10
Blood Group Genetics
L
ANDSTEINER’S DISCOVERY OF the
ABO blood group system demon-
strated that human blood was poly-
morhic. Red cells provided an easy and
accessible means to test for human polymor-
phisms in individuals of any age, and, as more
blood group antigens were described, red cell
typing provided a wealth of information about
human genetics.
Basic Principles
Inheritance of transmissible characteristics or
“traits,” including blood group antigens, forms
the basis of the science of genetics. The ge-
netic material that determines each trait is
found in the nucleus of a cell. This nuclear ma-
terial is called chromatin and is made up of
DNA (see Chapter 9). When a cell divides the
chromatin loses its homogenous appearance
Copyright © 2002 by the AABB. All rights reserved.
and forms a number of rod-shaped organelles
called chromosomes. Encoded in the chromo-
somal DNA are units of genetic information 10
called genes. The genes are arranged in a spe-
cific order along a chromosome with the pre-
cise location known as the locus.
Chromosomes
The number of chromosomes and chromo-
some morphology are specific for each spe-
cies. Human somatic cells have 46 chromo-
somes that exist as 23 pairs (one-half of each
pair inherited from each parent). Twenty-two
of the pairs are alike in both males and fe-
males and are called autosomes; the remain-
ing pair are the sex chromosomes, XX in
females and XY in males.
Each chromosome consists of two arms
(chromatids) joined at a primary constriction,
the centromere. The two arms are usually of
different lengths: the short, or petite, arm is
207
208 AABB Technical Manual
termed “p,” and the long arm is termed “q.”
The arms of individual chromosomes are indi-
cated by the chromosome number followed
by a p or q (ie, Xp is the short arm of the X
chromosome: 12q is the long arm of chromo-
some 12). When banded and stained, each
chromosome displays a unique pattern of
bands, which are numbered from the centro-
mere outward (see Fig 10-1). Chromosomes
are identified by the location of the centro-
mere and their banding pattern. The location
of individual genes along the chromosome
Figure 10-1. Diagram of Giemsa-stained normal
human chromosome 7. With increased resolution
(left to right), finer degrees of banding are evi-
dent. Bands are numbered outward from the
centromere (c), which divides the chromosome
into p and q arms.1
Copyright © 2002 by the AABB. All rights reserved.
may be determined and physically “mapped”
to specific band locations.
Lyon Hypothesis
In the somatic cells of females, only one X
chromosome is active. Inactivation of one of
the X chromosomes is a random process that
occurs within days of fertilization. Once an X
chromosome has become inactivated, all of
that cell’s clonal descendants have the same
inactive X. Hence, inactivation is randomly de-
termined but once the decision is made the
choice is permanent. This process is termed
the Lyon hypothesis.
Mitosis and Meiosis
Cells must reproduce their chromosomes as
they divide so that each daughter cell receives
the full complement of genetic information.
Cell division is of two kinds: mitosis and meio-
sis. Mitosis is the process whereby the body
grows or replaces dead or injured somatic
cells. This process consists of five stages: pro-
phase, prometaphase, metaphase, anaphase,
and telophase. The end result is two complete
daughter cells, each with a nucleus containing
all the genetic information of the original par-
ent cell (Fig 10-2).
Meiosis occurs only in primordial cells des-
tined to mature into a reproductive cell or ga-
mete cells. Diploid cells that undergo meiosis
give rise to haploid gametes (sperm and egg
cells with only 23 chromosomes). Hence, so-
matic cells divide by mitosis, giving rise to dip-
loid cells that have a 2N chromosome comple-
ment. Gametes are formed following meiosis
and are haploid cells with a 1N chromosome
complement.
Genetics and Heredity
Alleles
Alternative forms of genes, any one of which
may occupy a single locus on homologous

Figure 10-2. The two types of cell division are mitosis and meiosis.
chromosomes, are called alleles. The major al-
leles of the ABO system are A, B, and O. In the
Kell system, two alleles, K and k, determine the
K and k antigens. Individuals who have identi-
cal alleles at a given locus on both chromo-
somes are homozygous for the allele (eg, AA or
KK or kk). In the heterozygous condition, the al-
leles present at the particular locus on each
chromosome are nonidentical (eg, AO or AB
or Kk).
Individuals who are homozygous for an al-
lele in some blood group systems have more
antigen expressed on their red cells than per-
sons who are heterozygous for that allele. For
example, red cells from a person whose geno-
type is JkaJka have a “double dose” of the Jka
a
gene and as a result may express more Jk anti-
gen on the red cell surface than an individual
whose genotype is Jka Jkb (heterozygous for Jka).
The difference in amount of antigen expressed
on the red cell membrane between a homozy-
gous and a heterozygous phenotype can often
be detected serologically and is termed the
Copyright © 2002 by the AABB. All rights reserved.
Chapter 10: Blood Group Genetics 209
dosage effect. For example, some anti-Jka sera
may give the following pattern of reactivity:
Genotype of RBC Donor
Antibody JkaJka JkaJkb
Anti-Jka 3+ 2+
Dosage effect is not seen with all blood
group antigens or even with all antibodies of a
given specificity. Antibodies that typically
show dosage include Rh antibodies and anti-
bodies in the MN, Kidd, and Duffy blood
group systems.
Alleles arise by mutation and may result in
phenotypic diversity. Mutations may occur at
the chromosome, gene, or genome (DNA)
level (see Chapter 9) and may also result in the
creation of new polymorphisms associated
with the altered gene. Figure 10-3 illustrates
how mutations in the genes that code for the
MNS blood group antigens have resulted in
the creation of various low-incidence MNS
system antigens.
210 AABB Technical Manual

