The RHD variants in Chinese population

The Rhesus (Rh) blood group system is the most important blood group system in hemolytic disease of the fetus and newborn (HDFN). In clinical transfusions, the D antigen in the Rh blood group system comes third, behind antigens A and B which from ABO blood group system. Over the past decade, molecular technologies have been used to investigate the RHD allele in different ethnic groups. This review first introduces the basic structure of RhD protein and coding genes, then focuses on D-negative, weak D, partial D, DEL, RhD_null variants reported in the Chinese population. To date, more than 460 RHD variants have been reported around the world, but less than 70 RHD variants have been reported in the Chinese population. Further research is needed to identify more RHD polymorphism and establish criteria for blood detection and transfusion guidelines for RHD variants. Only in this way can we better guarantee the safety of blood transfusion and prevent the occurrence of HDFN. With the accumulation of research and clinical data, we should be clearer which RHD variants are to be regarded as RhD negative and which need to be regarded as RhD positive.     

The structure and function of the Rh antigen complex

The Rh locus, one of the important blood group systems in transfusion medicine, is controlled by three highly homologous genes: RHAG, RHD and RHCE. RHD and RHCE genes both contain 10 exons with opposite orientation, with genetic homology of higher than 92%. Based on this arrangement and configuration, a hybridization variant easily occurs, which causes variant or weak antigen expression. A 46-year-old woman of group A was admitted to hospital with bloody stool. Her RhD phenotype was confusing (agglutination < 1+) as detected by gel card. The unexpected antibody was identified to be anti-D. Only exon 2 of RHD was detected by sequence-speci?c primer polymerase chain reaction (SSP-PCR) with hybrid heterozygosis of c.150T > C, c.178A > C, c.201G > A, and c.307T > C by sequencing. The genotype of RHCE was confirmed to be Ccee by SSP-PCR and the serologic phenotype was Ccee too. However, the sequencing of RhCE was confirmed to be ccee with c.178CC, c.203AA, c.307CC on exon 2. Further analysis found that the difference between them depended on the replacement of exon 2 from RhD. The genotype of this patient was found to be RhCE-D(2)-CE/RhCE, leading to a confusing RhD phenotype.     

Molecular biology of Rh proteins and relevance to molecular medicine

The Rhesus (Rh) blood group system is expressed by a pair of 12-transmembrane-domain-containing proteins, the RhCcEe and RhD proteins. RhCcEe and RhD associate as a Rh core complex that comprises one RhD/CcEe protein and most likely two Rh-associated glycoproteins (RhAG) as a trimer. All these Rh proteins are homologous and share this homology with two human non-erythroid proteins, RhBG and RhCG. All Rh protein superfamily members share homology and function in a similar manner to the Mep/Amt ammonium transporters, which are highly conserved in bacteria, plants and invertebrates. Significant advances have been made in our understanding of the structure and function of Rh proteins, as well as in the clinical management of Rh haemolytic disease. This review summarises our current knowledge concerning the molecular biology of Rh proteins and their role in transfusion and pregnancy incompatibility.     

Serological and molecular analysis of ABO and Rh blood group chimeras

The serological examination, blood transfusion strategies and the molecular analysis to blood group chimera were conducted to demonstrate existent of chimera in blood group. The blood grouping of ABO or/and RhD, newborn red blood cells separated by capillary centrifugation. Aabsorption tests and DTT treated agglutination erythrocyte tests were implemented in four patients. Further molecular biological research was conducted on one patient''s sample. The results showed that for patient 1: ABO blood group was AB/B chimera, Rh blood cells contained the RhCE chimera gene; Patient 2: Rh blood cells contained the RhD chimera gene; Patient 3: ABO blood group was AB/B chimera, Rh blood cells contained the RhD chimera gene; Patient 4: ABO blood group was O/B chimera, Rh blood cells contained the RhCE chimera gene. The study suggests that the individuals categorized as chimeras are likely to be more common than existing literature reports. According to the serological tests, in the absence of a history of recent blood transfusion or disease to cause reduced antigen, the phenomena of hybrid aggregation of the ABO and Rh blood system were the main feature. In terms of transfusion strategy, the selection of ABO and Rh blood groups should be depended on the group of cells with more antigens.     

