfu#ion of ban4ed !B+# Eac$ type of tran#fu#ion $a# it# o*n ri#4# and benefit#, a# outlined in ;able > and in ;able 5
!a%le 3- T,e "ene=its (nd ris?s o= sim*le tr(ns=usion
"enefits Te+,ni+(l e(seIre-uires onl) *eri*,er(l IV (++ess Low donor e0*osureIonl) / or o= R16s ne+ess(r) 3ilution o= H<" S units Ris+s In+re(ses vis+osit) Ris? o= iron overlo(d

!a%le 9- T,e "ene=its (nd ris?s o= e0+,(n<e tr(ns=usion

"enefits 2rodu+es r(*id redu+tion in H<" S No in+re(se in vis+osit) No ris? o= iron overlo(dIsome o"serve redu+tions in serum =erritin over time Ris+s Re-uires l(r<e <(u<e IV, usu(ll) +entr(l venous +(t,eter Re-uires e0*ertise (nd s*e+i(l e-ui*mentIm() re-uire tr(ns=er o= *(tient to (not,er =(+ilit) Hi<,er donor e0*osureI(t le(st . units o= R16s =or (n (dult, usu(ll) more Hi<,er e0*ense

Indications for .ransfusion in (ic-le Cell #isease .ndication# for tran#fu#ion in S+, include? 0pla#tic +ri#i#? -$en !B+ production in t$e bone marro* i# interrupted, t$e delicate balance to maintain !B+ proC duction during c$ronic $emoly#i# i# di#rupted ;$erefore, if t$e patient $a# a drop in t$eir $emoglobin and become# #ymptomatic, tran#fu#ion i# re6uired until t$e underlying proce## abate# 5,29

Splenic Se6ue#tration? -$en a c$ildH# $emoglobin drop# and t$ey become #ymptomatic, tran#fu#ion i# nece#C #ary, in t$i# #etting (f intere#t, tran#fu#ion increa#e# t$e $emoglobin beyond *$atH# e:pected, #o it i# important to tran#fu#e #lo*ly to a2oid o2erCtran#fu#ion &epatic #e6ue#C tration can al#o occur 5,29 %regnancy? .n uncomplicated pregnancie#, t$ere i# no imC pro2ement in outcome# in *omen *$o are tran#fu#ed %aC tient# *it$ ot$er complication# of S+, #$ould be tran#fu#ed accordingly 5,29,A0 %riapi#m? %riapi#m i# t$e painful engorgement of t$e peni#, a# a re#ult of 2a#oCocclu#ion Supporti2e t$erapy con#i#ting of $ydration and analge#ia i# recommended, and a urologi#t #$ould be con#ulted -$en priapi#m doe# not re#ol2e, #imple tran#fu#ion or e:c$ange tran#fu#ion #$ould be con#idered ;$ere are no #tudie# to direct tran#fu#ion t$erapy .n addition, e:c$ange tran#fu#ion $a# been a##ociC ated *it$ ad2er#e neurologic #e6uelae, #uc$ a# #ei/ure# and increa#e# in intracranial pre##ure, #o t$ere i# a reluctance to perform e:c$ange until t$e patient i# refractory to ot$er treatment# 5,29,AB %re#urgical %rop$yla:i#? %atient# *it$ S+, are at $ig$ ri#4 for complication# *$en undergoing maNor #urgery +urrently, #ome practitioner# recommend t$at patient# be tran#fu#ed to a $emoglobin of B0 g<d' prior to #urgery 0 #tudy done comparing e:c$ange tran#fu#ion to #imple tran#fu#ion found t$at e:c$ange tran#fu#ion i# unnece#C #ary 5,29,A2 ;$ere are in2e#tigation# under*ay to determine *$et$er or not a $emoglobin lo*er t$an B0 g<d' i# #afe for certain #urgerie# AA 0cute +$e#t Syndrome 70+S8? ;ran#fu#ion, eit$er #imC ple or e:c$ange, implemented early in t$e cour#e, impro2e# o:ygenation and alle2iate# organ dy#function )or patient# *$o are #table, #imple tran#fu#ion #$ould be performed .f t$e patient deteriorate#, doe# not impro2e, or $a# a rapidly e2ol2ing cour#e, e:c$ange tran#fu#ion i# recommended BE,A> Simple tran#fu#ion #$ould only be performed until t$e $eC moglobin reac$e# about B0 g<d' Beyond t$at, t$ere i# conC cern for 2a#oCoccul#ion 5,29 Stro4e? ,ue to t$e ea#e of #imple tran#fu#ion in pediatC ric patient#, t$ey u#ually undergo #imple tran#fu#ion )or patient# *$o $a2e an initial #tro4e, e:c$ange tran#fu#ion i# u#ed to rapidly reduce t$e amount of &gb S t$at can be recruited and e:tend t$e immediate damage to t$e brain (nce a patient $a# a #tro4e, t$ey are at ri#4 for additional #tro4e# By performing a mont$ly tran#fu#ion, eit$er #imC ple or e:c$ange, t$i# ri#4 of recurrence i# reduced 0 recent #tudy #$o*ed t$at #topping mont$ly tran#fu#ion after t$e return of normal flo* by tran#cranial ,oppler re#ult# in recurrent #tro4e# and t$e return of abnormal ;+,# BA,B5,B9,A5 (f intere#t, during #tudie# to reduce t$e ri#4 of fir#t #tro4e, patient# on a c$ronic tran#fu#ion protocol al#o $ad a reducC tion in t$e ri#4 of acute c$e#t #yndrome and a reduction in t$e number of pain cri#e# B5,B9

Ad/erse ConseGuences of .ransfusion of Patients with (ic-le Cell #isease 0d2er#e con#e6uence# of tran#fu#ion of patient# *it$ S+, include? 0lloimmuni/ation? ,ue to t$e di#parity bet*een doC nor# and patient# *it$ S+, in t$e 5nited State#, patient# *it$ S+, are among t$o#e mo#t fre6uently alloimmmuC ni/ed Studie# $a2e #$o*n t$at t$e mo#t common antibodC ie# formed in t$i# population are +, E, and "B 2,A9 ;$ere are al#o ot$er antibodie# t$at are formed due to donorKrecipiC ent di#parity ;$erefore, in order to pre2ent alloimmuni/aC tion, #ome center# routinely perform !B+ p$enotype# on patient# *it$ S+, and only tran#fu#e !B+# t$at lac4 +, E, and "B, if t$e patient i# negati2e for t$e antigen ;$i# #tratC egy reduce# t$e rate of antibody formation in t$e#e atCri#4 patient# A9 ,e#pite t$e#e finding#, practice i# 2ariable 0naly/ing t$e re#ult# of t$e 200A JC+ +ollege of 0merican %at$ologi#t# %roficiency ;e#ting Sur2ey, (#by and S$ulC man found t$at only AE percent of Nort$ 0merican $o#piC tal# routinely perform antigen typing on t$e !B+# of nonC alloimmuni/ed patient# *it$ S+, .n t$e >A9 laboratorie# t$at do perform !B+ p$enotyping, +, E, and "B *ere t$e mo#t fre6uent antigen# t$at *ere matc$ed AE .n a #ur2ey of 50 academic medical center# in t$e 5S and +anada, EA perC cent of center# reported t$at t$ey performed routine p$eC notyping *it$ D9R of t$o#e center# al#o matc$ing for +, E, and "B AD ;$ere i# contro2er#y about pro2iding !B+# t$at lac4 additional antigen# 0# you matc$ for additional antiC gen#, it become# more difficult to find compatible unit# .t i# argued t$at it i# a better u#e of re#ource# to #a2e t$o#e rare unit# for patient# *it$ e:i#ting antibodie# A9 0not$er #tratC egy $a# been to u#e !B+# from donor# *$o are et$nically #imilar to t$e patient, t$ereby creating a better c$ance t$at t$e donor and patient *ill matc$ more clo#ely >0 -$ene2er a patient de2elop# an antibody, t$ey *ill al#o recei2e !B+# lac4ing t$e corre#ponding antigen >B &yper$emolytic Syndrome? 0 #eriou# type of $emoC lytic tran#fu#ion reaction, called t$e I$yper$emolytic #ynC drome,J can occur in t$e #etting of tran#fu#ion ,uring t$e#e epi#ode#, t$e patient# are typically being tran#fu#ed, and in#tead of ri#ing, t$eir $emoglobin fall# *it$ #ub#e6uent tran#fu#ion .t i# felt t$at t$ere i# a Iby#tanderJ $emoly#i# of t$e patientH# o*n !B+#, a# *ell a# de#truction of tran#fu#ed !B+# (f intere#t, t$e unit# tran#fu#ed are cro##matc$ comC patible, and no ne* alloantibodie# are identified at t$e time of tran#fu#ion )urt$er tran#fu#ion compound# t$e probC lem ;$erefore, it i# important to recogni/e t$e #yndrome and, if po##ible, #top tran#fu#ing .f tran#fu#ion i# nece#C #ary, intra2enou# immunoglobulin 7.V.G8 and intra2enou# #teroid# $a2e been found to be effecti2e .f tran#fu#ion i# re6uired becau#e of lifeC t$reatening anemia, it #$ould be done cautiou#ly, u#ing .V.G and #teroid# concurrently >2K>> .ron (2erload? Eac$ unit of tran#fu#ed !B+# contain# about 200K250 mg of iron -it$ c$ronic tran#fu#ion, t$i# iron accumulate# and can be depo#ited into organ# #uc$ a# t$e $eart, li2er, and endocrine gland# .n order to preC

