Red Blood Cell (RBC) Membrane Proteomics

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ed Blood Cell Blood Group Antigens:tructure and Functionarion E. Reid and Narla Mohandas

ed blood cell (RBC) blood group antigens are polymorphic, inherited, carbohydrate or protein structures located on thextracellular surface of the RBC membrane. They contribute to the architecture of the RBC membrane, and theirndividual function(s) are being slowly revealed. The biological qualities assigned to these RBC membrane structuresre based on observed physiological alteration in RBCs that lack the component, by documenting similarities in itsrotein sequence (predicted from the nucleotide sequence of the gene) to proteins of known function and byxtrapolation to identified functional homologues in other cells. The varied roles of RBC antigens include membranetructural integrity, the transport of molecules through the membrane, as receptors for extracellular ligands, adhesionolecules, enzymes, complement components and regulators, and in glycocalyx formation.emin Hematol 41:93-117. © 2004 Elsevier Inc. All rights reserved.

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RYTHROCYTE blood group antigens are poly-morphic, inherited, carbohydrate or protein

tructures located on the extracellular surface of theed blood cell (RBC) membrane. They are recognizedy antibodies that are made in antigen-negative indi-iduals after exposure to antigen-positive RBCshrough transfusion or pregnancy. The production oflood group antibodies has led to the identification ofumerous antigens and phenotypes, including natu-al knock-out (“null”) phenotypes. More than 250nown antigens have been assigned to 29 bloodroup systems, each encoded by genetically discreteenes (or closely linked gene families), which haveeen recognized by the International Society forlood Transfusion (ISBT).1,2 Carbohydrates attachedo proteins or lipids in specific linkages define anti-ens in the ABO, H, and P blood group systems. Anti-ens of the Lewis and Chido-Rodgers systems are ac-uired by the membrane from the plasma. Antigens ofhe remaining 24 blood group systems are located onntegral RBC membrane proteins or on glycosylphos-hatidylinositol (GPI)-linked proteins. Genes encoding7 of the blood group systems have been cloned andequenced,3 and the molecular bases of many antigensnd phenotypes have been delineated (for details, seettp://www.bioc.aecom.yu.edu/bgmut/index.htm). Onlyhe genes encoding for the P and RAPH systems remaino be characterized. Table 1 lists the 29 ISBT-recognizedlood group systems, the encoding genes, chromosomeocation, and the major antigens within each system.

Years of meticulous studies using hemagglutina-ion assays have provided not only a vast knowledgease regarding the nature of the various blood groupntigens but also identified blood samples with un-sual characteristics for detailed genetic and molec-lar analysis. Amino acid sequence, in most casesredicted from the nucleotide sequence, have pro-
ided insights into the topology and possible func-
Seminars in Hematology, Vol 41, N

ions of the proteins carrying the blood group anti-ens, but the biological significance of most of thelood group antigens has yet to be determined. Ineneral, the polymorphisms that we recognize aslood group antigens and that have importance inransfusion medicine do not measurably alter theunction of the specific component. The activitiesredicted for carrier proteins are usually based onequence homology with proteins of known func-ion, but their function in the mature RBC may not behe same as in other cells, or altered forms may serves recognition signals in senescent RBCs or play rolesuring earlier stages of erythroid development.

Many RBC membrane proteins with an extracellu-ar component are glycosylated by N- and/or O-gly-ans. These carbohydrate structures form a nega-ively charged barrier, the glycocalyx, around theBC. This barrier, which is approximately 10 to 15m deep, prevents spontaneous aggregation of theirculating RBCs, adhesion to endothelium, and pro-ects against microbial invasion.

The possible functions of the various componentsarrying blood group antigens can be divided into theollowing broad categories: membrane structural in-egrity, transport proteins, receptors for extracellularigands, adhesive proteins, extracellular enzymes,omplement regulators, and maintenance of surfaceharge in the glycocalyx. Table 2 lists the possible

From the Laboratory of Immunochemistry and the Lindsley F.imball Research Institute, New York Blood Center, New York, NY.

Supported in part by National Institutes of Health Grants No.L54459, HL54459, HL31579, and DK26263.

Address correspondence to Marion Reid, PhD, Lindsley F. Kim-all Research Institute, New York Blood Center, 310 E 67th St, Nework, NY 10021.© 2004 Elsevier Inc. All rights reserved.0037-1963/04/4102-0001$30.00/0
doi:10.1053/j.seminhematol.2004.01.001
o 2 (April), 2004: pp 93-117 93

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94 Reid and Mohandas

Table 1. Details of 29 Genetically Discrete Blood Group Systems

Name (No.) Gene Location

Gene Name

Associated Antigens Component Name Copy No. per RBCISBT ISGN

BO (001) 9q34.2 ABO ABO A, B, A, B, A1 Carbohydrate 250,000 to � 1,000,000NS (002) 4q28.2-q31.1 MNS GYP GYPB M, N, S, s, U, He,

Mia, Vw � 35more

GPA (CD235a); GPB(CD235b)

GPA: 1,000,000; GPB:200,000

(003) 22q11.2-qter P1 P1 P1 Carbohydrate 500,000h (004) 1p36.13-p34.3 RH RHD, RHCE D, C, E, c, e, f,

CW, V, G, � 36more

RhD (CD240D);RhCE (CD240CE)

RhD, RHCE combined:100,000 to 200,000

utheran (005) 19q13.2 LU LU Lua, Lub, Lu3,Lu4, Aua, Aub

� 12 more

Lutheranglycoprotein; B-CAM (CD239)

1,500 to 4,000

ell (006) 7q33 KEL KEL K, k, Kpa, Kpb,Ku, Jsa, Jsb �17 more

Kell glycoprotein(CD258)