Figure 10-3. How crossover, recombination, and nucleotide substitution (nt subs) result in variations of
genes producing glycophorin A and B. The changes are associated with the presence of various
low-incidence MNS system antigens. (Reprinted from Reid.2)

Allele (Gene) Frequencies Jk allele is extremely rare) that can be used to

The frequency of an allele (or its gene fre-
quency) is the proportion that it contributes to
the total pool of alleles at that locus within a
given population at a given time. This fre-
quency can be calculated from phenotype fre-
quencies observed within a population. The
sum of allele frequencies at a given locus must
equal 1.
The Hardy-Weinberg Law
The Hardy-Weinberg Law is based on the as-
sumption that genotypes are distributed in
proportion to the frequencies of individual al-
leles in a population, and will remain constant
from generation to generation if the processes
of mutation, migration, etc do not occur. For
example, the Kidd blood group system is basi-
cally a two-allele system (Jka and Jkb; the silent
illustrate the calculation of gene frequencies.
This calculation uses the Hardy-Weinberg equa-
tion for a two-allele system. If p is the frequency
a b
of the Jk allele and q is the frequency of the Jk
allele, then the frequencies of the three combi-
nations of alleles can be represented by the
equation p2 + 2pq + q2 = 1 where:
p = frequency of Jka allele
q = frequency of Jkb allele
p2 = frequency of Jka Jka genotype
2pq = frequency of Jka Jkb genotype
q2 = frequency of Jkb Jkb genotype
Using the observation that 77% of individ-
uals within a population express Jka antigen on
their red cells, then:
p2 + 2pq = frequency of
persons who are
Jk(a+) and carry

Copyright © 2002 by the AABB. All rights reserved.

 Chapter 10: Blood Group Genetics 211

the allele Jka more easily by direct counting. As shown in

= 0.77 Table 10-1, the random sample of 100 people
2 2 tested for Jka and Jkb antigens possess a total of
q = 1 – (p + 2pq) = frequency of per-
sons who are 200 alleles at the Jk locus (each person inher-
Jk(a–) (homozygous its two alleles, one from each parent). There
for Jkb ) are two Jka alleles inherited by each of the 28
q2 = 1 – 0.77 = 0.23 individuals who phenotype as Jk(a+b–) for a
a
q = 0.23 total of 56 alleles. There are 49 Jk alleles in
the individuals who are Jk(a+b+) for a total of
q = 0.48 (allele fre-
105 alleles or a gene frequency of 0.52 (105 ÷
quency of Jkb )
200). The frequency of Jk is 95 ÷ 200 =
b

0.48.
Because the sum of frequencies of both al-
The Hardy-Weinberg law is generally used
leles must equal 1.00,
to calculate allele and genotype frequencies in
p+q = 1
a population when the frequency of one ge-
p = 1–q
netic trait (eg, antigen phenotype) is known.
p = 1 – 0.48
However, it relies on certain assumptions: no
p = 0.52 (allele frequency of Jka )
mutation; no migration (in or out) of the popu-
lation; lack of selective advantage/disadvan-
Once the allele frequencies have been cal-
tage of a particular trait; and a large enough
culated, the number of Jk(b+) individuals
population so that chance alone cannot alter
(both homozygous and heterozygous) can be
an allele frequency. If all of these conditions
calculated as:
are present, the gene pool is in equilibrium
and allele frequencies will not change from
2pq + q2 = frequency of Jk(b+)
one generation to the next. If these assump-
= 2 (0.52 × 0.48) + (0.48)2
= 0.73 tions do not apply, changes in allele frequen-
cies may occur over a few generations and can
If both anti-Jka and anti-Jkb sera are avail- explain many of the differences in allele fre-
able, allele frequencies can be determined quencies between populations.

Table 10-1. Gene Frequencies in the Kidd Blood Group System Calculated
Using Direct Counting Method*
Gene Frequencies (%)
No. of No. of
Phenotype Individuals Kidd Genes Jka Jkb

Jk(a+b–) 28 56 56 0
Jk(a+b+) 49 98 49 49
Jk(a–b+) 23 46 0 46
Totals 100 200 105 95
Gene Frequency 0.525 0.475
*Assumes absence of silent Jk allele.

Copyright © 2002 by the AABB. All rights reserved.