2ent t$i#, medication# are u#ed to remo2e, or c$elate, iron .ntra2enou# c$elator# $a2e been u#ed, but t$eir efficacy i# $indered by it# $alfClife and poor patient compliance 0 ne* generation of oral c$elator# i# effecti2e #ince t$ere i# increa#ed compliance, and mode of action# re#ult# in a more continuou# c$elation Serum ferritin i# monitored in patient# on c$ronic tran#fu#ion protocol# *$o $a2e S+, >5 ;$e aim of treatment i# to reduce #erum ferritin and to remo2e iron from organ# .ransfusion Recommendations -$en a patient de2elop# complication# from S+,, it al#o ma4e# #en#e not to tran#fu#e t$em *it$ !B+# *it$ adC ditional &gb S ;$erefore, many laboratorie# *ill do a #imC ple #olubility te#t, a# de#cribed earlier, and #elect unit# t$at lac4 &gb S !eali/e t$at indi2idual# *it$ S+, are anemic and cannot #er2e a# blood donor#, $o*e2er, t$ere are acti2e donor# *it$ #ic4le cell trait >B 'eu4oreduction 7'!8 of blood product# $a# been pro2C en to reduce t$e ri#4 of cytomegalo2iru# 7+MV8 tran#mi#C #ion, reduce t$e ri#4 of febrile nonC$emolytic tran#fu#ion reaction#, and reduce t$e ri#4 of $uman leu4ocyte antigen 7&'08 alloimmuni/ation >B ;$ere are al#o #tudie#, t$oug$ contro2er#ial, t$at #$o* t$ere are deleteriou# immunologic #e6uelae of tran#fu#ion t$at are pre2ented by reducing t$e load of -B+# in tran#fu#ed blood product# Since patient# *it$ S+, are c$ronically tran#fu#ed, many belie2e t$at t$e#e patient# #$ould recei2e '! blood product# (f note, t$ere i# al#o a #tudy t$at #$o*# reduced rate# of !B+ alloimmuni/aC tion in patient# *$o recei2e '! blood product# >9 ;ran#fuC #ion recommendation# for patient# *it$ S+, are? c Blood product# t$at are #ic4le $emoglobin negati2e c Blood product# t$at are leu4oreduced c Blood product# t$at are negati2e for +, E, and "B antiC gen# if t$e patient lac4# t$e#e antigen# c Blood product# t$at are negati2e for any additional anC tigen# again#t *$ic$ t$e patient $a# antibody c Blood product# t$at are from 0frican 0merican donor#, if a program e:i#t# Summar$ ;$e #ub#titution of one amino acid in t$e $emoglobin molecule re#ult# in #ic4le $emoglobin 0# a re#ult, !B+# #ic4le in lo* o:ygen #tate# cau#ing occlu#ion of blood 2e#C #el#, increa#ed 2i#co#ity, and inflammation ;$e#e !B+# are prematurely remo2ed from t$e circulation, re#ulting in a c$ronic $emolytic anemia -it$ ne*born #creening and early treatment, t$e deat$ rate among c$ildren *it$ S+, $a# declined .n addition, a 2ariety of treatment# are being introduced to $elp manage t$e 2ariou# manife#tation# of di#ea#e ;ran#fu#ion, #imple or e:c$ange, i# a main#tay of t$erapy, #ince it reduce# t$e amount of &gb S in circulation and #uppre##e# eryt$ropoie#i# ;ran#fu#ion i# indicated for #ymptomatic anemia and #pecifically to pre2ent #tro4e 7fir#t or recurrent8, during acute #tro4e, and for acute c$e#t #yndrome 5nfortunately, tran#fu#ion carrie# ri#4#

for infectiou# di#ea#e tran#mi##ion, a# *ell a# immunologic and inflammatory #e6uelae )or patient# *it$ S+, *$o may be c$ronically tran#fu#ed, iron o2erload occur# fre6uently .n addition, due to difference# in !B+ antigen# bet*een doC nor# and recipient#, t$e#e patient# are at increa#ed ri#4 for de2elopment of !B+ alloantibodie#, *$ic$ can complicate furt$er tran#fu#ion .t i#, t$erefore, important to pre2ent alloimmuni/ation by tran#fu#ing leu4oreduced !B+# t$at matc$ t$e patient for t$e +, E, and "B antigen# &uman progenitor cell 7from bone marro*, perip$eral blood #tem cell#, or umbilical blood8 tran#plant can cure t$e di#ea#e, and i# u#ed for patient# *it$ #e2ere di#ea#e for *$om conC 2entional t$erapy may not be effecti2e References B )renette %S, 0t*e$ G) Sic4le cell di#ea#e? old di#co2C erie#, ne* concept#, and future promi#e J +lin .n2e#t 200EFBBE?D50KD 2 Vic$in#4y E%, Earle# 0, Jo$n#on !0, et al 0lloimmuC ni/ation in #ic4le cell anemia and tran#fu#ion of racially unmatc$ed blood N Engl J Med B990FA22?B9BEK2B A Elg$etany M;, Ban4i " Eryt$rocytic di#order# .n? Mc%$er#on !0, %incu# M!, ed# &enryH# clinical diagC no#i# and management by laboratory met$od# 2B#t ed %$iladelp$ia, %0? Saunder# El#e2ier, 200E?50>K>> > (gedegbe &( Sic4le cell di#ea#e? an o2er2ie* 'ab Med 2002FAA?5B5K>A 5 ($eneC)rempong " .ndication# for red cell tran#fu#ion in #ic4le cell di#ea#e Semin &ematol 200BFAD?5KBA 9 Ga#ton M&, Verter J., -ood# G, et al %rop$yla:i# *it$ oral penicillin in c$ildren *it$ #ic4le cell anemia 0 ranC domi/ed trial N Engl J Med B9D9FAB>?B59AK9 E 'ei4in S', Gallag$er ,, "inney ;!, et al Mortality in c$ilC dren and adole#cent# *it$ #ic4le cell di#ea#e +ooperati2e #tudy of #ic4le cell di#ea#e %ediatric# D B9D9FD>?500KD Gill )M, Sleeper '0, -einer SJ, et al +linical e2ent# in t$e fir#t decade in a co$ort of infant# *it$ #ic4le cell di#C ea#e Blood B995FD9?EE9KDA 9 %latt (S, Brambilla ,J, !o##e -), et al Mortality in #ic4le cell di#ea#eLlife e:pectancy and ri#4 factor# for early deat$ N Engl J Med B99>FAA0?B9A9K>> B0 ;elen MJ !ole of ad$e#ion molecule# and 2a#cular enC dot$elium in t$e pat$ogene#i# of #ic4le cell di#ea#e &eC matol 0m Soc &ematol Educ %rogram 200EFD>K90 BB "upyer# )0 Membrane lipid alteration# in $emoglobinC opat$ie# &ematology 0m Soc &ematol Educ %rogram B2 200EF9DKEA "ey NS, Slungaard 0, ,andelet ', et al -$ole blood ti#C #ue factor procoagulant acti2ity i# ele2ated in BA patient# *it$ #ic4le cell di#ea#e Blood B99DF9B?>2B9K 2A -ang -+ ;$e pat$op$y#iology, pre2ention, and treatC ment of #tro4e in #ic4le cell di#ea#e +urr (pin &ematol 200EFB>?B9BKE

B> 0dam# !J, Mc"ie V+, Nic$ol# ), et al ;$e u#e of tran#cranial ultra#onograp$y to predict #tro4e in #ic4C le cell di#ea#e N Engl J Med B992FA29?905KB0 B5 0dam# !J, Mc"ie V+, &#u ', et al %re2ention of a fir#t #tro4e by tran#fu#ion# in c$ildren *it$ #ic4le cell aneC mia and abnormal re#ult# on tran#cranial ,oppler ultraC #onograp$y N Engl J Med B99DFAA9?5KBB B9 0dam# !J, Mc"ie V+, Brambilla ,, et al Stro4e preC 2ention trial in #ic4le cell anemia +ontrol +lin ;rial# B99DFB9?BB0K29 BE Vic$in#4y E%, Neumayr ',, Earle# 0N, et al +au#e# and outcome# of t$e acute c$e#t #yndrome in #ic4le cell di#C ea#e National 0cute +$e#t Syndrome Study Group N Engl J Med 2000FA>2?BD55K95 BD Sa4$al4ar VS, !ao S%, -eedon J, Miller S; Ele2ated pla#ma #V+0MCB le2el# in c$ildren *it$ #ic4le cell di#C ea#e? impact of c$ronic tran#fu#ion t$erapy 0m J &eC matol 200>FE9?5EK90 B9 Style# '0, 0bboud M, 'ar4in S, 'o M, "uyper# )0 ;ran#fu#ion pre2ent# acute c$e#t #yndrome predicted by ele2ated #ecretory p$o#p$olipa#e 02 Br J &aematol 200EFBA9?A>AK> 20 +la#ter S, Vic$in#4y E% Managing #ic4le cell di#ea#e BMJ 200AFA2E?BB5BK5 2B %latt (, ;$orington B, Brambilla ,, et al %ain in #ic4le cell di#ea#e N Engl J Med B99BFA25?BBKB9 22 Steinberg M&, Barton ), +a#tro (, et al Effect of $yC dro:yurea on mortality and morbidity in adult #ic4le cell anemia !i#4# and benefit# up to 9 year# of treatment J0M0 200AF2D9?B9>5K5B 2A +$arac$e S, ;errin M', Moore !,, et al Effect of $yC dro:yurea on t$e fre6uency of painful cri#e# in #ic4le cell anemia N Engl J Med B995FAA2?BABEK22 2> -are !E, Pimmerman S0, S$ult/ -& &ydro:yurea a# an alternati2e to blood tran#fu#ion for t$e pre2ention of recurrent #tro4e in c$ildren *it$ #ic4le cell di#ea#e Blood B999F9>?A022K9 25 Pimmerman S0, Sc$ult/ -&, Burgett S, et al &ydro:yuC rea t$erapy lo*er# tran#cranial ,oppler flo* 2elocitie# in c$ildren *it$ #ic4le cell anemia Blood 200EFBB0?B0>AKE 29 'ocatelli ), !oc$a V, !eed -, et al !elated umbilical cord blood tran#plantation in patient# *it$ t$ala##emia and #ic4le cell di#ea#e Blood 200AFB0B?2BAEK>A 2E Bernaudin ), Socie G, "uent/ M, et al 'ongCterm re#ult# of related myeloablati2e #temCcell tran#plantation to cure #ic4le cell di#ea#e Blood 200EFBB0?2E>9K59 2D -oodard %, Jeng M, &andgretinger !, et al SumC mary of #ympo#ium? t$e future of #tem cell tran#planC tation for #ic4le cell di#ea#e J %ediatr &ematol (ncol 2002FA>?5B2KBE 29 Jo#ep$#on +,, 'u '', "illyer "', &illyer +, ;ran#fuC #ion in t$e patient *it$ #ic4le cell di#ea#e? a critical re2ie* of t$e literature and tran#fu#ion guideline# ;ran#fu# Med !e2 200EF2B?BBDKAA