3,500 to 17,000

ewis (007) 19p13.3 LE FUT3 Lea, Leb, Leab,Lebh, ALeb,BLeb

Carbohydrate Not determined

uffy (008) 1q22-q23 FY DARC Fya, Fyb, Fy3, Fy4,Fy5, Fy6

Fy glycoprotein(CD234)

13,000 to 14,000

idd (009) 18q11-q12 JK SLC14A1 Jka, Jkb, Jk3 Kidd glycoprotein 14,000 to 18,000iego (010) 17q21-q22 DI SLC4A1 Dia, Dib, Wra,

Wrb, Wda, Rba

� 14 more

Band 3 (CD233) 1,000,000

t (011) 7q22 YT ACHE Yta, Ytb Acetylcholinesterase 10,000g (012) Xp22.32 XG XG, MIC2 Xga, CD99 Xga glycoprotein

CD999,000

cianna (013) 1p34 SC ERMAP Sc1, Sc2, Sc3, Rd Sc glycoprotein(ERMAP)

Not determined

ombrock (014) 12p13.2-p12.1 DO DO Doa, Dob, Gya, Hy,Joa

Do glycoprotein(ART4)

Not determined

olton (015) 7p14 CO AQP1 Coa, Cob, Co3 Channel-formingintegral protein

120,000 to 200,000

andsteiner-Wiener (016)

19p13.3 LW ICAM LWa, LWab, LWb LW glycoprotein(ICAM-4) (CD242)

D�: 4,400 (adult) 5,150(cord); D�: 2,835(adult) 3,620 (cord)

hido/Rodgers(017)

6p21.3 CH/RG C4A, C4B CH1, CH2, Rg1 �6 more

C4A; C4B Not determined

h (018) 19q13.3 H FUT1 H Carbohydrate(CD173)

GP O adult: 1,700,000;lower on other ABOphenotypes

x (019) Xp21.1 XK XK Kx Xk glycoprotein 1,000erbich (020) 2q14-q21 GE GYPC Ge2, Ge3, Ge4,

Wb, Lsa, Ana,Dha

GPC (CD236); GPD GPC: 135,000; GPD:50,000

romer (021) 1q32 CROM DAF Cra, Tca, Tcb, Dra

� 9 moreDAF (CD55) 20,000

nops (022) 1q32 KN CR1 Kna, Knb, McCa,Sla, Yka � 3more

CR1 (CD35) 20 to 1,500

ndian (023) 11p13 IN CD44 Ina, Inb Hermes antigen(CD44)

2,000 to 5,000

k (024) 19pter-p13.2 OK BSG Oka Neurothelin,basoglin (CD147)

Not determined

aph (025) 11p15.5 MER2 MER2 MER2 Not defined Not determinedMH (026) 15q22.3-q23 JMH SEMA-L JMH H-Sema-L (CD108) Not determined(027) 6p24 IGNT IGNT I Carbohydrateloboside (028) 3q25 �GalN AcT1 B3GALT3 P CarbohydrateIL (029) 9p13 GIL AQP3 GIL AQP3

Abbreviations: ISBT, International Society of Blood Transfusion; ISGN, International Society for Gene Nomenclature.

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RBC Blood Group Antigens 95

unctions of the structures carrying the blood groups,he type of membrane component, presence in otherissues, null phenotypes, and disease associations.his review focuses on the structures of the molecules

hat express RBC blood group antigens, their known orossible functions, and the potential biological signifi-ance of blood group polymorphisms.

The Erythrocyte Membrane

he erythrocyte membrane consists of lipids, pro-eins, and carbohydrates, which interact to form aynamic and fluid structure with the strength andexibility needed to survive 4 months in the circula-ion. Numerous cycles of extensive deformation areuffered as the RBC passages through narrow capil-aries and sinusoids in the spleen, yet the RBC isithout intracellular machinery to repair membraneamage.4 The RBC membrane is a composite struc-ure with a lipid bilayer linked to a spectrin-basedkeletal protein network by the interaction of cyto-lasmic domains of bilayer-embedded membraneroteins with skeletal proteins. Cholesterol, phos-holipids, and glycolipids form the bilayer, with hy-rophobic tails facing inward and hydrophilic polaread groups outward on both extracellular and cyto-lasmic faces of the membrane. The lipid moleculesan diffuse rapidly within the plane of monolayers,ut movement across the bilayer is rather slow (lowates of “flip-flop”), enabling the maintenance ofembrane “sidedness.”5 Peripheral skeletal proteins

orm a two-dimensional protein network under theipid bilayer (the membrane skeleton).6 The mem-rane skeleton is associated with the lipid bilayerhrough specific interactions between the skeletalroteins and the cytoplasmic domains of integralransmembrane proteins. The major and well-definedelationships include spectrin interaction withnkyrin, which in turn binds to the cytoplasmic do-ain of band 3 (anion exchanger, AE1), a multipass

rotein; and spectrin interaction with protein 4.1,hich binds to the single-pass proteins glycophorin(GPC) and glycophorin D (GPD). Some integralembrane proteins interact with other transmem-

rane proteins (such as band 3 with glycophorin AGPA]; Kell with Kx; RhD and RHCE with RhAG), orith lipids (for example, Rh). Indeed, many of theroteins carrying blood group antigens associate withnd reside in the milieu of the erythrocyte membranes macromolecular complexes.7,8

Carbohydrates are essentially restricted to the extra-ellular surface of the RBC membrane, where they col-ectively form a negatively charged environment, thelycocalyx, which plays an important role in preventinged cell-red cell and RBC-endothelial interactions. Theajority of carbohydrates are attached to lipids on a

eramide backbone and to proteins by linkages to aspar- a

gine (N-linked) or to serine or threonine (O-linked)esidues.9 Figure 1 depicts the membrane componentshat carry blood group antigens.