212 AABB Technical Manual
Segregation
The term segregation refers to the concept
that the two members of a single gene pair (al-
leles) are never found in the same gamete, but
always segregate and pass to different ga-
metes. In blood group genetics, this can be il-
lustrated by the inheritance of the ABO
antigens (Fig 10-4). In this example, the mem-
bers of the parental generation (P1) are homo-
zygous for the A gene and the O gene. All
members of the first filial generation (F1) will
be heterozygous (AO) but will still express the
blood group A antigen (O is a silent allele). If
an F1 individual mates with an A/O individual,
the resulting progeny [termed the second filial
generation: (F2)] will type as blood group A (ei-
ther heterozygous or homozygous) or group
O. If the F1 individual mated with a heterozy-
Figure 10-4. Mendel’s law of independent segregation demonstrated by the inheritance of ABO genes.
Copyright © 2002 by the AABB. All rights reserved.
gous group B person (B/O) the offspring could
have the blood group A, B, AB, or O.
Independent Assortment
Mendel’s law of independent assortment
states that genes determining various traits are
inherited independently from each other. For
example, if one parent is group A (homozy-
gous for A) and K+k+, and the other parent is
group B (homozygous for B) and K–k+ (homo-
zygous for k), all the F1 children would be
group AB; half would be K+k+ and half K–k+
(Fig 10-5). A second filial generation could
manifest any of the following phenotypes:
group A, K+k+; group AB, K+k+; group B,
K+k+; group A, K–k+; group AB, K–k+;
group B, K–k+. The proportions would be
1:2:1:1:2:1.

Figure 10-5. Mendel’s law of independent assortment demonstrated by the inheritance of ABO and Kell
genes.
Independent assortment applies if the
genes are on different chromosomes or on dis-
tant portions of the same chromosome. One
exception to this rule is that closely linked
genes on the same chromosome do not sort in-
dependently but often remain together from
one generation to another. This observation is
termed linkage.
Linkage
Genetic linkage is defined as the tendency for
alleles close together on the same chromo-
some to be transmitted together. During mito-
sis each pair of homologous chromosomes
undergoes a series of recombinations. The re-
sultant reciprocal exchange of segments be-
tween the chromatids is termed crossing-over
(Fig 10-6). Genes close together on a chromo-
Copyright © 2002 by the AABB. All rights reserved.
Chapter 10: Blood Group Genetics 213
some tend to be transmitted together during
these recombinations and their alleles there-
fore do not segregate independently. Some-
times the linkage is very tight so that
recombination rarely occurs. The strength of
linkage can be used as a unit of measurement
to estimate the distance between different loci.
This type of analysis can help in identifying,
mapping, and diagnosing the genes responsi-
ble for certain inherited diseases.
The demonstration of linkage between the
gene controlling ABH secretion (Se) and the
expression of Lutheran blood group antigens
(Lua, Lub) was the first recognized example of
autosomal linkage in humans.3 Analysis of this
relationship also provided the first evidence in
humans of recombination due to crossing-over
and helped demonstrate that crossing-over oc-
curs more often in females than in males.
214 AABB Technical Manual

Figure 10-6. Very closely linked loci are rarely affected by crossing-over so that alleles of those loci are in-
herited together (N and S, M and s in the example shown). Loci on the same chromosome that are not
closely linked (the Ss locus and the Zz locus shown) can demonstrate crossing-over. Crossing-over is one
kind of recombination. It occurs between chromatids during meiosis, resulting in segregation of alleles on
the same chromosome.

Linkage Disequilibrium This is an example of linkage disequilib-

rium: the tendency of specific combinations of
When two loci are closely linked, alleles at
alleles at two or more linked loci to be inher-
those loci tend to be inherited together and
ited together more frequently than would be
are said to constitute a haplotype. Again, the
expected by chance.
close linkage between the loci controlling ex-
Another commonly cited example of link-
pression of M and N and of S and s is an exam-
age disequilibrium occurs in the HLA system
ple of linkage disequilibrium. The approxi-
(see Chapter 17). The combination of A1 with
mate frequencies of each of the four alleles
B8 occurs in some populations approximately
are:
five times more frequently than would be ex-
M = 0.53 S = 0.33
pected based on the frequencies of the indi-
N = 0.47 s = 0.67
vidual alleles, an example of positive linkage
If M, N, S, and s segregated independently,
disequilibrium. Linkage disequilibrium may
the expected frequency of each haplotype
be positive or negative, and it may indicate a
would be the product of the frequencies of the
selective advantage of one haplotype over an-
individual alleles. However, the frequencies
other. Over many generations, the alleles of
observed are not those expected:
even closely linked loci may reach equilibrium
Expected Observed and associate according to their individual fre-
Frequency Frequency quencies in the population.
MS = 0.53 × 0.33 = 0.17 0.24 When there is linkage equilibrium, the al-
Ms = 0.53 × 0.67 = 0.36 0.28 leles at two loci associate with frequencies that
NS = 0.47 × 0.33 = 0.16 0.08 reflect their individual frequencies. For exam-
Ns = 0.47 × 0.67 = 0.31 0.40 ple, if alleles in the population have the follow-
Total 0.47 × 0.67 = 1.00 1.00 ing frequencies:

Copyright © 2002 by the AABB. All rights reserved.