Immunopurification of the blood group RhD protein from human erythrocyte membranes

Rh proteins are membrane proteins encoded by genes at the blood group RH locus. They are of paramount importance in transfusion medicine, but their function is still unknown. Biochemical and biophysical studies of these proteins are scarce since only minute amounts of the very hydrophobic Rh proteins, can be purified from human erythrocytes. Recently, a human monoclonal antibody (LOR-15C9) was described as having the unique property to recognize the Rh30 protein carrying the major blood group D specificity (RhD protein), either in a membrane detergent extract or when blotted on a membrane. In this report, we describe one-step purification of the RhD protein from detergent extracts of red cell membranes, based on immunoaffinity chromatography carried out with immobilized LOR-15C9 IgG. The technique yielded RhD protein with high purity which was devoid of other associated proteins (RhAG, CD47, LW and GPB) that comprise the Rh complex in the erythrocyte membrane. By contrast immunoprecipitation performed with the same antibody led to co-isolation of both RhD and RhAG.     

RhD正定型及不规则抗体筛查的临床意义分析

目的:探究RhD正定型及不规则抗体筛查在预防临床输血不良反应中的应用价值及临床意义。方法:回顾性分析2010年至2011年、2017年至2018年于首都医科大学附属北京同仁医院输血科实施输血治疗的1892例患者,将2010年至2011年未实施Rh D正定型及不规则抗体筛查时输血治疗的901例患者设为对照组,将2017年至2018年实施RhD正定型及不规则抗体筛查后输血治疗的991例患者设为观察组。对比两组输血不良反应发生率,分析不同血液成分、不同性别、不同年龄输血不良反应发生率,并就2017年、2018年受血者RhD正定型及不规则抗体特异性分布进行罗列。结果:(1)2010年输血不良反应发生率为3.49%,2011年为2.40%,2017年为1.33%,2018年为0.74%,对照组不良反应发生率明显高于观察组(P<0.05)。(2)观察组不同血液成分输血的不良反应发生率显著低于对照组(P<0.05)。(3)两组不同年龄和性别输血不良反应发生率对比差异无统计学意义(P>0.05)。(4)观察组共检出20例RhD正定型及不规则抗体阳性患者,其中抗-M型5例,抗-D型3例,抗-E型2例,抗-C型2例,抗-P型2例,抗-LEa型1例,抗-LEb型1例,抗-JKa型1例,抗-N型1例,抗-H型1例,非特异性抗体1例。结论:RhD正定型及不规则抗体筛查能够显著降低输血不良反应发生率,有助于提高配血的准确性,提高输血治疗的安全性。     

Toxoplasma and reaction time: role of toxoplasmosis in the origin, preservation and geographical distribution of Rh blood group polymorphism

The RhD protein which is the RHD gene product and a major component of the Rh blood group system carries the strongest blood group immunogen, the D-antigen. This antigen is absent in a significant minority of the human population (RhD-negatives) due to RHD deletion or alternation. The origin and persistence of this RhD polymorphism is an old evolutionary enigma. Before the advent of modern medicine, the carriers of the rarer allele (e.g. RhD-negative women in the population of RhD-positives or RhD-positive men in the population of RhD-negatives) were at a disadvantage as some of their children (RhD-positive children born to pre-immunized RhD-negative mothers) were at a higher risk of foetal or newborn death or health impairment from haemolytic disease. Therefore, the RhD-polymorphism should be unstable, unless the disadvantage of carriers of the locally less abundant allele is counterbalanced by, for example, higher viability of the heterozygotes. Here we demonstrated for the first time that among Toxoplasma-free subjects the RhD-negative men had faster reaction times than Rh-positive subjects and showed that heterozygous men with both the RhD plus and RhD minus alleles were protected against prolongation of reaction times caused by infection with the common protozoan parasite Toxoplasma gondii. Our results suggest that the balancing selection favouring heterozygotes could explain the origin and stability of the RhD polymorphism. Moreover, an unequal prevalence of toxoplasmosis in different countries could explain pronounced differences in frequencies of RhD-negative phenotype in geographically distinct populations.     

Which RhD alleles are risk factors stimulating allo- anti-D?

The aim of this study was to identify the specific RhD alleles that are risk factors for stimulating allo-anti-D and develop a precise strategy for blood transfusion. To confirm the D phenotype, red blood cells suspended in saline should react to serological anti-D from three manufacturers. An antibody screen test, a saline phase test and a micro-column test were conducted to identify allo-anti-D and other allo-antibodies. RhD alleles were genotyped by PCR using sequence-specific primers. Seven hundred subjects who were either pregnant or had undergone transfusion were enrolled in our study; however, 28 samples were excluded because their RhD alleles were normal, as revealed by tests using genotyping kits. A total of 498 cases (74.1%) were RhD-null (lacking exons 1–10 of RhD), 336 were DEL RhD 1227A (20.2%), and 38 were RHD-CE (2-9) -D (5.6%). There were 136 cases (20.2%) with allo-anti-D among the 672 cases, with an allo-anti-D prevalence of 126 cases (25.3%) in 498 cases that were RhD-null, followed by 10 cases (26.3%) among 38 cases with RHD-CE (2-9) -D, and none in 366 cases with RhD1227A. RhD genetic polymorphism was observed in RhD-negative individuals. We concluded that RhD-null and partial D are risk factors for alloimmunization to the D antigen and should be transfused with Rh-negative blood. RHD1227A recipients can be transfused with RhD-positive blood. Pregnant women with the d/d and D-CE(2-9)-D alleles require appropriate anti-D prophylaxis and RhD1227A may induce a higher tolerance.     