A0 "o#$y M, Burd ', -allace ,, et al %rop$ylactic redCcell tran#fu#ion# in pregnant patient# *it$ #ic4le cell di#ea#e N Engl J Med B9DDFAB9?B>>EK52 AB !ac4off -!, ($eneC)rempong ", Mont$ S, et al NeuroC logic e2ent# after partial e:c$ange tran#fu#ion for priaC pi#m in #ic4le cell di#ea#e J %ediatr B992FB20?DD2K5 A2 Vic$in#4y E%, &aber4ern +M, Neumayr ', et al 0 comC pari#on of con#er2ati2e and aggre##i2e tran#fu#ion regiC men# in t$e perioperati2e management of #ic4le cell di#C ea#e N Engl J Med B995FAAA?209KBA AA Buc4 J, +a#bard 0, 'le*elyn +, Jo$n#on ;, ,a2ie# S+, -illiam#on 'M %reoperati2e tran#fu#ion in #ic4le cell di#ea#e? a #ur2ey of practice in England Eur J &aematol 2005FE5?B>K2B A> %latt (S ;$e acute c$e#t #yndrome of #ic4le cell di#ea#e N Engl J Med 2000FA>2?B90>KE A5 0dam# !J, Brambilla ,F (ptimi/ing %rimary Stro4e %re2ention in Sic4le +ell 0nemia 7S;(% 28 ;rial .n2e#C tigator# ,i#continuing prop$ylactic tran#fu#ion# u#ed to pre2ent #tro4e in #ic4le cell di#ea#e N Engl J Med 2005FA5A?2E99KED A9 Vic$in#4y E%, 'uban N', -rig$t E, et al %ro#pecti2e !B+ p$enotype matc$ing in a #tro4eCpre2ention trial in #ic4le cell anemia? a multicenter tran#fu#ion trial ;ran#C fu#ion 200BF>B?B0D9K92 AE (#by M, S$ulman .0 %$enotype matc$ing of donor red blood cell# unit# for non alloimmuni/ed #ic4le cell di#C ea#e patient#? a #ur2ey of BBD2 Nort$ 0merican laboratoC rie# 0rc$ %at$ol 'ab Med 2005FB29?B90KA AD 0fenyiC0nnan 0, Brec$er ME %reCtran#fu#ion p$enoC type matc$ing for #ic4le cell di#ea#e patient# ;ran#fuC #ion 2005F>>?9B9K20 A9 Ne## %M ;o matc$ or not to matc$? t$e 6ue#tion for c$ronically tran#fu#ed patient# *it$ #ic4le cell anemia ;ran#fu#ion B99>FA>?55DK90 >0 &illyer "', &are V-, Jo#ep$#on +,, et al %artner# for life? t$e tran#fu#ed program for patient# *it$ #ic4le cell di#ea#e offered at t$e 0merican !ed +ro## Blood Ser2ice#, Sout$ern !egion, 0tlanta, Georgia .mmuno$ematology 2009F22?B0DKBB

>B Brec$er ME ;ec$nical Manual B5t$ ed Bet$e#da, M,? 0merican 0##ociation of Blood Ban4#, 2005 >2 "ing "E, S$irey !S, 'en4ie*ica M-, et al ,elayed $emolytic tran#fu#ion reaction# in #ic4le cell di#ea#e? #imultaneou# de#truction of recipient#H red cell# ;ran#C fu#ion B99EFAE?AE9KDB >A %et/ ',, +al$oun ', S$ulman .0, et al ;$e #ic4le cell $emolytic tran#fu#ion reaction #yndrome ;ran#fu#ion B99EFAE?AD2K92 >> -in N, 3eg$en ;, Need#, et al 5#e of intra2enou# immunoC globulin and intra2enou# met$ylpredni#olone in $yperC $aemoly#i# #yndrome in #ic4le cell di#ea#e &ematology 200>F9?>AAK9 >5 %orter JB +oncept# and goal# in t$e management of tran#C fu#ional iron o2erload 0m J &ematol 200EFD2?BBA9K9 >9 Blumberg N, &eal JM, Getting# ") 'eu4oreduction of red cell tran#fu#ion i# a##ociated *it$ a decrea#ed incidence of red cell alloimmuni/ation ;ran#fu#ion 200AF>A?9>5K52 Additional Resources Mayo +linic Sic4le cell anemia 02ailable at? $ttp?<<*** mayoclinic com<$ealt$<#ic4leCcellCanemia<,S00A2> 0cC ce##ed July 20, 2009 Sic4le +ell ,i#ea#e 0##ociation of 0merica, .nc 02ailable at? $ttp?<<*** #ic4lecelldi#ea#e org< 0cce##ed July 20, 2009 Marc$ of ,ime# 02ailable at? $ttp?<<*** marc$ofdime# com< 0cce##ed July 20, 2009 'ab ;e#t# (n 'ine 02ailable at? $ttp?<<*** labte#t#online org< 0cce##ed July 20, 2009 (usan #8 Roseff$ M#$ Medical #irector$ .ransfusion Medi- cine$ Professor$ irginia Commonwealth !ni/ersity$ #e- "artment of Pathology$ P0 &ox <A3@@;$ Richmond A ;6;<A-3@@;8

Attention S"" and "" Students 3ou are eligible for a free BCyear #ub#cription to Immunohematology 0#4 your education #uper2i#or to #ubmit t$e name and

complete addre## for eac$ #tudent and t$e inclu#i2e date# of t$e training period to immunoQu#a redcro## org

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;$e +on#ortium for Blood Group Gene# i# a *orld*ide organi/aC tion *$o#e goal i# to $a2e a 2e$icle to interact, e#tabli#$ guideC line#, operate a proficiency program, and pro2ide education for laboratorie# in2ol2ed in ,N0 and !N0 te#ting for t$e prediction of blood group, platelet, and neutrop$il antigen# Immunohematology 4009?45)75#786

0e$ 4ords: Blood group allele#, +on#ortium for Blood Group Gene#, proficiency, target allele#

of appropriately *orded report# of molecular analy#e# for bot$ blood donor# and tran#fu#ion recipient# Member# continue to #upport t$e current recommendation t$at blood component# #$ould not be labeled *it$ molecular te#t reC #ult# a# t$e #ole mean# of antigen identification Molecular data continue to be a #ource of information in t$e re#olution of comple: #erologic problem#, and are not intended a# t$e #ole mean# for patient tran#fu#ion management deci#ion# !arget Alleles ;$e li#t of target allele# prepared by t$e +BGG after meeting in 200E *a# adopted ;$e preferred current termiC nology i# li#ted in ;able B of t$i# report under t$e $eading ;arget antigen 7target allele8 &o*e2er, t$e final naming of allele# relie# on t$e deci#ion of t$e .nternational SociC ety for Blood ;ran#fu#ion -$en referring to a particular #ingleCnucleotide polymorp$i#m, nucleotide c$ange# folC lo* t$e de#ignated po#ition, e g , B25GX0F intronic nucleC otide c$ange# repre#ented in t$e lo*er ca#e, e g , KAAtXc ;$e a##ociated amino acid #ub#titution# 7not #$o*n8 flan4 t$e de#ignated po#ition, e g , %roB0ASer or %B0AS Becau#e gene numbering #y#tem# 2ary, and to a2oid ambiguity in t$e location of nucleotide c$ange#, t$e +BGG $a# adopted GenBan4 gene reference #e6uence# 7!efSe6Gene8 and refC erence SN% number# 7r#d8 for blood group gene# and nucleC otide# 7;able B8 ;$e#e number# pro2ide t$e #et of common reference# u#ed to communicate or report molecular te#ting re#ult# *uidelines for Molecular !esting ;$e +BGG $a# de2eloped guideline# for free and generC al di#tribution .n 200E, t$e +BGG guideline# *ere #$ared *it$ t$e 00BB Molecular ;e#ting Standard# %rogram 5nit 7S%58 .n addition, fi2e +BGG member# are committee member# of t$e 00BB Molecular ;e#ting S%5, and one member 7ME!8 $old# liai#on #tatu# *it$ t$e committee ;$e 00BB Standard# for Molecular ;e#ting for !ed +ell, %latelet, and Neutrop$il 0ntigen# *a# publi#$ed in 200D 5 ;$e intent of t$e +BGG guideline# i# to maintain an indeC pendent forum and 2oice for propo#ed molecular te#ting #tandard# in .S( format for u#e by international laboratoC rie# ;$e member# *ill update, modify, or ot$er*i#e amend t$e +BGG guideline# by proce## of di#cu##ion and con#enC #u# ;$e +BGG guideline# *ill not become #tandard# a# #uc$ to reflect t$e fact t$at t$e +BGG i# not re#pon#ible for laboratory in#pection or accreditation
G!

$e +on#ortium for Blood Group Gene# 7+BGG8 i# a nonprofit organi/ation *$o#e mi##ion i# I;o e#tabC li#$ guideline#, to pro2ide education, and to pro2ide a proficiency e:c$ange for laboratorie# in2ol2ed in ,N0 or !N0 te#ting for t$e determination of blood group, platelet, and neutrop$il antigen# J ;$e con#ortium *a# e#tabli#$ed at t$e inaugural meeting on (ctober 2A, 200>, in BaltiC more, Maryland, by a group of people *it$ #cientific or inC du#try e:perience and intere#t in t$e field ;$e con#ortium i# coordinated by Marion !eid *it$ a##i#tance of country coordinator#? 'ilian +a#til$o for Bra/il, Gregory ,enomme 7*it$ Mary#e St 'oui# a# #ucce##or in 20098 for +anada, and +onnie -e#t$off for t$e 5nited State# 0ll member# are e:pected to interact and participate Ne* member# are enC couraged to refer to t$e pre2iou#ly publi#$ed information for bac4ground and progre## information BK> ;$e e:c$ange of information i# mainly accompli#$ed t$roug$ electronic mailing#, proficiency e2aluation e:erci#e#, and a yearly meeting !he C"** Document ;$e C&'' #ocument outline# t$e function of t$e +BGG ;$i# document contain# information on t$e #tructure, orC gani/ational rule# and byla*#, regulatory compliance plan, preferred terminology, and progre## on t$e *or4ing partie# including proficiency e:c$ange program, guideline# of pracC tice, ,N0 repo#itory, funding, form# and di#claimer#, and propo#ed -eb #ite .t i# $ig$ly recommended t$at +BGG member# refer to t$i# document for t$e aforementioned dutie# and acti2itie# Meeting# are $eld annually, in part, for member# to di#cu## out#tanding i##ue# and to pro2ide t$e opportunity to gi2e input and accept amendment# to t$e document ;$e C&'' #ocument i# di#tributed to memC ber# and i# a2ailable to nonmember# on re6ue#t !emplate Disclaimers +BGG member# continue to recogni/e t$e importance

IMMUNOHEMATOLOGY, Volume !, Num"er , ##$

* Full listing of the members of the CBGG can be found in the appendix.