 Chapter 10: Blood Group Genetics 215

M 0.53 Z 0.30 trait has at least one parent with the trait, con-
N 0.47 z 0.70 tinuing backward through generations.
Total 1.00 1.00
then the frequencies of the combination Autosomal Recessive Trait
should be the product of the frequency of each
allele: People who exhibit a recessive trait are homo-
zygous for the encoding allele. Their parents
MZ 0.53 × 0.3 = 0.16 may or may not express the trait. However,
Mz 0.53 × 0.7 = 0.37 parents who lack the trait must be carriers, ie,
NZ 0.47 × 0.3 = 0.14 heterozygotes for an allele whose presence is
Nz 0.47 × 0.7 = 0.33 not phenotypically apparent.
Total 1.00 If the frequency of the variant gene is low,
the recessive trait will be rare and generally
In such a case, the alleles are in linkage will occur only in members of one generation,
equilibrium because they are inherited inde- not in preceding or successive generations un-
pendently. less consanguineous mating occurs. Blood rel-
atives are more likely to carry the same rare
gene than unrelated persons from a random
population. When offspring are homozygous
Patterns of Inheritance for a rare allele (frequency: <1:10,000) and
Dominant and Recessive Traits display the trait, the parents are often blood
relatives [Fig 10-7(B)]. Recessive traits may re-
Traits are the observed expressions of genes.
main unexpressed for many generations, so
A trait that is observable when the determin-
that appearance of a rare recessive trait does
ing allele is present is called dominant; when
not necessarily imply consanguinity, although
different alleles on homologous chromosomes
family ethnicity and geographic origin may be
each produce an observable trait, the term
informative. The higher the frequency of the
co-dominant is used. A recessive trait is observ-
recessive gene, the less the likelihood of con-
able only when the allele is not paired with a
sanguinity. Traits inherited in either autosomal
dominant allele (two recessive alleles are pres-
dominant or autosomal recessive fashion typi-
ent). Describing traits as dominant and reces-
cally occur with equal frequency in males and
sive depends on the method used to detect
females.
gene products. Observable traits are called
phenotypes. Thus, blood group antigen typing
identifies a phenotype. In some cases, geno- Sex-Linked Dominant or Co-dominant Trait
types may be inferred from the phenotype, es- A male always receives his single X chromo-
pecially when family studies are performed, some from his mother. The predominant fea-
but genotypes are not usually determined di- ture of X-linked inheritance, of either
rectly by typing red cells. dominant or recessive traits, is absence of
male-to-male (father-to-son) transmission of
Autosomal Dominant Trait the trait. Because a male passes his X chromo-
An autosomal dominant trait shows a charac- some to all his daughters, all daughters of a
teristic pattern of inheritance. The trait ap- man expressing a dominant X-linked trait also
pears whenever an individual possesses the possess the allele and express the trait. If a
allele. Figure 10-7(A) presents a pedigree woman expresses a dominant trait, but is het-
showing the pattern of autosomal dominant erozygous, each child, male or female, has a
inheritance. Typically, each person with the 50% chance of inheriting that allele and ex-

Copyright © 2002 by the AABB. All rights reserved.

216 AABB Technical Manual

Figure 10-7. Four pedigrees showing different patterns of inheritance.

pressing the trait. If the mother possesses the
determining allele on both X chromosomes, all
her children will express the trait [Fig 10-7
(C)]. A sex-linked dominant trait of interest in
blood group genetics is the Xg blood group
system. X-linked dominant traits tend to ap-
pear in each generation of a kindred, but with-
out male-to-male transmission.
Sex-Linked Recessive Trait
Hemophilia A provides a classic example of
X-linked recessive inheritance [Fig 10-7(D)].
Among the children of an affected male and a
female who lacks the determining allele, all
sons are normal and all daughters are carriers.
Males inherit the trait from carrier mothers or,
very rarely, from a mother homozygous for
the allele, who therefore expresses the trait. In
the mating of a normal male and a carrier fe-
male, one half of the male offspring are af-
fected and one half of the females are carriers.
If the recessive X-linked allele is rare, the
trait will be exhibited almost exclusively in
males. If the X-linked allele occurs more fre-

Copyright © 2002 by the AABB. All rights reserved.