Molecular cloning and primary structure of a Rhesus (Rh)-like protein from the marine sponge Geodia cydonium

 In humans, the 30 000 M _r Rhesus (Rh) polypeptide D (RhD) is a dominant antigen (Ag) of the Rh blood group system. To date, an Rh-like protein has been found in chimpanzees, gorillas, gibbons, and rhesus monkeys. Related to the 30 000 M _r Rh Ag protein are two polypeptides of 50 000 M _r , the human 50 000 M _r Rh Ag and the RhD-like protein from Caenorhabditis elegans. The function of all these proteins is not sufficiently known. Here we characterize a cDNA clone (GCRH) encoding a putative 57 000 M _r polypeptide from the marine sponge Geodia cydonium, which shares sequence similarity both to the RhD Ag and the Rh50 glycoprotein. The sponge Rh-like protein comprises 523 aa residues; hydropathy analysis hints at the presence of ten transmembrane domains. An N-terminal hydrophobic cleavage signal sequence is missing, suggesting that the first membrane-spanning domain of the sponge Rh-like protein acts as a signal-anchor sequence. The sponge Rh-like protein, like the human Rh50, lacks the CLP motif which is characteristic of the 30 000 M _r RhD. In addition, the hydropathy profile of the sponge Rh-like protein is of a similar size and shape as that of human Rh50. This data indicates that the RhD and its structurally related Rh50 glycoprotein, which are highly immunogenic in humans, share a common ancestral molecule with the G. cydonium Rh-like protein. Received: 9 April 1997 / Revised: 29 May 1997     

Molecular definition of red cell Rh haplotypes by tightly linked SphI RFLPs.

The Rh blood group system of human red cells contains five major antigens D, C/c, and E/e (the latter four designated "non-D") that are specified by eight gene complexes known as Rh haplotypes. In this paper, we report on the mapping of RH locus and identification of a set of SphI RFLPs that are tightly linked with the Rh structural genes. Using exon-specific probes, we have localized the SphI cleavage sites resulting in these DNA markers and derived a comprehensive map for the RH locus. It was found that the SphI fragments encompassing exons 4-7 of the Rh genes occur in four banding patterns or frameworks that correspond to the distribution and segregation of the common Rh haplotypes. This linkage disequilibrium allowed a genotype-phenotype correlation and direct determination of Rh zygosity related to the Rh-positive or Rh-negative status (D/D, D/d, and d/d). Studies on the occurrence of SphI RFLPs in a number of rare Rh variants indicated that Rh phenotypic diversity has taken place on different haplotype backgrounds and has arisen by diverse genetic mechanisms. The molecular definition of Rh haplotypes by SphI RFLP frameworks should provide a useful procedure for genetic counseling and prenatal assessment of Rh alloimmunization.     

Evolutionary genetics of the human Rh blood group system

The evolutionary history of variation in the human Rh blood group system, determined by variants in the RHD and RHCE genes, has long been an unresolved puzzle in human genetics. Prior to medical treatments and interventions developed in the last century, the D-positive (RhD positive) children of D-negative (RhD negative) women were at risk for hemolytic disease of the newborn, if the mother produced anti-D antibodies following sensitization to the blood of a previous D-positive child. Given the deleterious fitness consequences of this disease, the appreciable frequencies in European populations of the responsible RHD gene deletion variant (for example, 0.43 in our study) seem surprising. In this study, we used new molecular and genomic data generated from four HapMap population samples to test the idea that positive selection for an as-of-yet unknown fitness benefit of the RHD deletion may have offset the otherwise negative fitness effects of hemolytic disease of the newborn. We found no evidence that positive natural selection affected the frequency of the RHD deletion. Thus, the initial rise to intermediate frequency of the RHD deletion in European populations may simply be explained by genetic drift/founder effect, or by an older or more complex sweep that we are insufficiently powered to detect. However, our simulations recapitulate previous findings that selection on the RHD deletion is frequency dependent and weak or absent near 0.5. Therefore, once such a frequency was achieved, it could have been maintained by a relatively small amount of genetic drift. We unexpectedly observed evidence for positive selection on the C allele of RHCE in non-African populations (on chromosomes with intact copies of the RHD gene) in the form of an unusually high F( ST ) value and the high frequency of a single haplotype carrying the C allele. RhCE function is not well understood, but the C/c antigenic variant is clinically relevant and can result in hemolytic disease of the newborn, albeit much less commonly and severely than that related to the D-negative blood type. Therefore, the potential fitness benefits of the RHCE C allele are currently unknown but merit further exploration.     