GH

IMMUNOHEMATOLOGY, Volume !, Num"er , ##$

61GG:

##J re*ort

#roficienc$ #rogram 0n e:c$ange of #ample# among #e2eral blood center#, tran#fu#ion #er2ice#, and reference laboratorie# #er2e# a# one mec$ani#m to e2aluate proficiency in molecular te#tC ing ;$e proficiency program# in2ol2e t$e #ending out of a #ingle #ample 7eit$er ,N0 or *$ole blood8 by a member in t$e #pring and fall of eac$ year .n t$e fall of 200D, t$e +BGG blood group program pro2ided it# fir#t *$ole blood #ample for proficiency e:c$ange, *$ic$ *a# coordinated t$roug$ t$e +anadian Blood Ser2ice#, Net*or4 +enter for 0pplied ,e2elopment 7Net+0,8 laboratory Before any di#C tribution, t$e target antigen mu#t be te#ted by a %+!C ba#ed met$od and be confirmed by #erology, *it$ t$e additional ca2eat t$at t$e proficiency e:erci#e *ill not in2ol2e rare alC lele# 0 limited number of antit$etical blood group antigen# are e2aluated, *$ic$ are ba#ed on t$e a##ay# performed by all participating member# 0# of #pring 200D, t$e allele# are a# follo*#? R4C)H)1R4C)He$ 'BP&H(1'BP&Hs$ *)LH21 *)LH;$ FBHA1FBH&$ FBHI66C1. 'A.A$ and %*HA1%*H& ;$e co#t of #ample preparation and #$ipping t$e ,N0 #ample i# borne in turn by eac$ #ubmitting laboratory ;o participate in t$e #ample e:c$ange, proficiency program member# mu#t agree to pro2ide a #ample for di#tribution in a #ub#e6uent year t$roug$ a predetermined rotation 0lt$oug$ participation in t$e +BGG proficiency program mandate# t$at #ample# are di#carded after t$e re#ult# $a2e been 2alidated, proficiency program member# mu#t en#ure t$ey comply *it$ regulatory bodie# ;$u#, before Noining t$e proficiency e:c$ange program and committing to #upC ply a #ample for t$e e:c$ange, ne* member# #$ould addre## t$eir in#titutional re6uirement# on informed con#ent ;o pre2ent communication error# becau#e of different reporting mec$ani#m#, a report form $a# been de2eloped #pecifically for t$e +BGG proficiency program, a copy of *$ic$ i# contained in t$e C&'' ;33A #ocument +ommuC nication of re#ult# bet*een t$e #ubmitting and te#ting laboC ratorie# i# done by u#ing t$i# form %re#ently, proficiency report# for FB or 'BP&H(1s #$ould include appropriate di#claimer# in t$e comment #ection for t$o#e laboratorie# t$at do not e2aluate common modifying and #ilencing nuC cleotide c$ange# for t$e#e gene# 0 #ummary of t$e re#ult# from t$e participating laboratorie# for eac$ proficiency e:C erci#e i# compiled by t$e #ubmitting laboratory and #ubmitC ted to t$e Ne* 3or4 Blood +enter for arc$i2al purpo#e# ;$e proficiency e2aluation# for platelet# and neutroC p$il# are di#tributed to a #pecific group of member# Important (otice A%out Manuscripts for Immunohematology %lea#e eCmail all manu#cript# for con#ideration to immunoQu#a redcro## org

Serologic confirmation i# not mandated by t$i# group o*ing to t$e lac4 of regulated anti#era ;$e fir#t e:c$ange for plateC let genotyping *a# coordinated by Vagner +a#tro 7%latelet .mmunology 'aboratory of &ematology and &emot$erapy +enter of t$e State 5ni2er#ity of +ampina#, 5N.+0M%8 ;$i# #ample *a# pre2iou#ly genotyped by %+!C!)'% and %+!CSS% to t$e t*o &%0 #y#tem# mo#t fre6uently in2ol2ed in platelet alloimmuni/ation? &%0CB and &%0C5 Conclusions ;$e +BGG i# a #elfC$elp, notCforCprofit organi/ation de#igned a# an interacti2e collaborati2e for member# to learn from eac$ ot$er and to #tri2e to ac$ie2e e:cellence in molecular te#ting of blood group, platelet, and neutrop$il antigen# 0nyone intere#ted and *illing to contribute intelC lectually i# *elcome to Noin ;o become a member contact Marion !eid 7mreidQnybloodcenter org8, 'ilian +a#til$o 7ca#til$oQunicamp br8, Mary#e St 'oui# 7mary#e #tCloui#Q $emaC6uebec 6c ca8, Greg ,enomme 7greg denommeQ bc* edu8, or +onnie -e#t$off 7-e#t$off+Qu#a redcro## org8 Ac+nowledgments -e t$an4 !obert !atner for $elp in t$e preparation of t$i# manu#cript and 'a4#$mi Gaur and ;anya "errigan for t$eir $elp a##embling t$e GenBan4 gene and SN% reference acce##ion code# ;$e finding# and conclu#ion# in t$e article #$ould not be con#trued to repre#ent any agency determiC nation or policy References B ,enomme G, !eid M .naugural meeting of t$e +on#orC tium for Blood Group Gene# 7+BGG8? a #ummary report .mmuno$ematology 2005F2B?B29KAB 2 !eid ME +on#ortium for Blood Group Gene# ;ran#fuC #ion 200EF>E7Suppl8?9DSKB00S A !eid ME, -e#t$off +M, ,enomme G, +a#til$o ' +onC #ortium for Blood Group Gene# 7+BGG8? Miami 2009 report .mmuno$ematology 200EF2A?DBK> > !eid ME, -e#t$off +, ,enomme G, +a#til$o ' +on#orC tium for Blood Group Gene# 7+BGG8? 200E report .mmuno$ematology 200EF2A?B95KD 5 Guidance for #tandard# for molecular te#ting for red cell, platelet, and neutrop$il antigen# Bet$e#da, M,? 00BB %re##, 200D

Immunohematology is on the 4e%D *** redcro## org<immuno$ematology )or more information, #end an eCmail me##age to immunoQu#a redcro## org

!a%le ,- List o= "lood <rou* t(r<et (nti<ens (nd (lleles

IS"! s$stem name ;s$m%ol< num%er !arget antigen ;target allele< *ene5 ;RefSe&*ene< !arget nucleotide num%er ;*ene"an+ S(# rsE< Controls and comments Control each nt anal$sis with the three genot$pic classes when appropriate 8 M(n) A81 (lleles ,(ve "een des+ri"ed, multi*le t(r<ets (re ne+ess(r) =or identi=i+(tion& T(r<ets =or non> H/delG Grou* O (lleles not listed&

A1O @A1OA ##/

A @ABO*A1A A (ABO*A2) A @ABO*A1A 1 @ABO*B1A

A1O @NG_006669.1A

nt /#H/[6 @rs!H%$ %#JA nt nt nt nt ! H6\G @rsGJ!%$J$A G#%G\A @rsJ/GHG.%A G$H6\A @rsJ/GHG.HA J#%G\6 @rsJ/GHG.GA

A @ABO*A1A O @ABO*01A MNS @MNSA ## M @GYPA*MA N @GYPA*NA GY2A @NG]##G.G#& A

nt H/G8[G @rsJ/GHG/$A nt !$6\TEG/G\AEG T\G @rsGHJ H#EGHJG !HEGH!J $%A nt G is t,e %rd nt o= +odon .

S @G21BSA s @G21BsA S silen+ed

GYPB (NG_007483.1)

nt /.%T\6 @rsGHJ%%H!A

3is+l(imer re-uired i= null (lleles not tested& P @see note "elowA

nt %#6\T intron !N!<\t R ! (NG_007494) R !" R C# (NG_009208) E0on . ^ G E0 . %G "* insert intron insert

R, @RHA ##.

T(r<ets m() v(r) (s t,ere (re m(n) (**ro(+,es Insert *resent in R C#*C

6 @R C#*CA + @R C#*$A

nt %#GT\6 @rsHGHGJ!A E @R C#*#A e @R C#*eA 6w 60 V ^ VS V @VS>A Lut,er(n @LUA ##! 5ell @5ELA ##H Lu( @%U*01A Lu"@%U*02A 5 @&#%*01A ? @&#%*02A 5*( @&#%*03A 5*" @&#%*04A 7s( @&#%*06A 7s" @&#%*07A 3u==) @:YA ##J :)( @'Y*AA :)" @'Y*BA :)0 :) null @R16A 5idd @75A ##$ 3ie<o @3IA #/# Yt @YTA #// S+i(nn( @S6A #/% 7? @(&*AA 7?" @(&*BA
(

nt HGH6\G @rsH#$% #A

nt /

A\G

P P P P

nt /#HG\A nt G%%6\G @rs/#!%%H/A nt /##HG\T %U (NG_007480.1) &#% (NG_007492.1) nt %#A\G @rs J%$$H!%A nt !GJT\6 @rsJ/GH#!JA nt J./T\6 @rsJ/GH#!$A nt /G$#6\T @rsJ/GH#%JA 'Y (NC_000001.9) nt / !G\A @rs/ #G!A nt H!6\T @rs%.!$$#J A nt >%%t\+ @rs J/.GGJA (& (NC_000018.8) !) (NG_007498.1) Y* (NG_007474.1) +C (NG_008749.1) nt J%JG\A @rs/#!J%$HA nt !H/T\6 @rs J!H..A

P 2romoter GATA>/ "o0 Testin< =or null (lleles m() "e (*> *ro*ri(te&

3i( 3i" Yt( Yt" S+/ S+

nt /#!G6\A @rs/G$$J#!A nt /H$G\A @rs!H# ! %JA P

3om"ro+? @3OA #/.

3o( 3o" H) 7o
(

!O (NG_007477.1)

nt G$%A\G @rs// GHA nt % %G\T @rs J%H G$GA nt %!#6\T @rs J%H G$JA

6olton @6OA #/! L(ndsteiner>9iener @L9A #/H 6romer @6RA # / 5no*s @5NA #

6o( 6o" L9( L9" 6r( 5n( 5n" M+6( M+6" Sl( Vil

CO (NG_00747,.1) %- (NG_007728.1) CROM (NG_00746,.1) &N (NG_007481.1)

nt /%.6\T @rs J%H H$ A nt %#JA\G nt HG$G\6 @rsH#J %G%A

P P

nt .HJ/G\A @rs./ G.GHJA nt .GHJA\G @rs/G#.GHH#A nt .J#/A\G @rs/G#.GHH/A P P

Indi(n @INA # % O5 @O5A # .