quently in the population, affected females
will be seen because the likelihood increases
that an affected male will mate with a carrier
female and produce daughters, half of whom
will be homozygous for the abnormal allele.
Blood Group Co-dominant Traits
Blood group antigens, as a rule, are expressed
as co-dominant traits: heterozygotes express
the products of both alleles. If an individual’s
red cells type as both K+ and k+, the Kk geno-
type may be inferred. Figure 10-8 shows the
inheritance patterns of the two active alleles of
the Kidd blood group system (Jka and Jkb) and
the co-dominant phenotypic expression of the
two antigens Jka and Jkb.
In the ABO system the situation is more
complex. The genes of the ABO system do not
code for membrane proteins but control pro-
duction of enzymes termed glycosyltrans-
ferases. These enzymes add specific sugars to
a precursor structure on the red cell mem-
brane, resulting in specific antigen expression.
In an A1A2 heterozygote, the phenotype is A1;
Jka Jka Jkb Jkb
Jk(a+b–) Jk(a–b+)
Jka Jkb
Jk(a+b+)
Jkb Jkb Jka Jka
Jk(a–b+) Jk(a+b–)
Jka Jkb Jka Jkb
Jk(a+b+) Jk(a+b+)
Figure 10-8. Inheritance and co-dominant expression of Kidd blood group antigens.
Copyright © 2002 by the AABB. All rights reserved.
Chapter 10: Blood Group Genetics 217
2
the presence of the A allele cannot be in-
1
ferred. Although the A allele appears
2
dominant to that of the A allele by simple cell
typing, techniques that identify the specific
transferases reveal that an A1A2 heterozygote
does generate the products of both alleles, ie,
both A1 and A2 transferases. Similarly, in an
A2O person, A2 seems dominant to O. The O
allele codes for a specific protein but this pro-
tein appears to be nonfunctional. The pres-
ence of ABO genes can be demonstrated by
molecular techniques (see Chapter 13).
Chromosomal Assignment
The loci of all major blood group genes have
been mapped to one or another of the 22
pairs of autosomes as shown in Table 10-2.
The Xg and XK loci are the only blood group
genes mapped to the X chromosome.
Interaction among alleles or the products of
different genes may modify the expression of a
trait. The terms “suppressor” and “modifier”
are used to describe genes that affect the ex-
pression of other genes; however, the mecha-
Jkb Jkb Jka Jka
Jk(a–b+) Jk(a+b–)
Jka Jkb
Jk(a+b+)
Jka Jkb Jkb Jkb Jka Jka
Jk(a+b+) Jk(a–b+) Jk(a+b–)
Jka Jkb Jka Jkb
Jk(a+b+) Jk(a+b+)
218 AABB Technical Manual

Table 10-2. Chromosomal Locations of Human Blood Group System Genes*

Gene(s)
ISBT Designation
System ISBT No. Symbol (ISGN) Location

ABO 001 ABO ABO 9q34.1-q34.2

MNS 002 MNS GYPA, GYPB, GYPE 4q28.2-q31.1
P 003 P1 P1 22q11.2-qter
Rh 004 RH RHD, RHCE 1p36.13-p34.3
Lutheran 005 LU LU 19q13.2-q13.3
Kell 006 KEL KEL 7q33
Lewis 007 LE FUT3 19p13.3
Duffy 008 FY DARC 1q22-q23
Kidd 009 JK SLC14A1 18q11-q12
Diego 010 DI SLC4A1 17q21-q22
Yt 011 YT ACHE 7q22.1
Xg 012 XG XG Xp22.3
Scianna 013 SC SC 1p35-p32
Dombrock 014 DO DO 12p13.2-p12.1
Colton 015 CO AQP1 7p14
Landsteiner-Wiener 016 LW LW 19p13.3
Chido/Rodgers 017 CH/RG C4A, C4B 6p21.3
Hh 018 H FUT1 19q13.3
Kx 019 XK XK Xp21.1
Gerbich 020 GE GYPC 2q14-q21
Cromer 021 CROM DAF 1q32
Knops 022 KN CR1 1q32
Indian 023 IN CD44 11p13
Ok 024 OK CD147 19p13.3
Raph 025 MER2 MER2 11p15.5

1 4 5
*Modified from Zelinski ; Denomme, Rios, and Reid ; and Garratty et al.

nism of these postulated gene interactions is D antigen expression when the C allele is on
not always fully understood. Some observa- the paired chromosome (cis position) as re-
tions in blood group serology have been ex- ported with previously available reagents6
plained by gene interaction: weakening of the and the suppression of Lutheran antigen ex-

Copyright © 2002 by the AABB. All rights reserved.