The Prevalence of unexpected antibodies in Saudi's plasma prior blood transfusion and their association with clinical conditions: A cross-sectional study

Unexpected antibodies, also called irregular antibodies, are not known to exist in a person's serum before testing. This research aims to assess the prevalence of unexpected antibodies and their correlation with several clinical conditions. This cross-sectional prospective study, undertaken from June 2019 to June 2020, included ABO, Rh grouping, cross-matching, and antibody screening. Antibody identification was performed only on patients who tested positive in the screening test. From a total of 9764 participants who were screened for unexpected antibodies, 107 (1.1%) tested positive. The Rh blood group system antibodies were the most frequent, particularly anti-D. There was also a significant correlation between the unexpected antibodies and history of transfusion, pregnancy, and autoimmune diseases as P ≤ 0.05. The most prominent unexpected antibodies in the study belong to the Rh system (Anti-D). Moreover, as a result of the strong correlation between the unexpected antibodies as well as the history of transfusion, pregnancy, and autoimmune diseases, the highest safety criteria must be followed during the transfusion of blood to patients with these clinical conditions.     

Development and application of electronic crossmatch in Dongguan city

Electronic crossmatching is a computer-assisted technology used to confirm if red blood cell (RBC) blood products are suitable for the intended recipient. In addition to mainland China, electronic crossmatching has been used in many countries. Here we have developed an electronic crossmatching system for clinical application. The primary and advanced system of electronic crossmatching was developed, the primary system includes ABO and RhD blood group antigens, and the advanced system includes 18 common RBC group antigens. We completed in-situ and online testing; the system was installed in six general hospitals in Dongguan for clinical application. A total of 31,941 crossmatches were performed by both electronic and serological crossmatching from July 1st, 2015 to April 30th, 2016. The electronic crossmatch shows to be more powerful than serological crossmatching, if RBC blood products and recipients were compatible when electronic and serological crossmatch completed, all blood were issued to clinic. In this condition, no case of hemolytic transfusion adverse reaction occurred. In conclusion, the electronic crossmatch system can be used in transfusion medicine and is capable of reducing laboratory workload and costs, as well as improving transfusion safety.     

Biochemistry of the erythrocyte Rh polypeptides: a review

The clinically important Rh blood group system is complex, consisting of multiple distinct antigens. Despite clinical recognition for over 50 years, the Rh blood group antigens have remained poorly understood on a molecular level until the recent identification and characterization of the "Rh polypeptides," the core structural proteins of the Rh antigens. This group of erythrocyte membrane proteins of molecular weight 30,000-35,000 daltons was first recognized by employing Rh-specific antibodies to immunoprecipitate radiolabeled components of erythrocyte membranes. By using antibodies specific for the Rh D, c, and E antigens, a series of highly related non-identical proteins were immunoprecipitated, indicating that the Rh antigens are composed of multiple related proteins. The Rh polypeptides have been purified and characterized, and they were found to have several unusual biochemical characteristics. The Rh polypeptides penetrate the membrane bilayer; they are linked to the underlying membrane skeleton; they are covalently fatty acid acylated with palmitate. While the Rh antigenic reactivity is unique to human erythrocytes, the Rh polypeptides have been isolated from erythrocytes of diverse species and are thought to be fundamental components of all mammalian erythrocyte membranes. The functional role of the Rh polypeptides remains undefined, but a role in the organization of membrane phospholipid is suspected.     

Blood transfusion and lung surgeries in pediatric age group: a single center retrospective study

Incompatibility of blood groups or unexpected antibodies are primary considerations when acute hemolysis occurs during or after transfusion. However, less attention is paid to drug-induced immune hemolytic anemia (DIIHA), which is a rare but potentially life-threatening autoimmune disease. We present the case of a 34-year-old woman (group A, RhD+) who was treated with multiple antibiotics after meningioma resection. As her hemoglobin (Hb) decreased significantly from 109 g/L to 52 g/L without obvious bleeding, a blood transfusion was conducted soon after the medication, during which acute hemolysis occurred. An unexpected antibody, anti-M (MNS blood group system), was identified in the patient. It was confirmed that both the recipient and donor were group A, M antigen negative (M−) with CCDee phenotype, and no agglutination reactivity was observed in major crossmatch by testing the specimens before and after transfusion. Meanwhile, the results of the direct antiglobulin test (DAT) changed from negative to positive. Anti-meropenem, a drug-dependent antibody of meropenem, was detected, and hemolysis resolved after cessation. Anti-meropenem may mainly act through an \     