In( In" O?(

)N (NG_008937.1) O& (NG_007468.1)

nt ! 6\G nt G.G\A P Hetero;)<ote not re-uired

B NG]num"er&n re*resent t,e Gen1(n? re=eren+e <ene se-uen+e @Re=Se-GeneA (++ession +ode =or e(+, "lood <rou* s)stem <ene& _ T,e rs num"er in "r(+?ets re*resents t,e Gen1(n? SN2 re=eren+e se-uen+e @SN2 rsA (++ession +ode =or t,e <iven nu+leotide @ntA& P Homo;)<ous r(re (lleles (re not re-uired =or mole+ul(r testin<& ppendiMember# of +BGG at end of 200D? +oordinator) Marion >6 1eid8 ;h. 'aboratory of .mmunoc$emi#try and 'aboratory of .mmuno$ematology Ne* 3or4 Blood +enter AB0 Ea#t 9Et$ Street Ne* 3or4, N3 B0095 +ountry +oordinators) +onnie -e#t$off, %$, Molecular Blood Group and %latelet 0ntigen ;e#ting 'aboratory 0merican !ed +ro##C%ennCJer#ey !egion E00 Spring Garden Street %$iladelp$ia, %0 B9B2A Maryse ,t!<ouis8 ;h. (perational !e#earc$, &emaCOuebec B0E0, 02enue de# Science#CdeClaCVie Ouebec, Ouebec GBV 5+A, +anada <ilian Maria de +astilho8 ;h. 'aboratory of .mmuno$ematology &emocentroCState 5ni2er#ity of +ampina# 75N.+0M%8 !ua +arlo# +$aga# >D0 Bareo Geraldo +ampina#, Seo %aulo, BA0DBC9E0, Bra/il Members) 'ai @u8 M.8 ;h. ,epartment of %at$ology and 'aboratory Medicine 5ni2er#ity of ;e:a# &ealt$ Science +enter at &ou#ton 9>AB )annin Street, MSB 2 222 &ou#ton, ;@ EE0A0 .aniel '6 'ellissimo8 ;h. Molecular ,iagno#tic# 'aboratory Blood+enter of -i#con#in 9AD N BDt$ Street Mil*au4ee, -. 5A2AA Imelda M6 'romilo* ,.0ME, S0 +re##ierC#urCMorat, S*it/erland &ony ,6 +asina (rt$oC+linical ,iagno#tic#, .nc B00B &ig$*ay 202 !aritan, NJ 0DD99 =agner +astro &ematology and &emot$erapy +enter &emocentroCState 5ni2er#ity of +ampina# 75N.+0M%8 !ua +arlo# +$aga# >D0 Bareo Geraldo +ampina#, Seo %aulo, BA0DBC9E0, Bra/il <aura +ooling8 M. 5ni2er#ity of Mic$igan &o#pital# B500 Ea#t Medical +enter ,ri2e 0nn 0rbor, M. >DB09C005> na ;aula +oAac8 M. +entro !egional de &emoterapia de !ibeireo %reto !ibeireo %reto, S % +E% B>05BCB>0, Bra/il .aniel de la =ega8 ;h. Ser2icio de Medicina ;ran#fu#ional &o#pital .taliano Garibaldi Vira#oro B2>9 !o#ario 720008 0rgentina

3regory .enomme8 ;h. .mmuno$ematology !eference 'aboratory Blood +enter of -i#con#in 9AD N BDt$ Street Mil*au4ee, -. 5A20BCE2BED Belene M6 .e;alma .mmuno$ematology 'aboratory Ne* 3or4 Blood +enter AB0 Ea#t 9Et$ Street Ne* 3or4, N3 B0095 <a/shmi "6 3aur8 M,c8 ;h. %uget Sound Blood +enter 92B ;erry 02enue Seattle, -0 9DB0>CB259 3haAala ;6 Bashmi8 ;h. Bioarray Solution# A5 ;ec$nology ,ri2e, Suite B00 -arren, NJ 0E059 "im Bue!1oye 'aboratory of .mmunoc$emi#try Ne* 3or4 Blood +enter AB0 Ea#t 9Et$ Street Ne* 3or4, N3 B0095 ,usan &6 7ohnson8 M,&M8 M&0 ,+;2,'' Manager, .mmuno$ematology Ser2ice# Blood+enter of -i#con#in 9AD Nort$ BDt$ Street Mil*au4ee, -. 5A2AA Ballie <ee!,tro/a ,epartment of ;ran#fu#ion Medicine +linical +enter National .n#titute# of &ealt$ B0 +enter ,ri2e MS+ BBD> Bet$e#da, M, 20D92 +hristine <omas!9rancis8 M,8 9I'M, .mmuno$ematology 'aboratory Ne* 3or4 Blood +enter >5C0B Vernon Bl2d 'ong .#land +ity, N3 BBB0B &anya "anigan Bio;ro2e .ncorporated B2 Gill Street -oburn, M0 0BD0B "ir/ .6 "itchen +linical 'aboratorie# Blood Sy#tem# 'aboratorie# 2>2> -e#t Erie ,ri2e ;empe, 0P D52D2 3andhi 76 Manish8 M. 'aboratory Medicine and %at$ology Mayo +linic 200 )ir#t Street, S !oc$e#ter, MN 55905

MariAa 6 Mota8 ;h. ,epartamento de &emoterapia &o#pital .#raelita 0lbert Ein#tein 02 0lbert Ein#tein, 92E C >Y andar, Morumbi Seo %aulo, S% +E% 0595BC90B Bra/il 7oann M6 Moulds8 ;h. +linical .mmunogenetic# 'ifeS$are Blood +enter# D9B0 'in*ood 02enue S$re2eport, '0 EBB09 7ohn 76 Moulds8 M&0 ,+;2,'' Scientific Support Ser2ice# 'ifeS$are Blood +enter# D9B0 'in*ood 02enue S$re2eport, '0 EBB09 ,andra :ance8 M,8 M&0 ,+;2,'' ;ec$nical Ser2ice# 0merican !ed +ro## %ennCJer#ey !egion E00 Spring Garden Street %$iladelp$ia, %0 B9B2A Marcia Cago :o$aretti8 M.8 ;h. ,i2i#ion of .mmuno$ematology and ;ran#fu#ion )undafao %roCSangue<&emocentro de Sangue 02 0ng1lica, 2 29B Sao %aulo, Bra/il 7oseph (ng Blood +enter# of t$e %acific 2E0 Ma#onic 02enue San )ranci#co, +0 9>BBD 7ordDo ;ellegrino8 7r6 !ua Sampaio )erra/ E50 ap >B B +ampina#, Seo %aulo, Bra/il +E% BA02>C>AB Maria 1ios8 ;h. ,E;;,<(B!!<+BE! 29 'incoln ,ri2e N.& +ampu# Building 29, !oom B2> Bet$e#da, M, 20D92 .ennis 1oscetti G;. ,iagno#tic# 20925 +ro##road# +ircle, Suite 200 -au4e#$a, -. 5ABD9 .a*n M6 1umsey8 1&0+,M<&2 %E%)0! ;eam, Global ,e2elopment 0merican 0##ociation of Blood Ban4# DB0B Glenbroo4 !oad Bet$e#da, M, 20DB> 3ayle &eramura %uget Sound Blood +enter 92B ;erry 02enue Seattle, -0 9DB0>CB259

1ebecca &homas Memorial Blood +enter# EAE %el$am Bl2d St %aul, MN 55BB> ntonio ,ergio &orloni8 M. Mayo +linic BA>00 Ea#t S$ea Boule2ard Scott#dale, 0P D5259 ,unitha =ege8 M, Molecular Blood Group and %latelet 0ntigen ;e#ting 'aboratory 0merican !ed +ro## E00 Spring Garden Street %$iladelp$ia, %0 B9B2A 1ita 9ontDo 5endel .n#tituto de &emoterapia SirioC'ibane# !ua , 0dma Jafet, 9B C 2 0ndar Sao %aulo, +E% 0BA0DC050 Bra/il Mar/ @aAer8 M. !B+ Serology !eference 'aboratory +entrali/ed ;ran#fu#ion Ser2ice 5ni2er#ity of %itt#burg$ A9A9 Boule2ard of t$e 0llie# %itt#burg$, %0 B52BA

<iaison Members) ,heryl 6 "ochman ,e2ice# !e2ie* Branc$ +enter for Biologic# E2aluation and !e#earc$ (ffice of Blood !e#earc$ and !e2ie* ,i2i#ion of Blood 0pplication# )ood and ,rug 0dmini#tration B>0B !oc42ille %i4e, &)MCA90 !oc42ille, M, 20D52CB>>D 7ill ,torry8 ;h. Blodcentralen S4gneC5ni2er#ity &o#pital SEC22B D5 'und, S*eden

)or information concerning Immunohematology$ %ournal of &lood 'rou" (erology and )ducation, or t$e Immunohematology Methods and Procedures manual, contact u# by eCmail at immunoQu#a redcro## org

)or information concerning t$e National !eference 'aboratory for Blood Group Serology, including t$e 0merican !are ,onor %rogram, plea#e contact Sandra Nance, by p$one at 72B58 >5BC>A92, by fa: at 72B58 >5BC25AD, or by eCmail at #nanceQu#a redcro## org

)ree Classified Ads and Announcements Immunohematology *ill publi#$ cla##ified ad# and announcement# 7SBB #c$ool#, meeting#, #ympo#ia, etc 8 *it$out c$arge ,eadline# for receipt of t$e#e item# are a# follo*#? ,eadline# B#t *ee4 in January for t$e Marc$ i##ue B#t *ee4 in 0pril for t$e June i##ue B#t *ee4 in July for t$e September i##ue B#t *ee4 in (ctober for t$e ,ecember i##ue ECmail or fa: t$e#e item# to immunoQu#a redcro## org or 72B58 >5BC25AD