Terminology for Blood Groups

committee for terminology of RBC surface anti-ens, sanctioned by the ISBT, has established guide-ines. Over time, notations devised to describe bloodroup antigens have changed. A single letter (A, D,), a symbol with a superscript (Fya, Jkb, Lua), a

ymbol with a number (Fy3, Lu4, K12), and three orour letters (DAK, MAR, FPPT, TSEN) may be usedithin the same blood group system,1 creating very

onfusing terminology. Many components carryinglood group antigens have been assigned CD (cluster ofifferentiation) numbers. Here we use the terminologyecommended by the ISBT.

Expression Pattern

any proteins and carbohydrate structures carryinglood group antigens are also expressed on non-rythroid cells: for examples, A, B, H, Kna (CD35),na (CD44), Oka (CD147), and Cromer-related anti-ens (CD55) have a wide tissue distribution.10,11

The ability to culture stem cells and to separateells based on their staged differentiation, plus thevailability of monoclonal antibodies, has enabledhe timing of expression of blood group antigensuring in vitro erythroid maturation. As the pro-rythroblasts differentiate into reticulocytes, the or-er of blood group antigen expression is as follows:PC, Kell, RhAG, LW, RhCE, GPA, band 3, RhD,utheran, and Duffy.12 There is little information onhe function of these various proteins during ery-hroid development.

Ontogeny

everal blood group antigens are not expressed or arenly weakly expressed on fetal RBCs and do not reachdult levels until approximately 2 years of age. CordBCs do not express Lea, Sda, Ch, Rg, or AnWjntigens. Cord red cells express the following anti-ens more weakly than do adult RBCs: A, B, H, P1, I,eb, Lua, Lub, Yta, Vel, Doa, Dob, Gya, Hy, Joa, Xga, Kn,nd Bg. In contrast, the i and LW antigens are moretrongly expressed on cord RBCs than on adult cells.

atural “Knockouts” in Humanshe detection of an alloantibody to a high incidencentigen during compatibility or prenatal testing hased to the discovery of RBCs with null phenotypes.ull RBCs lack certain blood group antigens and usu-

lly also the specific carbohydrate or carrier protein is

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Table 2. Function, Structure, Tissue Distribution, and Disease Association for Some Components Carrying Blood Group Systems

FunctionSystemName

Predicted Topology(no. of amino

acids) Present in Other Tissue Null Phenotype Disease Association

tructureMembrane attachment;

interacts with 4.1Rand p55

Gerbich Type I single pass(GPC 128; GPD107)

Fetal liver, renalendothelium, brain,cerebellum, ilium

Leach Hereditary elliptocytosis,hemolytic anemia;decreased 4.1R and p55

tructure and transportAnion exchanger Diego Multipass with 14

spans (911)Granulocytes, kidney:

intercalated cells ofdistal and collectingtubules, testes

1 case—transfusion-dependent

Southeast Asian ovalocytosis,hereditary spherocytosis,renal tubular acidosis

Possible neuro-transmitter; predictedtopology

Kx Multipass with 10passes (444)

Fetal liver, adult skeletalmuscle, brain,pancreas, heart

McLeod Acanthocytosis, musculardystrophy, hemolytic anemia;McLeod syndromesometimes associated withCGD

H4 transport (?) or CO2

transport?Rh Multipass with 12

spans (RhD417; RhCE417)

Rhnull Hemolytic anemia, hereditarystomatocytosis,hematologicalmalignancies

ransportUrea transporter Kidd Multipass with 10

passes (389)Vasa recta endothelium;

?renal medullavascular supply

Jk(a�b�) Impaired urea transport,urine concentrating defect

Water channel Colton Multipass with 6spans (269)

Kidney, liver, gall bladder,eye, capillaryendothelium

Co(a�b�) Monosomy 7, congenitaldyserythropoietic anemia

Glycerol/water/ureatransport

GIL Multipass with 6spans (292)

Kidney, liver, pancreas,lung, spleen, prostate

GIL-negative

eceptors/adhesionChemokine/Plasmodiumvivax receptor

Duffy Multipass with 7spans (338)

Endothelial, and epithelialcells, Purkinje cells ofbrain, colon, lung,spleen, thyroid, thymus,collecting ducts ofkidney

Fy(a�b�) Resistance to P vivaxinvasion

Binds hyaluronic acid,mediates adhesion ofleukocytes

Indian Type I single pass(341)

Wide tissue distribution 1 case (?acquired)congenitaldyserythropoieticanemia [alsoYt(a�b�)]

Depressed in pregnancy

Binds laminin Lutheran IgSF type I (Lu597; BCAM557)

Fetal liver, placenta,arterial walls, marrowepithelium

Lu(a�b�)recessive type

Increased expression possiblyinvolved in vaso-occlusionin sickle cell disease

Binds CD11/CD18;ligand for integrins

Landsteiner-Wiener

IgSF type I (241) Blood cells, epidermis,blood/brain barrier

LWnull also Rhnull Depressed in pregnancy andin some malignantdiseases

Possible adhesionmolecule

Ok IgSF type I (248) All cells tested Not described

Adhesion molecules Xg type I single pass(Xg 180; CD99163)

Fibroblasts, fetal liver,spleen, thymus,adrenal, adult marrow

Not described

Adhesion moleculeFunction in RBCs notknown

JMH GPI-linked (656) Activated lymphocytes,neurons, epithelia,testes

Not described Absent form PNH III RBCs

Possible adhesionmolecules

Scianna Type I (475) Erythroid-specific Sc:�1,�2,�3

Binds microbes;glycocalyx;complementregulation; chaperonefor band 3

MNS Type I single pass(GPA 131; GPB72)