pression by the dominant modifier gene,
In(Lu).7
When products of two different genes are
important in the sequential development of a
biochemical end product, the gene interaction
is called epistasis. Failure to express A or B an-
tigens if H substance has not first been pro-
duced (absence of the H gene) is an example
of epistasis. A mutation database of gene loci
encoding common and rare blood group anti-
gens has been established (Blood Group Anti-
gen Mutation Database) and is available on
the Internet.4
Population Genetics
Some understanding of population genetics is
essential for parentage testing and helpful in
such clinical situations as predicting the likeli-
hood of finding blood compatible with a se-
rum that contains multiple antibodies.
Calculations utilize published phenotype fre-
quencies.
Phenotype Frequencies
The frequencies of blood group phenotypes
are obtained by testing many randomly se-
lected people of the same race or ethnic group
and observing the proportion of positive and
negative reactions with a specific blood group
antibody. In a blood group system, the sum of
phenotype frequencies should equal 100%.
For example, in a Caucasian population, 77%
of randomly selected individuals are Jk(a+).
The frequency of Jk(a–) individuals should be
23%. If blood is needed for a patient with
anti-Jka, 23% or approximately one in four
ABO-compatible units of blood should be
compatible.
Calculations for Combined Phenotypes
If a patient has multiple blood group antibod-
ies, it may be useful to estimate the number of
units that will have to be tested in order to find
units of blood negative for all the antigens. For
Copyright © 2002 by the AABB. All rights reserved.
Chapter 10: Blood Group Genetics 219
example, if a patient has anti-c, anti-K, and
a
anti-Jk , how many ABO-compatible units of
blood would have to be tested to find four
units of the appropriate phenotype?
Phenotype Frequency (%)
c– 20
K– 91
Jk(a–) 23
To calculate the frequency of the combined
phenotype, the individual frequencies are
multiplied as the phenotypes are independent
of one another. Thus, the proportion of per-
sons who are c– is 20%. Of the 20% of c– in-
dividuals, 91% are K–; hence, 18% (0.20 ×
0.91 = 0.18) are c− and K−. Of this 18% of c–
K– individuals 23% will be Jk(a–); therefore,
only 4% of individuals will have c–K–Jk(a–)
blood (0.2 × 0.91 × 0.23 = 0.04). Therefore,
of 100 units tested, four compatible units
should be found. Calculations such as this in-
fluence decisions about asking for assistance
from the local blood supplier or reference lab-
oratory when trying to find compatible blood
for an alloimmunized patient.
Parentage Testing
Blood group antigens, many of which are ex-
pressed as co-dominant traits with simple
Mendelian modes of inheritance, are useful in
parentage analyses. If one assumes maternity
and that test results are accurate, paternity can
be excluded in either of two ways:
1. Direct exclusion of paternity is estab-
lished when a genetic marker is present
in the child, but is absent from the
mother and the alleged father. Example:
Blood Group Phenotype
Child Mother Alleged Father
B O O
The child has inherited a B gene, which
could not be inherited from either the mother
or the alleged father, assuming that neither
220 AABB Technical Manual
the mother nor the alleged father is of the rare
Oh phenotype. Based on the phenotypes of
mother and child, the B gene must have been
inherited from the biologic father and is called
a paternal obligatory gene.
2. Exclusion is indirect when the child lacks
a genetic marker that the alleged father
(given his observed phenotype) must
transmit to his offspring. Example:
Blood Group Phenotype
Child Mother Alleged Father
Jk(a+b–) Jk(a+b–) Jk(a–b+)
In this case, the alleged father is presum-
ably homozygous for Jkb and should have
transmitted Jkb to the child.
Direct exclusion is more convincing than
indirect exclusion when trying to establish
parentage. Apparent indirect exclusion can
sometimes result from the presence of a silent
allele. In the example above, the alleged father
could have the genotype JkbJk and could have
transmitted the silent allele (Jk) to the child.
a
The child’s genotype could actually be Jk Jk in-
stead of the far more common JkaJka. Interpre-
tation of phenotypic data must take into ac-
count all biologic and analytic factors known
to influence results.
When the alleged father cannot be ex-
cluded from paternity, it is possible to calcu-
late the probability of paternity. The probabil-
ity that the alleged father transmitted the
paternal obligatory genes is compared with
the probability that any other randomly se-
lected man from the same racial population
could have transmitted the genes. The result is
expressed as a likelihood ratio (paternity in-
dex) or as a percentage (posterior probability
of paternity given some prior probability).
Methods for parentage analysis often include
the study of many genetic systems other than
red cell blood groups (ie, HLA system). Many
parentage testing laboratories currently em-
ploy a method of DNA analysis (see Chapter
9) as a means of evaluating cases of disputed
Copyright © 2002 by the AABB. All rights reserved.
parentage. The AABB has developed stan-
dards for laboratories that perform parentage
studies.8
Chimerism
A chimera is one whose cells are derived from
more than one distinct zygotic line. Although
rare, this may occur when an anastomosis oc-
curs within the vascular tissues of twin em-
bryos, or when two fertilized zygotes fuse to
form one individual. This condition, while not
hereditary, leads to dual (multiple) phenotypic
populations of cells within one individual.
Blood types of such rare individuals may dem-
onstrate a mixed-field appearance, with dis-
tinct populations of cells of the person’s true
genetic type, as well as cells of the implanted
type. Chimeras also demonstrate immune tol-
erance: a genetically group O person with im-
planted A cells does not produce anti-A. More
commonly, chimeras are artificial and arise
from transfer of actively dividing cells, eg,
through hematopoietic transplantation (see
Chapter 25).
Blood Group Nomenclature
Until recently, terminology and notations for
blood group systems embodied many incon-
sistencies as blood group serologists failed to
follow conventions of classic Mendelian genet-
ics. Listed below are a few examples of the
confusion engendered by many decades of un-
coordinated scientific publications.
1. An allele that determines a dominant
trait often is signified by a capital letter;
one that determines a recessive trait is
denoted by both lowercase letters. The
A and B co-dominant genes of the ABO
system are signified by a capital letter.
The O gene is also given a capital but
does not present as a dominant trait.
Without prior knowledge, it would be
impossible for one to recognize that