S*ei+(l 3edi+(tion

4- Fohn Fudd6 )I"MS6 MI"iol

3& M(llor) 8 Jo$n Judd, ).BMS, M.Biol, i# being $onored by Immunohematology$ %ournal of &lood 'rou" (erology and )ducation for $i# many contribuC tion# to t$e Nournal and to t$e field of blood ban4ing Jo$n #er2ed on t$e editoC rial board of Immunohematology for E year#, from 2002 t$roug$ 200D -e t$an4 $im for gi2ing genC erou#ly of $i# time and idea# to impro2e t$e #cope and concept of t$e Nournal ;$i# included contributing nine article# publi#$ed bet*een B9E9 and 2005 t$at *ere #ignificant to t$e intere#t of t$e reader# of Immunohematology &e al#o *a# a dedicated, 4no*ledgeable, and re#pon#i2e peer re2ie*er of #ubmitted article# from t$e beginning of t$e publication and during t$e lengt$ of $i# 2ery important career Jo$n retired in 200D after A> year# a# director of a fir#tC rate 00BBCaccredited reference laboratory at t$e 5ni2erC #ity of Mic$igan &i# career i# a tribute to $i# determination to in2e#tigate t$e unu#ual and t$e undi#co2ered .n B9E2, $e #tudied at t$e Sir Jo$n +a## +ollege in 'ondon, England, *$ere $e *a# elected a )ello* of t$e .n#titute of Biomedical Science# 7).BMS8 &e came to t$e 5ni2er#ity of Mic$igan in B9E> and *a# t$e director of t$e reference laboratory and profe##or of immuno$ematology in t$e ,epartment of %aC t$ology until $i# retirement in 200D &e i# no* emeritu# profe##or of immuno$ematology, ,epartment of %at$olC ogy, at t$e 5ni2er#ity of Mic$igan Jo$n *a# a*arded t$e u#ual blue and gold embo##ed c$air at retirement to pro2e it] Jo$n and $i# *ife, Jane, t$en mo2ed to Nort$ +arolina to rela: and *atc$ t$e golfer# go by Jo$n $a# recei2ed many a*ard#, including t$e .2or ,un#ford Memorial 0*ard and t$e Jo$n Elliott MemoC rial 0*ard from t$e 0merican 0##ociation of Blood Ban4# 700BB8F t$e )ounder# 0*ard and "ay Beattie 'ecture from t$e Mic$igan 0##ociation of Blood Ban4# 7M0BB8F t$e %etC ta*ayCS$eppard 0*ard of t$e Nort$ +arolina 0##ociation of Blood Ban4#F ' Jean Stubbin# Memorial 'ecture of t$e 5;MB Medical Branc$F !onald ,ubin Memorial 'ecturer,

N30BBF and Su/anne 'eiden Memorial 'ecturer, +0BB Society .n Nort$ +arolina, t$e e:tra room o2er t$e garage i# called t$e )!(G 7furni#$ed room o2er garage8F $o*e2er, in Jo$nH# ca#e, it i# called a ;!(G 7trop$y room o2er gaC rage8 for all of $i# *ellCde#er2ed a*ard#] Jo$n recei2ed t$e#e a*ard# for $i# many in2e#tigati2e #tudie#, re#earc$ report#, re2ie* paper#, pre#entation#, and publication# .n 200D, Jo$n coaut$ored t$e t$ird edition of %uddJs Methods in Immunohematology, a maNor reference met$od# manual for laboratory *or4er# ;$i# edition conC tain# more t$an B50 met$od# and procedure# document# ,uring t$e #pan of $i# career, $e $a# $ad more t$an D0 #cientific paper# publi#$ed in peerCre2ie*ed Nournal# 0dC ditionally, Jo$n i# t$e aut$or of re2ie* article# on lectin#, polyagglutination, elution #tudie#, pretran#fu#ion #tudie#, !$ blood group#, MNSC#y#tem antibodie#, and in2e#tigaC tion of t$e po#iti2e ,0; ;$e#e are Nu#t #ome of t$e topic# t$at $e #tudied and in2e#tigated in dept$ 0 popular #pea4er, Jo$n ga2e numerou# pre#entaC tion# at local, #tate, national, and international meeting# (ne could al*ay# count on Jo$n to tal4] .n fact, $e and t$e late Jo$n +a#e, of Gamma Biological#, .nc , *ere famou# for t$eir Ic$at#J on t$e 00BB SS++ forum and *ere *ell 4no*n for debating, in dept$, many 6ue#tion# concerning blood group #erology and it# comple:itie# .n addition to t$i# impre##i2e #cientific career, Jo$n al#o managed to be acti2e on many committee# of t$e 00BB, M0BB, and .nternational Society of Blood ;ran#fu#ion &e *a# al#o on t$e board of t$e 00BB for > year# and *a# on t$e board and pre#ident of t$e M0BB ;$e editor#, aut$or#, and re2ie*er# of Immunohematology$ %ournal of &lood 'rou" (erology and )ducation$ *ould li4e to t$an4 Jo$n for $i# contribution# to t$e field of blood ban4ing during $i# A> year# at t$e benc$ a# an in2e#tigator, and a# an aut$or, educator, and mentor -e *ould particuC larly li4e to ac4no*ledge $i# contribution# during t$e pa#t #e2eral year# a# an editor, peer re2ie*er, and contributing aut$or to Immunohematology Jo$n, you may be gone from t$e field, but you cannot be forgotten 'i4e t$e imporC tant #cienti#t# before you, you $a2e left a large and la#ting legacy of 4no*ledge and re#pect ;$an4 you, and may you and Jane $a2e a long, $ealt$y, and $appy retirement ,elore# Mallory, M;70S+%8SBB Emeritu# Editorial Board Immunohematology

IMMUNOHEMATOLOGY, Volume !, Num"er , ##$

J/

Letter =rom t,e Editors

"lood *roup ReviewsGA (ew )eature

$e editor# of Immunohematology pre#ent a ne* feature t$at i# e:tremely e:citing Starting *it$ t$i# i##ue, Immunohe- matology *ill publi#$ a #erie# of 2D IBlood Group !e2ie*#J in upcoming i##ue# E:pert# in t$e field $a2e agreed to put t$eir con#iderable 4no*ledge and energy into *riting a t$oroug$ re2ie* of eac$ of t$e 2D #elected area# !eader# *ill t$en $a2e compre$en#i2e re2ie*# of all t$e maNor blood group #y#tem# and ot$er topic# at t$eir fingertip# (f additional 2alue *ill be t$e reference# for eac$ article to *$ic$ t$e reader can refer if intere#ted in reading t$e original *or4 ;$e aut$or# *ill pre#ent eac$ blood group re2ie* in t$e follo*ing format? $i#tory, nomenclature, genetic#, molecular ba#i#, bioc$emi#try, anC tibodie# in #y#tem, and clinical #ignificance ;$e topic# t$at *ill appear in #e6uential i##ue# are detailed in t$e table belo*

-$en all t$e topic# $a2e been publi#$ed, Immunohematology *ill publi#$ t$e entire collection a# a #tandCalone re#ource ;$i# #erie# pro2ide# an e:cellent opportunity for e:perienced #taff to obtain continuing education, and it *ill be an educaC tional tool for ne* #taff ;$e editor# en2i#ion a copy of t$e collected re2ie*# a# a mu#tC$a2e for tran#fu#ion medicine facilitie#, librarie#, and per#onal boo4#$el2e# e2ery*$ere

A1O MNS R, (nd RHAG LU 5EL (nd 50 LE

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6R 5N IN I O5 RA2H

7MH 28Glo"oside Lows GIL

Sandra Nance +onnie M -e#t$off Editor#CinC+$ief Immunohematology

Announ+ements

Masters ;MSc< in !ransfusion and !ransplantation Sciences at !he 'niversit$ of "ristol6 England

0pplication# are in2ited from medical or #cience graduate# for t$e Ma#ter of Science 7MSc8 degree in ;ran#fu#ion and ;ran#plantation Science# at t$e 5ni2er#ity of Bri#tol ;$e cour#e #tart# in (ctober 2009 and *ill la#t for B year 0 partCtime option la#ting 2 or A year# i# al#o a2ailable ;$ere may al#o be opportunitie# to continue #tudie# for %$, or M, follo*ing t$e MSc ;$e #yllabu# i# organi/ed Nointly by ;$e Bri#tol .n#titute for ;ran#fu#ion Science# and t$e 5ni2er#ity of Bri#tol, ,epartment of %at$ology and Microbiology .t include#? c c c c c Scientific principle# of tran#fu#ion and tran#plantation +linical application# of t$e#e principle# %ractical tec$ni6ue# in tran#fu#ion and tran#plantation %rinciple# of #tudy de#ign and bio#tati#tic# 0n original re#earc$ proNect

0pplication can al#o be made for ,iploma in ;ran#fu#ion and ;ran#plantation Science or a +ertificate in ;ran#fu#ion and ;ran#plantation Science &he course is accredited by the Institute o% 'iomedical ,ciences6 )urt$er information can be obtained from t$e -eb #ite? $ttp?<<*** blood co u4<ibgrl<M#c&ome $tm )or furt$er detail# and application form# plea#e contact? ,r %atricia ,enningC"endall 5ni2er#ity of Bri#tol, %aul (HGorman 'ifeline +entre, ,epartment of %at$ology and Microbiology, Sout$mead &o#pital, -e#tburyConC;rym, Bri#tol BSB0 5NB, England )a: T>> BBE9 595 A>2, ;elep$one T>> BEE9 595 >55, eCmail? p a denningC4endallQbri#tol ac u4

Announ+ements, +ont& Meetings Septem%er .9 Illinois Association of "lood "an+s ;ILA""< ;$e .llinoi# 0##ociation of Blood Ban4# 7.'0BB8 )all Meeting *ill be $eld September 25, 2009, at t$e 'i#le<Naper2ille &ilC ton in 'i#le, .llinoi# )or additional detail# plea#e 2i#it t$e -eb #ite at *** ilabb org or contact "ri#ti -illiam# at 7A098 E>5CD999 or -illia"rQu#a redcro## org Specialist in "lood "an+ ;S""< #rogram ;$e ,epartment of ;ran#fu#ion Medicine, National .n#titute# of &ealt$, i# accepting application# for it# BCyear Speciali#t in Blood Ban4 ;ec$nology %rogram Student# are federal employee# *$o *or4 A2 $our#<*ee4 ;$i# program introduce# #tudent# to all area# of tran#fu#ion medicine, including reference #erology, cell proce##ing, &'0, and infectiou# di#ea#e te#ting Student# al#o de#ign and conduct a re#earc$ proNect N.& i# an E6ual (pportunity (rgani/ation 0pplication deadline i# ,ecember AB, 2009, for t$e July 20B0 cla## See *** cc ni$ go2<dtm X education for broc$ure and application )or furt$er information contact "aren M Byrne at 7A0B8 >5BCD9>5 or "ByrneQmail cc ni$ go2 Monoclonal anti%odies availa%le at no charge ;$e Ne* 3or4 Blood +enter $a# de2eloped a *ide range of monoclonal antibodie# 7bot$ murine and $umani/ed8 t$at are u#eful for donor #creening and for typing !B+# *it$ a po#iti2e ,0; ;$e#e include antiC0B, CM, C#, C5, C,, C!$BE, C", C4, C"pa, CJ#b, C)ya, C)yA, C)y9, -rb, C@ga, C+,99, C,ob, C&, CGe2, CGeA, C+,55 7bot$ S+!2<A and S+!>8, C(4a, C., and antiC +,59 Mo#t of t$e antibodie# are murine .gG and re6uire t$e u#e of antiCmou#e .gG for detection 7antiC", 4, and C"pa8 Some are directly agglutinating 7antiC0B, CM, C-rb and C!$BE8 and a fe* $a2e been $umani/ed into t$e .gM i#oform 7antiC J#b8 ;$e antibodie# are a2ailable at no c$arge to anyone *$o re6ue#t# t$em %lea#e 2i#it our -eb #ite for a complete li#t of a2ailable monoclonal antibodie# and t$e procedure for obtaining t$em )or additional information, contact? Gregory &al2er#on, Ne* 3or4 Blood +enter, AB0 Ea#t 9Et$ Street, Ne* 3or4, N3 B002BF eCmail? g$al2er#onQnybloodcenter orgF p$one? 72B28 5E0CA029F fa:? 72B28 EAEC>9A5F or 2i#it t$e *eb #ite at $ttp?<< *** nybloodcenter org Xre#earc$ Ximmunoc$emi#try Xcurrent li#t of monoclonal antibodie# a2ailable Advertisements