Mk Mk (lack GPA &GPB) En(a�)(lack GPA)S�S� (lackGPB)

Decreased P falciparuminvasion; may be receptorfor E coli

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Table 2. (Continued)

Function System NamePredicted Topology (no. of

amino acids)Present in Other

Tissue Null Phenotype Disease Association

nzymesCleaves big

endothelin 3 toET-3, a potentvasoconstrictor

Kell Type II single pass (732) Bone marrow, fetalliver, testes, brain,lymphoid tissue,heart

Knull (K0)

Acetylcholinesterase Yt GPI-linked (557) Granulocytes,innervated tissue,including brain andmuscle

1 case(?acquired)congenitaldyserythropoieticanemia [alsoIn(a�b�)

Absent from PNH IIIRBCs

Enzymatic (ART4) Dombrock GPI-linked (314) WBCs Gy(a�) Absent from PNH IIIRBCs

omplementComplement

regulation, bindsC3b;disassemblesC3/C5convertase

Cromer GPI-linked (347) Vascular endothelium,epithelia GI, GU,CNS; soluble formin plasma and urine

Inab Absent from PNH IIIRBCs; Dra is thereceptor foruropathogenic E coli

Complementregulation, bindsC3b and C4b;mediatesphagocytosis

Knops Type I single pass (1998) B lymphocytes, asubset of Tlymphocytes, othernucleated bloodcells, glomerularpodocytes, folliculardendritic cells

Not reported Antigens depressed incertain autoimmuneand malignantconditions

Complementcomponents

Chido/Rodgers Adsorbed from plasma Plasma C4-deficient RBCspredisposes forSLE

Certain phenotypes haveincreasedsusceptibility to someautoimmuneconditions andinfections

therGlycocalyx ABO Carbosyltransferases type II

(354)Epithelial cells,

secretions,ectoderm,endoderm

Group O Altered expression insome hematologicaldisorders

Glycocalyx H Fucosyl-transferase type II (365) Broad distribution;soluble—all fluidsexcept CSF insecretors

Bombay (Oh) Decreased in sometumor cells; increasedin hematopoieticstress

Glycocalyx Lewis Fucosyltransferase type II (361)Adsorbed onto RBC

Blood cells,gastrointestinaltract, skeletalmuscle, kidney,adrenal

Le(a�b�) Increased expression infucosisdosis; Lewisantibodies may beimportant in graftrejection

Glycocalyx I N-acetylglucosaminyltransferasetype II (400)

Broad tissuedistribution

i (adultI–negative)

Cateracts in Asians

Glycocalyx GLOB N-acetylgalactosaminyltransferasetype II (321)

Blood cells; solubleform in cyst fluid

Receptor E coli and B19parovirus

Unknown RAPH Unknown Fibroblasts; somecancer cells

MER2-null The 3 known humananti-MER2 were madeby Indian Jews withrenal failure

Abbreviations: IgSF, immunoglobulin superfamily; GI, gastrointestinal; GU, genitourinary; CNS, central nervous system.

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bsent. These natural “knockout” models have revealednsights into the function of membrane proteins.

Membrane Proteins WithStructural Function

everal blood group systems are carried on proteinshat have structural functions and thus are involvedn the maintenance of the bioconcave discoid shapend membrane material properties of the RBC (Table). The absence of GPC and GPD, band 3, Kx, Rh, orutheran proteins result in morphological changes.roteins carrying Diego, Kx, and Rh antigens also are

nvolved in transport of molecules across the lipidilayer (Tables 1 and 2).

erbich Blood Group System and GPCnd GPDhe Gerbich (Ge) antigens, three of high incidenceGe2, Ge3, and Ge4) and four of low incidence (Wb,

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igure 1. Model of RBC membrane components carrying blood grarbohydrate moieties attached to lipids or to proteins, protein backoieties. Most protein blood group antigens are carried on integra

ew are carried on glycosylphosphatidylinositol (GPI)-linked proteinhe components carrying blood group antigens are named with th

s , An , and Dh ), are carried on the extracellular w

omain of GPC and/or GPD.13 GPC and GPD are typemembrane glycoproteins encoded by the GYPC genen chromosome 2. GPD is generated from the sameRNA as GPC by means of an alternate initiation

odon.14,15 GPC is a 32-kd protein bearing one N-inked oligosaccharide and approximately 12-linked oligosaccharides in the N-terminal, extra-

ellular domain. The desialylated form of GPC isxposed on the surface of early erythroid progenitorserthrocyte burst-forming unit [BFU-E]) and is aseful marker of early normal or leukemic erythroidifferentiation.16 Normally, glycosylated GPC firstppears at the later erythroctye colony-forming unitCFU-E) stage (17). The transmembrane domainasses through the lipid bilayer as a single �-helix.he cytoplasmic domain of GPC forms a complexith protein 4.1 (4.1R) and p55 and is a major site of

ttachment of the spectrin-actin–based skeleton tohe plasma membrane. Residues Tyr94 to Arg166 ofhe 30-kd membrane binding domain of 4.1R interact

ntigens. The various antigens determinants are represented by thealone, or by both protein backbone and the attached carbohydrate

nsmembrane (type I, type II, and multi-pass) proteins; however, ad antigens in one system (Ch/Rg) are adsorbed from the plasma.od group system in parentheses.