these notations represent allelic prod-
ucts in a blood group system.
2. Some co-dominant traits have been des-
ignated with capital letters and allelic re-
lationships with lowercase letters; for
example, K and k of the Kell blood group
system and C and c of the Rh system.
3. Some co-dominant traits have identical
base symbols but different superscript
symbols, such as Fya and Fyb (Duffy sys-
a b
tem) and Lu and Lu (Lutheran system).
4. In some allelic pairs, the lower fre-
quency antigen is expressed with an “a”
superscript (Wra has a lower frequency
than Wrb). In other allelic pairs, the “a”
superscript denotes the higher incidence
antigen (Coa has a higher frequency than
Cob).
5. Some authors have denoted absence of
a serologic specificity with a base sym-
bol devoid of superscripts, and others
use a lowercase version of the base sym-
bol. In the Lutheran system, the as-
sumed amorphic gene is called Lu, not
lu, while the amorph in the Lewis system
is le.
Colloquial use of these terminologies, even
in some published articles and texts, has com-
pounded their improper use. Early model
computers or printers also did not easily ac-
cept certain terminologies (eg, superscripts,
subscripts, unusual fonts).
In recent years, concerted attempts have
been made to establish rational, uniform crite-
ria for the notations used to designate pheno-
type, genotype, and locus information for
blood group systems. Issitt and Crookston9
presented guidelines for the nomenclature
and terminology of blood groups. The Interna-
tional Society of Blood Transfusion (ISBT)
Working Party on Terminology for Red Cell
Surface Antigens has provided a standardized
system for classifying blood group antigens.10
Similar international committees have estab-
lished principles for assigning nomenclature of
the hemoglobins, immunoglobulin allotypes,
Copyright © 2002 by the AABB. All rights reserved.
Chapter 10: Blood Group Genetics 221
histocompatibility antigens, clusters of differ-
entiation, and other serum protein and red cell
enzyme systems. Although many of the older
terminologies must be retained to avoid even
further confusion, common conventions now
exist for correct usage.
Correct Terminology
The following are among the accepted termi-
nologies for expressing red cell antigen pheno-
types and genotypes (Tables 10-3 and 10-4).5
1. Genes encoding the expression of blood
group antigens are written in italics (or
underlined if italics are not available). If
the antigen name includes a subscript
(A1), the encoding gene is expressed with
a superscript (A1).
2. Antigen names designated by a super-
script or a number (eg, Fya, Fy:1) are
written in normal (Roman) script. Nu-
meric designations are written on the
same line as the letters. Superscript let-
ters are lowercase. (Some exceptions oc-
cur, based on historic usage: hrS, hrB.)
3. When antigen phenotypes are ex-
pressed using single letter designations,
results are usually written as + or –, set
on the same line as the letter(s) of the an-
tigen: K+ k–.
4. To express phenotypes of antigens desig-
nated with a superscript letter, that letter
is placed in parentheses on the same line
as the symbol defining the antigen:
Fy(a+) and Fy(a–).
5. For antigens designated by numbers, the
symbol defining the system is notated in
capital letters followed by a colon, fol-
lowed by the number representing the
antigen tested. Plus signs do not appear
when test results are positive (K:1), but a
minus sign is placed before negative test
results: K:1, K:–1. If tests for several anti-
gens in one blood group have been
done, the phenotype is designated by
the letter(s) of the locus or blood group
system followed by a colon, followed by
222 AABB Technical Manual

Table 10-3. Examples of Gene, Antigen, and Phenotype Terms

System Genes Antigens Phenotypes

ABO A A1 A2 B A A1 A2 B A A1 A2 B
Rh DCEce DCEce D+C+ E–c+e+
MN MNSs MNSs M+N+S–s+
P P1 P1 P1+ P1–
Lewis Le le Lea Leb Le(a+) Le(a–b+)
Kell K k Kpa Jsa K k Kpa Jsa K–k+Kp(a+)Js(a–)
Kell K1 K2 K3 K1 K2 K3 K:–1,2,–3
Scianna Sc1 Sc2 Sc Sc1 Sc2 Sc:–1,–2,–3
Kidd Jka Jkb Jk3 Jka Jkb Jk3 Jk(a+)Jk(a+b+)Jk:3
1 4 5
*Modified from Zelinski , and Denomme, Rios and Reid , and Garratty et al

antigen numbers separated by commas: Although numeric terminology has been

K:–1,2,–3,4. Only antigens tested are devised for various systems and antigens, it
listed; if an antibody defining a specific should not be assumed that it must replace
antigen was not tested, the number of conventional terminology. The use of conven-
the antigen is not listed: K:–1,–3,4. tional antigen names is also acceptable. In

5
Table 10-4. Examples of Correct and Incorrect Terminology
Term Description Correct Terminology Incorrect Terminology

Phenotype Fy(a+) Fya+, Fy(a+), Fya(+), Fya+, Fya(+), Duffya+,

Duffya-positive
Phenotype Fy(a+b–) Fya+b–, Fy(a+b–), Fya(+)b(–), Fya(+)b(–)
Antibody Anti-Fya Anti Fya, Anti-Duffy
Antigen K Kell (name of system)
Antibody Anti-k Anti-Cellano
Phenotype K:1, K:–1 K1+, K:1+, K(1), K:(1), K1–, K:1–, K1-negative
Phenotypes A Rh+, B Rh– A+ (means positive for A antigen)
B– (means negative for B antigen)
Phenotype M+N– M(+), MM (implies unproved genotype)
Phenotype Rh:–1,–2,–3,4,5 Rh:–1,–2,–3,+4,+5
Rh:1–,2–,3–,4+,5+
Note: The examples shown may not represent the only correct terminologies. In the Rh system, for example, use of
CDE terminology is also acceptable and is more commonly used. The example demonstrates the correct usage if
numeric terminology is used.