N(tion(l 2l(telet Serolo<) Re=eren+e L("or(tor)

Diagnostic testing for: ` Neon(t(l (lloimmune t,rom"o+)to*eni( @NAITA ` 2osttr(ns=usion *ur*ur( @2T2A ` Re=r(+toriness to *l(telet tr(ns=usion ` He*(rin>indu+ed t,rom"o+)to*eni( @HITA ` Alloimmune idio*(t,i+ t,rom"o+)to*eni( *ur*ur( @AIT2A Medical consultation availa%le !est methods: ` GTI s)stems tests I dete+tion o= <l)+o*rotein>s*e+i=i+ *l(telet (nti"odies I dete+tion o= ,e*(rin>indu+ed (nti"odies @2:. ELISAA ` 2l(telet sus*ension immuno=luores+en+e test @2SI:TA ` Solid *,(se red +ell (d,eren+e @S2R6AA (ss() ` Mono+lon(l immo"ili;(tion o= *l(telet (nti<ens @MAI2AA ` Mole+ul(r (n(l)sis =or H2A>/(8/" :or =urt,er in=orm(tion, +ont(+t #latelet Serolog$ La%orator$ @ /!A .!/>. #! M(r)(nn 5e(s,en>S+,nell @ /!A .!/>.#./ o==i+e ms+,nellbus(&red+ross&or< S(ndr( N(n+e @ /!A .!/> .%H sn(n+ebus(&red+ross&or< Ameri+(n Red 6ross 1lood Servi+es Musser 1lood 6enter G## S*rin< G(rden Street 2,il(del*,i(, 2A /$/ %>%!$.
6LIA li+ensed J.

N(tion(l Neutro*,il Serolo<) Re=eren+e L("or(tor)

Our l("or(tor) s*e+i(li;es in <r(nulo+)te (nti"od) dete+tion (nd <r(nulo+)te (nti<en t)*in<& Indications for granuloc$te serolog$ testing include: ` Alloimmune neon(t(l neutro*eni( @ANNA ` Autoimmune neutro*eni( @AINA ` Tr(ns=usion rel(ted (+ute lun< inaur) @TRALIA Methodologies emplo$ed: ` Gr(nulo+)te (<<lutin(tion @GAA ` Gr(nulo+)te immuno=luores+en+e ") =low +)tometr) @GI:A ` Mono+lon(l (nti"od) immo"ili;(tion o= neutro*,il (nti<ens @MAINAA !RALI investigations also include: ` HLA @2RAA 6l(ss I (nd 6l(ss II (nti"od) dete+tion :or =urt,er in=orm(tion +ont(+t: (eutrophil Serolog$ La%orator$ @H!/A R(nd) S+,uller@H!/A $/>HG!J s+,ullerrbus(&red+ross&or< meri+(n Red 6ross 1lood Servi+es Neutro*,il Serolo<) L("or(tor) /## Sout, Ro"ert Street St& 2(ul, MN !!/#G $/>HG$G

6LIA li+ensed

IMMUNOHEMATOLOGY, Volume !, Num"er , ##$

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Re=eren+e (nd 6onsult(tion Servi+es

Anti%od$ identification and pro%lem resolution HLA>A, 1, 6, (nd 3R t)*in< HLA>dise(se (sso+i(tion t)*in< 2(ternit) testin<83NA :or in=orm(tion, +ont(+t Me,di;(de, 5(s,i (t @!#%A J#># /#, or write to: 2(+i=i+ Nort,west Re<ion(l 1lood Servi+es ATTENTION: Tissue T)*in< L("or(tor) Ameri+(n Red 6ross %/%/ Nort, V(n+ouver 2ortl(nd, OR $G
6LIA li+ensed, ASHI (++redited

I<A8Anti>I<A Testin<
IgA and anti IgA testing is availa%le to do the following: ` Identi=) I<A>de=i+ient *(tients ` Investi<(te (n(*,)l(+ti+ re(+tions ` 6on=irm I<A>de=i+ient donors Our ELISA =or I<A dete+ts *rotein to #&#! m<8dL& :or (ddition(l in=orm(tion +ont(+t 6ind) :li+?in<er (t @ /!A .!/>.$#$, or e>m(il: =li+?in<er+bus(&red+ross&or<, or write to: Ameri+(n Red 6ross 1lood Servi+es Musser 1lood 6enter G## S*rin< G(rden Street 2,il(del*,i(, 2A /$/ %>%!$. ATTN: 6ind) :li+?in<er

N(tion(l Re=eren+e L("or(tor) =or 1lood Grou* Serolo<)

Immunohematolog$ Reference La%orator$ AA11, AR6, New Yor? St(te, (nd 6LIA li+ensed @ /!A .!/>.$#/I .>,r& *,one num"er @ /!A .!/> !%JI :(0 American Rare Donor #rogram @ /!A .!/>.$##I .>,r& *,one num"er @ /!A .!/> !%JI :(0 (rd*bus(&red+ross&or< Immunohematology
7ourn(l o= 1lood Grou* Serolo<) (nd Edu+(tion 6LIA li+ensed

3onor I<A S+reenin<

` E==e+tive tool =or s+reenin< l(r<e volumes o= donors ` Gel di==usion test t,(t ,(s ( /!>)e(r *roven tr(+? re+ord: A**ro0im(tel) $# *er+ent o= (ll donors identi=ied (s I<A de=i+ient ") (re +on=irmed ") t,e more sensitive testin< met,ods :or (ddition(l in=orm(tion, +(ll 5(t,) 5(,erl (t: @JH#AHGJ> GH., e>m(il: ?(,erl?bus(&red+ross&or< or write to: Re=eren+e L("or(tor) Ameri+(n Red 6ross1iomedi+(l Servi+es 6onne+ti+ut Re<ion #$ :(rmin<ton Ave& :(rmin<ton, 6T #H#%

@ /!A .!/>.$# I 2,one, "usiness ,ours @ /!A .!/> !%JI :(0 immunobus(&red+ross&or< Hualit$ Control of Cr$oprecipitated A7) @ /!A .!/>.$#%I 2,one, "usiness ,ours @ /!A .!/> !%JI :(0

6LIA li+ensed
IMMUNOHEMATOLOGY, Volume !, Num"er , ##$

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"lood *roup Antigens I Anti%odies

A guide to clinical relevance & technical tips
") Marion E- Reid I Christine Lomas )rancis T,is +om*(+t T*o+?et"oo?U =rom t,e (ut,ors o= t,e B.//0 G1/23 A4567e4 'a$5sB//8 is ( must =or (n)one w,o is involved in t,e l("or(tor) or "edside +(re o= *(tients wit, "lood <rou* (llo(nti"odies& T,e "oo? +ont(ins +lini+(l (nd te+,ni+(l in=orm(tion ("out t,e ne(rl) %## IS1T re+o<ni;ed "lood <rou* (nti<ens (nd t,eir +orres*ondin< (nti"odies& T,e in=orm(tion is listed in (l*,("eti+(l order =or e(se o= =indin<Ieven in t,e middle o= t,e ni<,t& In+luded in t,e "oo? is in=orm(tion rel(tin< to: ` 6lini+(l si<ni=i+(n+e o= (nti"odies in tr(ns=usion (nd H3N& ` Num"er o= +om*(ti"le donors t,(t would "e e0*e+ted to "e =ound in testin< /## donors& V(ri(tions in di==erent et,ni+ <rou*s (re <iven& ` 6,(r(+teristi+s o= t,e (nti"odies (nd o*tim(l te+,ni-ue@sA =or t,eir dete+tion& ` Te+,ni+(l ti*s to (id t,eir identi=i+(tion& ` 9,et,er t,e (nti"od) ,(s "een =ound (s (n (uto(nti"od)&

Ordering Information
T,e "oo?, w,i+, +osts c !, +(n "e ordered in two w()s: ` Order online =rom t,e *u"lis,er (t: www&s""*o+?et"oo?&+om ` Order =rom t,e (ut,ors, w,o will si<n t,e "oo?& Send ( +,e+?, m(de *()("le to TNew Yor? 1lood 6enterU (nd indi+(te T2o+?et "oo?U on t,e memo line, to: M(rion Reid L("or(tor) o= Immuno+,emistr) New Yor? 1lood 6enter %/# E(st HGt, Street New Yor?, NY /##H! 2le(se in+lude t,e re+i*ientMs +om*lete m(ilin< (ddress&

#oc+et%oo+ Education )und

T,e (ut,ors (re usin< ro)(lties <ener(ted =rom t,e s(le o= t,is *o+?et"oo? =or edu+(tion(l *ur*oses to mentor *eo*le in t,e ao)s o= immuno,em(tolo<) (s ( +(reer& T,e) will (++om*lis, t,is in t,e =ollowin< w()s: ` S*onsor wor?s,o*s, semin(rs, (nd le+tures ` S*onsor students to (ttend ( meetin< ` 2rovide +o*ies o= t,e *o+?et"oo? @See www&s""*o+?et"oo?&+om =or det(ils to (**l) =or =undsA

JH

IMMUNOHEMATOLOGY, Volume !, Num"er , ##$

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1e+omin< ( S*e+i(list in 1lood 1(n?in< @S11A