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8 in the cytoplasmic domain of GPC and the corre-ponding residues 61 to 77 of GPD.18-23 Amino acidesidues 112 to 128 of GPC and residues 91 to 107 ofPD bind to the PDZ domain of p55, which is aember of the membrane-associated guanylate ki-

ase (MAGUK) family of proteins.24,25 Residuesyr214 to Glu246 of the 4.1R membrane binding do-ain bind to p55 at a positively charged, 39–amino

cid segment located between the SH3 domain andhe guanylate kinase domain of p55.26 The complexf GPC/GPD, 4.1R, and p55 is important in maintain-ng cell shape and membrane mechanical stability,ince absence of GPC and GPD (the Ge:�2,�3,�4 oreach phenotype) results in elliptocytosis with de-reased membrane stability.20,27

GPC and GPD are expressed in a variety of tissuesTable 2) but at lower levels than in erythroid cellsnd with different glycosylation patterns28,29; theyay have an analogous function in the membraneechanics of non-erythroid cells.Mutations in exon 1, exon 2, or exon 3 of GYPC

odify the N-terminal extracellular domain of GPC andPD and thus alter the antigenicity of RBCs but do not

ffect cellular mechanical properties.29,30 Examples in-lude Ge-type RBCs that lack amino acids encoded byxon 2; Yus-type RBCs that lack amino acids encoded

Table 3. RBC Changes Associated With Pro

Blood GroupSystem Phenotype Absent

orphologicalGerbich Leach

(Ge�2�3�4)GPC and GPD

and p55)Diego Band 3, protKx McLeod Xk (reducedRh Rhnull RhD, RhCE, L

CD47; GPBLutheran Lu(a�b�)

recessiveLU glycoprote

CD44)ther changesKidd Jk(a�b�) Kidd glycopro

Colton Co(a�b�) Aquaporin-1

MNS En(a�)U�MkMk

GPAGPBGPA, GPB

o observed changeRh D� RhDKell Knull (K0) Kell glycoproDuffy Fy(a�b�) Duffy glycoprLW LW(a�b�) LW glycoprotScianna Sc:�1,�2,�3 ERMAPDombrock Gy(a�) Dombrock glCromer Inab DAFGil Gil� Aquaporin-3

y exon 3; and Wb� RBCs that have a missense muta- p

ion of GYPC, converting Asn at position 8 to Ser,hereby precluding N-glycosylation at this site.31,32

hese variant forms of GPC have the normal cytoplas-ic domain, which can interact with 4.1R and p55. The

ariant RBCs have normal levels of 4.1R and are normo-ytic. By contrast, in the Leach phenotype there is com-lete loss of GPC and GPD secondary to deletion ofxons 3 and 427,33 or a frameshift mutation33; affectedndividuals do not have significant hemolysis, but aroportion of their RBCs are elliptocytic34,35 and exhibitecreased membrane deformability and mechanical sta-ility (�50% as measured by ektacytometry)20,36 (seerticle by Gallagher in this issue). GPC-deficient RBCsre also partially deficient in 4.1R and p5522,37 and thushe disturbance in membrane mechanical propertiesxhibited by Leach RBCs likely derives from a defectivePC/GPD/4.1R/p55 complex. Individuals with ho-ozygous 4.1R deficiency also exhibit low GPC

�70%) in their elliptocytic RBCs,38,39 emphasizing thathe cellular content of each component of the ternaryomplex depends on the expression level of the others.

embrane Proteins With Both Structuraland Transport Function

critical function of the cell membrane is to trans-

ased Null Phenotypes (natural knock-outs)

ced) Protein(s) In Vivo Change

uced protein 4.1 Elliptocytosis

.1 (reduced GPA) PoikilocytosisAcanthocytosis

educed RhAG; Stomatocytosis, spherocytosis

-CAM (reduced Acanthocytosis in dominant type

Impaired urea transport Urineconcentrating defect

Reduced osmotic waterpermeability

Increased glycosylation of band3 [En(a�) and MkMk]

oteinSome have GI abnormalities

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ipid bilayer, in order to bring nutrients into the RBC,emove waste products, and control ion gradients.pecialized transmembrane transport proteins carryut this key function. Membrane transport proteinsan be classified as carrier proteins that physicallyove a solute across the membrane, and channel

roteins that form a hydrophobic pore in the mem-rane through which the specific solute or ion passes.he proteins that carry blood group antigens Diego,h, Kidd, Colton, and GIL have membrane transport

unction. They are multipass proteins with the NH2-erminus and COOH-terminus both oriented to theytoplasmic side of the lipid bilayer; the protein as-ociated with Kx also may have this structure andunction.

iego Blood Group System and Anionransport

ntigens of the Diego system are carried on band 3synonyms include anion transporter, AE1, andLC4A1), a transmembrane protein that traverses theembrane 12 or 14 times40-42 and which transports

nions.43 The Diego antigens are derived from aminocid substitutions within band 3. The Dia/Dib poly-orphism is associated with a Leu854Pro substitu-

ion, and expression of Wra/Wrb is associated withys658Glu. For expression, Wrb requires the interac-ion of band 3 and GPA.44,45 The N-glycan on theourth extracellular loop of band 3 (Asn642) carries

ore than half of the mature red cell A, B, H, and Intigens. With the exception of the Dia/Dib polymor-hism, the Diego blood group polymorphisms areot associated directly with any functional alterationf band 3.

Band 3 is a major integral membrane protein,omprising 25% to 30% of the RBC membrane pro-ein (�1.2 million copies per RBC); it resides in theembrane as a dimer. Residues 1 through 403 form

he 43-kd NH2-terminal cytoplasmic domain; thisesidue functions as an anchor point for the mem-rane skeleton through interactions with the periph-ral membrane proteins ankyrin, 4.1R, and protein.2, and as a binding reservoir for hemoglobin, dena-ured hemoglobin, the glycolytic enzymes glyceral-ehyde 3-phosphate dehydrogenase, phosphofruc-okinase and aldose, as well as for catalase andemichromes.46 Residues 509 to 911 form a channelhat exchanges HCO3

� and Cl�, facilitating the criti-al function of RBCs in CO2 uptake in tissues andubsequent release of CO2 in the lungs (a huge num-er of bicarbonate and chloride anions are ex-hanged: �20 billion/second per RBC).