Serological studies on the blood of the primates: iii.distribution of serological factors related to human isoagglutinogens in the blood of lower monkeys

During the differentiation and maturation of erythrocytes, the surface molecules of erythrocytes are gradually expressed and stabilized. These molecules are to be antigenic in addition to their functions of maintain-ing cell membrane structural stability, material transport and exchange of cells and signal transmission between cells. The antigenic molecules on the erythrocyte surface are called erythrocyte blood group antigens. The blood group antigens and their corresponding blood group antibodies in vivo are important indicators for clinical blood transfusion and organ transplantation, and also form the basis for research on blood group related diseases. Three hundred and sixty-eight erythrocyte blood group antigens have been confirmed so far, which are classified into 39 blood group systems, 5 blood group collections and 2 blood group series. Based on the diversity of blood group antigens and their composition of glycolipids, glycoproteins and other molecules, this study mainly reviews the classification, molecular structure, antibody response and gene regulation of blood group antigens, and explains the main reasons for the diversity of blood group antigens.     

Case report. An immediate hemolytic transfusion reaction apparently caused by anti-Dia.

The Diego blood group system has had its primary applications in population genetics and anthropology, although it can also give rise to clinical problems. Anti-Dia has ofter been reported to cause hemolytic disease of the newborn. The patient presented in the report experienced an immediate hemolytic transfusion reaction apparently due to anti-Dia. We believe it to be the only such case reported since the Diego system was first discovered in 1956.     

Distribution of ABO blood groups and other genetic markers in mothers of infants with congenital malformations

The distribution of ABO and Rh (antigen D) blood groups and of serum albumin, haptoglobin and transferrin variants, in a group of mothers of malformed newborns was investigated. In the first phase of the study, the results showed borderline statistical differences in the distribution of the transferrin types between the study group and a suitable control population. The second phase of the research, where only transferrin phenotypes were studied, showed the same trend as in the first one, but the results were not statistically significant. We conclude that probably there are no true distribution differences, but that it would be desirable to study this problem in a different ethnic group.     

Mice Expressing RHAG and RHD Human Blood Group Genes

Anti-RhD prophylaxis of haemolytic disease of the fetus and newborn (HDFN) is highly effective, but as the suppressive mechanism remains uncertain, a mouse model would be of interest. Here we have generated transgenic mice expressing human RhAG and RhD erythrocyte membrane proteins in the presence and, for human RhAG, in the absence, of mouse Rhag. Human RhAG associates with mouse Rh but not mouse Rhag on red blood cells. In Rhag knockout mice transgenic for human RHAG, the mouse Rh protein is “rescued” (re-expressed), and co-immunoprecipitates with human RhAG, indicating the presence of hetero-complexes which associate mouse and human proteins. RhD antigen was expressed from a human RHD gene on a BAC or from RHD cDNA under control of β-globin regulatory elements. RhD was never observed alone, strongly indicative that its expression absolutely depends on the presence of transgenic human RhAG. This first expression of RhD in mice is an important step in the creation of a mouse model of RhD allo-immunisation and HDFN, in conjunction with the Rh-Rhag knockout mice we have developed previously.     

Characterization of the Mouse Rh Blood Group Gene

The Rh blood group system is of clinical importance in blood transfusion and as the cause of hemolytic disease of the newborn. Other than their role as carriers of Rh antigens, very little is known about the function of the Rh polypeptides. As a first step to generate an animal model system in which to study the structure and function of Rh, and to extend the phylogenetic analysis of RH genes, the Rh homologue from Mus musculus was characterized. Comparison of RH from humans and mice revealed 71 and 58% sequence identity at the nucleotide and amino acid levels, respectively. Mouse Rh mRNA encodes a protein which is 1 amino acid longer (418 aa) than that of human (417 aa). Rh protein was detected in mouse erythrocyte membranes and was comparable in size to human Rh. Mouse erythrocytes do not show serologic reactivity with human Rh antibodies, probably because the greatest divergence between the mouse and the human genes was seen in the predicted extracellular loops, while the transmembrane regions were more conserved. The mouse RH locus consists of only one gene, which is important for future genetic manipulation and which also indicates that the RH gene duplication seen in humans has occurred since the mammalian radiation.