4hat is a certified Specialist in "lood "an+ing ;S""<J ` Someone wit, edu+(tion(l (nd wor? e0*erien+e -u(li=i+(tions w,o su++ess=ull) *(sses t,e Ameri+(n So+iet) =or 6lini+(l 2(t,olo<) @AS62A "o(rd o= re<istr) @1ORA e0(min(tion =or t,e S*e+i(list in 1lood 1(n?in<& ` T,is *erson will ,(ve (dv(n+ed ?nowled<e, s?ills, (nd ("ilities in t,e =ield o= tr(ns=usion medi+ine (nd "lood "(n?in<& Individuals who have an S"" certification serve in man$ areas of transfusion medicine: ` Serve (s re<ul(tor), te+,ni+(l, *ro+edur(l (nd rese(r+, (dvisors ` 2er=orm (nd dire+t (dministr(tive =un+tions ` 3evelo*, v(lid(te, im*lement, (nd *er=orm l("or(tor) *ro+edures ` An(l);e -u(lit) issues *re*(rin< (nd im*lementin< +orre+tive (+tions to *revent (nd do+ument issues ` 3esi<n (nd *resent edu+(tion(l *ro<r(ms ` 2rovide te+,ni+(l (nd s+ienti=i+ tr(inin< in "lood tr(ns=usion medi+ine ` 6ondu+t rese(r+, in tr(ns=usion medi+ine 4ho are S""sJ Su*ervisors o= Tr(ns=usion Servi+es Su*ervisors o= Re=eren+e L("or(tories du(lit) Assur(n+e O==i+ers 4h$ %e an S""J 2ro=ession(l <rowt, M(n(<ers o= 1lood 6enters Rese(r+, S+ientists Te+,ni+(l Re*resent(tives LIS 6oordin(tors 6onsumer S(=et) O==i+ers Re=eren+e L(" S*e+i(list Edu+(tors

7o" *l(+ement

7o" s(tis=(+tion

6(reer (dv(n+ement

7ow does one %ecome an S""J ` Attend ( 6AAHE2>(++redited S*e+i(list in 1lood 1(n? Te+,nolo<) 2ro<r(m OR ` Sit =or t,e e0(min(tion "(sed on +riteri( est("lis,ed ") AS62 =or edu+(tion (nd e0*erien+e However: In re+ent )e(rs, ( <re(ter *er+ent(<e o= individu(ls w,o <r(du(te =rom 6AAHE2>(++redited *ro<r(ms *(ss t,e S11 e0(m& Conclusion: T,e 1EST route =or o"t(inin< (n S11 +erti=i+(tion is e to (ttend ( 6AAHE2>(++redited S*e+i(list in 1lood 1(n? Te+,nolo<) 2ro<r(m

6ont(+t t,e =ollowin< *ro<r(ms =or more in=orm(tion:

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9(lter Reed Arm) Medi+(l 6enter Ameri+(n Red 6ross, Sout,ern 6(li=orni( Re<ion AR6>6entr(l OH Re<ion 1lood 6enter o= Sout,e(stern 9is+onsin 6ommunit) 1lood 6enter86TS 3()ton, O,io Gul= 6o(st S+,ool o= 1lood 1(n? Te+,nolo<) Ho0wort, 1lood 6enter, Univ& o= 6in+inn(ti Indi(n( 1lood 6enter 7o,ns Ho*?ins Hos*it(l

9illi(m Tur+(n Mi+,(el 6oover 7o(nne 5os(n?e L)nne LeMense N(n+) L(n< 6l(re 9on< Sus(n 9il?inson 7()(nn( Sl()ten 7(n Li<,t

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IMMUNOHEMATOLOGY, Volume !, Num"er , ##$

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Journal of Blood Group Serology and Education

Immunohematology
Instructions to0ut$or# the .n#truction# for

I& GENERAL INSTRU6TIONS 1e=ore su"mittin< ( m(nus+ri*t, +onsult +urrent issues o= Immuno,em(tolo<) =or st)le& 3ou"le>s*(+e t,rou<,out t,e m(nus+ri*t& Num"er t,e *(<es +onse+utivel) in t,e u**er ri<,t>,(nd +orner, "e<innin< wit, t,e title *(<e& II& S6IENTI:I6 ARTI6LE, REVIE9, OR 6ASE RE2ORT 9ITH LITERATURE REVIE9 A& E(+, +om*onent o= t,e m(nus+ri*t must st(rt on ( new *(<e in t,e =ollowin< order: /& Title *(<e & A"str(+t %& Te0t .& A+?nowled<ments !& Re=eren+es H& Aut,or in=orm(tion G& T("les J& :i<ures 1& 2re*(r(tion o= m(nus+ri*t /& Title *(<e (& :ull title o= m(nus+ri*t wit, onl) =irst letter o= =irst word +(*it(li;ed @"old titleA "& Initi(ls (nd l(st n(me o= e(+, (ut,or @no de<reesE (ll 6A2SA, e&<&, M&T& 7ONES, 7&H& 1RO9N, AN3 S&R& SMITH +& Runnin< title o= f.# +,(r(+ters, in+ludin< s*(+es d& T,ree to ten ?e) words & A"str(+t (& One *(r(<r(*,, no lon<er t,(n %## words "& 2ur*ose, met,ods, =indin<s, (nd +on+lusion o= stud) %& 5e) words (& List under ("str(+t .& Te0t @seri(l *(<esA: Most m(nus+ri*ts +(n usu(ll), "ut not ne+ess(ril), "e divided into se+tions @(s des+ri"ed "elowA& Sur ve) results (nd review *(*ers m() need individu(li;ed se+tions (& Introdu+tion 2ur*ose (nd r(tion(le =or stud), in+ludin< *ertinent "(+?<round re=eren+es "& 6(se Re*ort @i= indi+(ted ") stud)A 6lini+(l (nd8or ,em(tolo<i+ d(t( (nd "(+?<round serolo<)8mole+ul(r +& M(teri(ls (nd Met,ods Sele+tion (nd num"er o= su"ae+ts, s(m*les, items, et+& studied (nd des+ri*tion o= (**ro*ri(te +ontrols, *ro+edures, met,ods, e-ui*ment, re(<ents, et+& E-ui*ment (nd re(<ents s,ould "e identi=ied in *(rent,eses ") model or lot (nd m(nu=(+turerMs n(me, +it), (nd st(te& 3o not use *(tientMs n(mes or ,os*it(l num"ers& d& Results 2resent(tion o= +on+ise (nd se-uenti(l results, re=errin< to *ertinent t("les (nd8or =i<ures, i= (**li+("le e& 3is+ussion Im*li+(tion (nd limit(tions o= t,e stud), lin?s to ot,er studiesE i= (**ro*ri(te, lin? +on+lusions to *ur*ose o= stud) (s st(ted in introdu+tion !& A+?nowled<ments: A+?nowled<e t,ose w,o ,(ve m(de su"st(nti(l +ontri"utions to t,e stud), in+ludin< se+ret(ri(l (ssist(n+eE list (n) <r(nts& H& Re=eren+es (& In te0t, use su*ers+ri*t, Ar("i+ num"ers& "& Num"er re=eren+es +onse+utivel) in t,e order t,e) o++ur in t,e te0t& G& T("les (& He(d e(+, wit, ( "rie= titleE +(*it(li;e t,e =irst letter o= =irst word @e&<&, T("le /& Results o= & & &A use no *un+tu(tion (t t,e end o= t,e title&
JJ

"& Use s,ort ,e(din<s =or e(+, +olumn needed (nd +(*it(li;e =irst letter o= =irst word& Omit verti+(l lines& +& 2l(+e e0*l(n(tion in =ootnotes @se-uen+e: B, P, O, g, h, BB, PPA& J& :i<ures (& :i<ures +(n "e su"mitted eit,er ") e>m(il or (s *,oto<r(*,s @!i j Gi <loss)A& "& 2l(+e +(*tion =or ( =i<ure on ( se*(r(te *(<e @e&<& :i<& / Results o=& & & A, endin< wit, ( *eriod& I= =i<ure is su"mitted (s ( <loss), *l(+e =irst (ut,orMs n(me (nd =i<ure num"er on "(+? o= e(+, <loss) su"mitted& +& 9,en *lottin< *oints on ( =i<ure, use t,e =ollowin< s)m"ols i= *ossi"le: & $& Aut,or in=orm(tion (& List =irst n(me, middle initi(l, l(st n(me, ,i<,est de<ree, *osition ,eld, institution (nd de*(rtment, (nd +om*lete (ddress @in+ludin< kI2 +odeA =or (ll (ut,ors& List +ountr) w,en (**li+("le& III& E3U6ATIONAL :ORUM A& All su"mitted m(nus+ri*ts s,ould "e (**ro0im(tel) ### to !## words wit, *ertinent re=eren+es& Su"missions m() in+lude: /& An immuno,em(tolo<i+ +(se t,(t illustr(tes ( sound investi<(tive (**ro(+, wit, +lini+(l +orrel(tion, re=le+tin< (**ro*ri(te +oll("or(tion to s,(r*en *ro"lem solvin< s?ills & Annot(ted +on=eren+e *ro+eedin<s 1& 2re*(r(tion o= m(nus+ri*t /& Title *(<e (& 6(*it(li;e =irst word o= title& "& Initi(ls (nd l(st n(me o= e(+, (ut,or @no de<reesE (ll 6A2sA & Te0t (& 6(se s,ould "e written (s *ro<ressive dis+losure (nd m() in+lude t,e =ollowin< ,e(din<s, (s (**ro*ri(te i& 6lini+(l 6(se 2resent(tion: 6lini+(l in=orm(tion (nd di==erenti(l di(<nosis ii& Immuno,em(tolo<i+ Ev(lu(tion (nd Results: Serolo<) (nd mole+ul(r testin< iii& Inter*ret(tion: In+lude inter*ret(tion o= l("or(tor) results, +orrel(tin< wit, +lini+(l =indin<s iv& Re+ommended T,er(*): In+lude "ot, tr(ns=usion (nd nontr(ns=usion>"(sed t,er(*ies v& 3is+ussion: 1rie= review o= liter(ture wit, uni-ue =e(tures o= t,is +(se vi& Re=eren+e: Limited to t,ose dire+tl) *ertinent vii& Aut,or in=orm(tion @see II&1&$&A viii& T("les @see II&1&G&A IV& LETTER TO THE E3ITOR A& 2re*(r(tion /& He(din< @To t,e EditorA & Title @=irst word +(*it(li;edA %& Te0t @written in letter R*(r(<r(*,S =orm(tA .& Aut,or@sA @t)*e =lus, ri<,tE =or =irst (ut,or: n(me, de<ree, institution, (ddress Rin+ludin< +it), st(te, ki* +ode (nd +ountr)SE =or ot,er (ut,ors: n(me, de<ree, institution, +it) (nd st(teA !& Re=eren+es @limited to tenA H& T("le or =i<ure @limited to oneA

Send (ll m(nus+ri*ts ") e>m(il to immunobus(&red+ross&or<

IMMUNOHEMATOLOGY, Volume !, Num"er , ##$

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