Although HCO3� and Cl� are the predominant

hysiologically relevant anions exchanged by band 3,he specificity of the channel is broad, and larger
nions such as sulfate, phosphate, pyruvate, and su- m
eroxide are also transported, although at muchlower rates.47 Several potent and experimentallyseful inhibitors of band 3 anion transport arenown, the most commonly employed being stilbeneisulfonates, such as 4,4�-diisothiocyanostilbene-,2�-disulfonate (DIDS).47 The COOH terminus, likehe NH2 terminus, is on the cytoplasmic side of theembrane and binds carbonic anhydrase II.48

Band 3 contributes to maintaining the structuralntegrity of the RBC membrane. Deficiency of band 3auses membrane surface area loss and alterations inhe RBC shape, as spherocytosis. Approximately onefth of human cases of hereditary spherocytosis (HS)esult from deficiency of band 3 (see Eber and Lux inhis issue).49-52 Numerous mutations identified in theand 3 gene in HS lead to decreased synthesis, alteredembrane insertion, decreased protein stability, and

nability to bind protein 4.2.6,53 Mice completely de-cient in band 3 that survive gestation have a severepherocytic hemolytic anemia, closely resembling se-ere HS in humans. These mice have undetectablemounts of protein 4.2 and GPA54,55 but normalpectrin, actin, and protein 4.1 and normal mem-rane skeleton architecture by electron micros-opy.55 These observations indicate that band 3 is,urprisingly, not required for membrane skeletonssembly but functions in stabilizing membrane lip-ds. Loss of this function may be critical to the patho-enesis of HS. In addition to mouse models, there is aecessive form of HS in cattle with mild to moderateemolytic anemia and complete deficiency of band 3,ue to a nonsense mutation at codon 646.56 Theattle, like band 3–deficient mice, have defectivenion transport, lack protein 4.2, and have reducedumbers of intramembrane particles by electron mi-roscopy.

In contrast to spherocytic morphology associatedith reduced amounts of band 3 assembled onto theBC membrane, deletion of amino acids 401 to 408

n band 3 causes Southeast Asian ovalocytosisSAO),57-59 an autosomal-dominant condition char-cterized by rounded elliptocytic cells, mild or absentemolysis, and the presence of unusually rigid andeat-tolerant RBCs. Red cells in SAO resist malarial

nvasion, and they show altered expression of severallood group antigens60 (see article by Gallagher inhis issue). SAO band 3 protein has an abnormal-glycan, is misfolded in the membrane, and doesot transport anions or bind transport inhibitorsuch as H2DIDS or eosin maleimide.61,62 No SAOomozygote has been found, suggesting lethality.he altered membrane organization may be respon-ible63 for the selective depression of several bloodroup antigens, including S, s, U, Ena; D, C, e; Kpb;ka, Jkb; Dib, Wrb; Xga; Sc1; IF and IT antigens. SAO isound predominantly in Melanesia and Malaya and

ay have an incidence of up to 25% in some popula-

ttcosao

(abd(sbtcdcTiftac(wipibdgmtb

itmfTsioseaomdprtcco

fdtHhR

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(a(mepttsprc

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MliBdce


ions.60 SAO RBCs deplete intracellular adenosineriphosphate (ATP) more readily than do normal redells, and ATP depletion correlates with the inabilityf Plasmodium falciparum to invade the RBCs. Ontorage at 4°C, SAO RBCs become markedly perme-ble to monovalent cations, and the increased activityf the sodium pump results in the rapid loss of ATP.64

Mutation of band 3 Arg589 in transmembraneTM) domain 6, Ser613 in TM 7, and an 11–aminocid deletion in the COOH-terminal domain haveeen independently associated with the autosomal-ominant form of distal renal tubular acidosisdRTA), characterized by impaired distal nephronecretion of hydrogen ions.65-68 The phenotype iselieved to result from faulty targeting of band 3 tohe apical rather than the basolateral membrane ofollecting tubule type A intercalated cells, not to aefect in anion transport.69 Mutation of Gly701 (lo-ated in the intracellular loop between TM8 andM9) is associated with autosomal recessively inher-

ted dRTA, with the phenotype again deriving fromaulty band 3 trafficking. Incomplete processing ofhe band 3 N-linked lactosaminoglycan moiety due todeficiency in the relevant glycosyltransferase(s) oc-urs in congenital dyserythropoietic anemia type IICDA II or hereditary erythroblast multinuclearityith positive acid serum test [HEMPAS]), although it

s probably not the primary molecular defect. Thehenotype of binucleate/multinucleate erythroblasts

n the bone marrow and a characteristic RBC mem-rane dysmorphology is believed to derive from bothecreased anion transport and increased band 3 ag-regation in the membrane.70 A rare Pro868 to Leuutation in TM14 of band 3 causes hereditary acan-

hocytosis; affected RBCs exhibit decreased ankyrininding and increased anion transport.6

In addition to these functions, band 3 also may benvolved in RBC senescence. Hemichromes, a par-ially denatured form of hemoglobin, bind to band 3ore avidly than does hemoglobin, resulting in the

ormation of hemichrome-band 3 aggregates.71,72

his clustering of band 3 is believed to generate a cellurface epitope identified by autologous IgG antibod-es, which may act as a signal for the removal of agedr defective RBCs from the circulation by phagocyto-is.73,74 Band 3 clustering can generate multivalentpitopes comprised of surface sialylated poly-N-cetyllactosaminyl chains, which in turn can be rec-gnized by anti–band 3 IgG autoantibodies and byacrophages directly.75,76 There is considerable evi-

ence that antibodies are bound to band 3 in aged andathological RBCs.6 Antibodies to senescent antigen,esident on the band 3 carbohydrate,77,78 likely bindo aggregated or oligomerized band 3.74,79-82 Band 3lusters have been visualized by immunofluores-ence microscopy and detected by biochemical meth-