Copyright © 2002 by the AABB. All rights reserved.


some systems, notably Rh, multiple terminolo-
gies exist and not all antigens within the sys-
tem have names in each type.
ISBT Nomenclature
The ISBT Working Party on Terminology for
Red Cell Surface Antigens has devised a nu-
meric nomenclature suitable for computeriza-
tion.11 A six-digit designation indicates each
blood group specificity. The first three num-
bers identify the blood group system and the
last three numbers identify the individual
specificity. This numeric terminology is de-
signed mainly for computer databases and is
not necessarily intended to supplant more
common usage.
For ISBT classification, each defined blood
group system must be genetically distinct. As-
signment of antigens to a specific blood group
system is dependent on genetic, serologic,
and/or biochemical relationships. Gene clon-
ing has made the task of assignment more de-
finitive and has allowed some designations
previously unproved by traditional family
studies (ie, the expansion of the Diego system
to include a number of low-incidence anti-
gens).
Some recognized antigens, however, have
not yet been proven to be part of a recognized
system. Collections (termed the 200 series)
are apparently related sets of antigens for
which definitive genetic information is lacking.
Other isolated antigens of high (901 series) or
Copyright © 2002 by the AABB. All rights reserved.
Chapter 10: Blood Group Genetics 223
low (700 series) incidence are listed together
until genetic information becomes available.
In recent years, the number of antigens in
these three series has dramatically declined as
further genetic and biochemical data allow re-
assignment.
References
1. Zelinski T. Chromosomal localization of human
blood group genes. In: Silberstein LE, ed. Molecu-
lar and functional aspects of blood group antigens.
Bethesda, MD: American Association of Blood
Banks, 1995:41-73.
2. Reid ME. Molecular basis for blood groups and
functions of carrier proteins. In: Silberstein LE, ed.
Molecular and functional aspects of blood group
antigens. Bethesda, MD: American Association of
Blood Banks, 1995:75-125.
3. Mohr J. A search for linkage between the Lutheran
blood group and other hereditary characters. Acta
Path Microbiol Scand 1951;28:207-10.
4. Denomme GA, Rios M, Reid ME. Molecular proto-
cols in transfusion medicine. New York: Academic
Press, 1999.
5. Garratty G, Dzik W, Issitt PD, et al. Terminology
for blood group antigens and genes—historical ori-
gins and guidelines in the new millennium. Trans-
fusion 2000;40:477-89.
6. Ceppellini R, Dunn LC, Turri M. An interaction be-
tween alleles at the Rh locus in man which weak-
ens the reactivity of the Rho factor (Du). Proc Natl
Acad Sci U S A 1955;41:283.
7. Crawford NM, Greenwait TJ, Sasaki T. The pheno-
type Lu(a–b–) together with unconventional Kidd
groups in one family. Transfusion 1961;1:
228-32.
8. Standards for parentage testing laboratories. 5th
ed. Bethesda, MD: American Association of Blood
Banks, 2001.
9. Issitt PD, Crookston MC. Blood group terminology:
Current conventions. Transfusion 1984;24:2-7.
10. Daniels GL, Anstee DJ, Cartron J-P, et al. Blood
group terminology 1995. ISBT working party on
terminology for red cell surface antigens. Vox Sang
1995;69:265-79.
224 AABB Technical Manual

Appendix 10-1. Glossary of Terms in Blood Group Genetics

Allelic: Pairs of genes located at the same site on chromosome pairs.
Centromere: A constricted region of a chromosome that connects the chromatids during
cell division.
Chromatid: One of the two potential chromosomes formed by DNA replication of each
chromosome before mitosis and meiosis. They are joined together at the
centromere.
Chromatin: The deeply staining genetic material present in the nucleus of a cell that is not
dividing.
Chromosome: A linear thread made of DNA in the nucleus of the cell.
Co-dominant: A gene that expresses a trait with assistance from its allele,
Dominant: A gene that expresses a trait without assistance from its allele.
Gene: The basic unit of heredity, made of DNA. Each gene occupies a specific location
on a chromosome.
Locus: The site of a gene on a chromosome.
Lyon hypothesis: The idea that one of the female X chromosomes is inactivated during
embryogenesis. This inactivated chromosome forms the Barr body in the cell
nucleus.
Meiosis: A process of two successive cell divisions producing cells, egg, or sperm that
contain half the number of chromosomes found in somatic cells.
Mitosis: Division of somatic cells resulting in daughter cells containing the same num-
ber of chromosomes as the parent cell.
Recessive: A gene that in the presence of its dominant allele does not express itself. A re-
cessive trait is apparent only if both alleles are recessive.
Sex-linked: A gene contained within the X or Y chromosome.
Somatic cell: Nonreproductive cells or tissues.
X-linked: A gene on the X chromosome for which there is no corresponding gene on the Y
chromosome.

Copyright © 2002 by the AABB. All rights reserved.