79,80
ds in aged RBCs. Aggregation probably results s
rom cumulative oxidative damage because similaramage, including the binding of autologous IgG,akes place on oxidized RBCs or RBCs containingeinz bodies, a product of oxidative denaturation ofemoglobin.6 Senescent antigen also is exposed onBCs infected with P falciparum.83,84

x Blood Group Systemx, the single antigen of the Kx system, is carried by

he Xk protein, which is encoded by XK, a gene on thehort arm of the X chromosome. While Xk proteinas structural but not sequence similarity with a

amily of proteins involved in transport of neuro-ransmitters, its transport substrate(s) have not beenefined.85,86 In the RBC membrane, the Xk protein isovalently linked to the Kell glycoprotein (a type IIembrane protein with endopeptidase activity) by a

isulfide bond, thereby forming a stable com-lex.87,88

Male hemizygotes who lack Xk on their RBCsMcLeod syndrome) have weak expression of Kellntigens, variable echinocytosis or acanthocytosis8% to 85%), and mild compensated hemolytic ane-ia (3% to 7% reticulocytes).89-91 Some tear drop

rythrocytes and bizarre poikilocytes are alsoresent. Female heterozygotes have occasional acan-hocytes (as expected from X-chromosome inactiva-ion) and very mild hemolysis.89,90 The abnormalhape is apparently due to an alteration of lipid orrotein in the inner bilayer, because it can be cor-ected by substances like chlorpromazine, which ac-umulate between inner bilayer lipids.92

In the fifth decade, patients with McLeod syndromeevelop a myopathy or neuropathy or both,93-98 firstanifest as areflexia and an elevated serum creatine

hosphokinase (CPK)94 but later progressive.98,99 Inhe sixth decade, a cardiomyopathy (cardiomegaly) oreuropathy (dystonic or choreiform movements, withr without peripheral neuropathy, psychiatric distur-ances, and seizures) may appear. Imaging studieshow caudate atrophy and decreased dopamine D2-eceptors.93,95,97,100-103 At this stage the disease is some-imes confused with chorea-acanthocytosis.96 The skel-tal muscle myopathy is usually not evidentlinically, although changes may be seen in biopsypecimens.98,104-106 (For more information about thecLeod Syndrome, see www.nefo.med.uni-muenchen.

e/�adanek/McLeod.html).The exact cause of the membrane defect in

cLeod syndrome is yet to be defined. Protein andipid composition is normal,107-109 but the density ofntramembranous particles (IMPs) is increased.109

and 3, the major IMP protein, may be abnormallyissociated in McLeod RBCs compared to normal redells, where it exists primarily as dimers and tetram-rs.110 There is also increased phosphorylation of
ome lipids and membrane proteins, especially band

3n

ccbthm

RTilflaRpwtsitIsoaD

iaocaepm

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R

gtdRtsamgm

Ppf

KoTJsrPmtbtwaciKsbsciTCssEtmptwtb

CoT


, spectrin, phosphatidic acid and polyphosphoi-ositides.108

The Xk gene is less than 500 kb distal to thehronic granulomatous disease (CGD) locus on the Xhromosome. As a consequence, some males haveoth CGD and McLeod syndrome, due to deletionshat encompass both loci. Absence of Xk protein alsoas been attributed to various splice site or framehiftutations in XK.85,111,112

h Blood Group Systemhe Rh blood group system is comprised of at least 45

ndependent antigens carried by two nonglycosy-ated, palmitoylated proteins encoded by variantorms of two homologous genes, RHD and RHCE,ocated on chromosome 1.113,114 RHD encodes the Dntigen and RHCE encodes the CcEe set of antigens.h antigen expression at the RBC surface requires theresence of the Rh-associated glycoprotein (RhAG),hich exhibits 36% sequence identity with Rh pro-

eins and is encoded by a gene located on chromo-ome 6. RhD, RhCE, and RhAG form a core complexn the RBC membrane that is stabilized by NH2-erminal and COOH-terminal domain associations.n addition to the interaction between the three Rhubunits, the Rh core complex also contains severalther proteins: LW glycoprotein (ICAM-4), integrin-ssociated protein (IAP, CD47), GPB, and possiblyuffy protein.Although the function of the Rh protein complex

n the normal RBC is not known, the complex may acts ammonium transporter, based on a weak homol-gy to the Mep/Ant family of proteins and a singleomplementation study in yeast.115,116 The Rh proteinslso might facilitate diffusion of CO2 gas.117-120 How-ver, there is not yet definitive evidence of the trans-ort function of Rh protein complex in the RBCembrane.The importance of Rh complex in regulating RBC

embrane structure is revealed by the rare Rhnullhenotype, which exhibits stomatocytic and sphero-ytic morphology with loss of membrane surfacerea, cell dehydration, cation permeability abnormal-ties, and shortened RBC survival leading to a com-ensated hemolytic anemia (chromium 51–labeledBC half-life of 10 to 14 days).121-123 Osmotic fragil-

ty is only mildly increased but ektacytometry showssignificant loss of membrane surface, particularly inenser (and presumably older) cells.123 RBC mem-rane K� or Rb� (a K� analogue) permeability isbout twice normal, compatible with a mild xerocy-osis syndrome.123,124 Indeed, in one patient a major-ty of the Rhnull RBCs were dense and K�-depleted;owever, in another case, cation and water concen-rations were normal.122

Stomatocytosis and hemolysis are also features of
hmod disease. The Rhnull phenotype has two distinct i
enetic backgrounds. The amorph type of Rhnull ishe result of inactivating mutations in RHCE in tan-em with a deleted RHD, but with no alteration inHAG. The less rare regulator type of Rhnull and also

he Rhmod phenotype (in which the Rh antigens areuppressed) have normal RHD and RHCE but aressociated with diverse mutations in RHAG. Theseutations result in the generation of defective RhAG

lycoproteins that are absent or reduced in the RBCembrane.113,114

Membrane Proteins WithTransport Function

roteins carrying Kidd, Colton, and GIL antigensass through the lipid bilayer multiple times andunction as transporters (Tables 1 and 2).

idd Blood Group System and Transportf Ureahe three common phenotypes [Jk(a�b�),

k(a�b�) and Jk(a�b�)] of the Kidd blood groupystem are encoded by two co-dominant alleles. Theare Jk(a�b�) null phenotype is most abundant inolynesians and Finns. That the Kidd glycoproteinight transport urea stemmed from the observation

hat Jk(a�b�) RBCs are relatively resistant to lysisy 2 mol/L urea.125 Indeed the Kidd glycoprotein ishe urea transporter in the RBC membrane,126,127

hich functions by rapidly transporting urea intond out of red cells as they pass through the high ureaoncentration in the renal medulla, thereby prevent-ng RBC dehydration.128. Urea transport acrossiddnull RBC membranes is approximately a thou-

and times slower than across normal membranes,129

ut no phenotypic changes in either RBC shape orurvival are associated with the absence of Kidd gly-oprotein. Two patients with Jk(a�b�) RBCs had anmpaired ability to maximally concentrate urine.130

wo Jk(a�b�) individuals (one Caucasian, one ofhinese origin) were found to have different intronic

plice site mutations in a Jkb allele that caused exonkipping and the production of truncated proteins.xpression studies using Xenopus oocytes showed

hat such proteins are not transported to the plasmaembrane and that they do not facilitate urea trans-

ort.131 A different missense mutation, identified inhree Finnish families, may alter N-glycosylationhich in turn could affect the gross conformation of

he Kidd glycoprotein and its insertion into the mem-rane.132

olton Blood Group System and Transportf Waterhe Colton system consists of Coa, an antigen of high

ncidence (99.9%) and antithetical to the less com-

maeC

fpt(sthA((RtitfivheiCfccoosms

GG

AmgRCAsGittsSRiamc

Bsglra

DTsTFFptdg

kflitspnAspsftftvtts

pgodfgmatheFigt


on Cob (incidence of 10% in most populations),nd the Co3 antigen that is present on all RBCsxcept those of the very rare null phenotype,o(a�b�).Membranes of RBCs and some kidney tubules dif-

er from those of most other cells in their high waterermeability, due to a molecular water channel pro-ein.133,134 This protein, designated aquaporin-1AQP-1), carries antigens in the Colton blood groupystem. The suggested function of AQP-1 is to facili-ate rehydration of RBCs after their shrinkage in theypertonic environment of the renal medulla.135

QP-1, a 28-kd channel-forming integral proteinCHIP-28), is a member of the major integral proteinMIP) family and the main water channel inBCs.136,137 The protein has been crystalized and the

etrameric complex forms an “hour-glass” structuren the RBC membrane.138 Absence of AQP-1 washought to be incompatible with life, but the identi-cation of Co(a�b�) individuals by serologists pro-ided natural knockout models. Four such probandsave been tested.139,140 Human RBCs lacking AQP-1xhibit markedly reduced osmotic water permeabil-ty but no obvious phenotypic abnormality, ando(a�b�) individuals are apparently healthy. De-

ective urinary concentrating ability as well as de-reased pulmonary vascular permeability occur withomplete deficiency of AQP�1.141,142 Reconstitutionf the recombinant protein into Xenopus oocytes136

r liposomes133 confirmed its function as a water-elective channel. AQP-1 knockout mice appear nor-al but after water deprivation for 36 hours become

everely dehydrated and lethargic.143

IL Blood Group System and Transport oflycerol, Water, and Urea

quaporin-3 (AQP-3) is also a MIP channel-formingolecule and differs from AQP-1 in that it transports

lycerol, water, and urea.144 AQP-3 also traverses theBC membrane six times with both NH2- andOOH-termini located towards the cytoplasm.PQ-3 is expressed in kidney, liver, pancreas, lung,pleen, and prostate.145 The blood group antigen,IL,146 was shown to be expressed on APQ-3 in two

ndividuals whose plasma contained antibodies tohis high incidence antigen.147 Both had the same Go A nucleotide substitution in intron 5, leading tokipping of exon 5 and failure to express APQ-3.tudies of glycerol permeability in AQP-3–deficientBCs have suggested that another protein is also

nvolved in glycerol transport. GILnull RBCs are notssociated with any overt functional defect, andouse RBCs, which lack an equivalent AQP3 mole-

148
ule, transport glycerol efficiently. F
Membrane Proteins as Receptors forLigands, Parasites, Bacteria, and Viruses

ased on their structure or function in other cells,ome proteins in the RBC membrane that carry bloodroup antigens appear to be receptors for specificigands and/or microbes, suggesting they play a directole in pathogenesis of infectious diseases (Tables 1nd 2).

uffy Blood Group Systemhe Fya and Fyb antigens of the Duffy blood groupystem are encoded by two alleles, FY A and FY B.here are four major phenotypes: Fy(a�b�),y(a�b�), Fy(a�b�), and Fy(a�b�).149 They(a�b�) phenotype, rare in most populations, isredominant among black populations, particularlyhose originating in West Africa, in whom the inci-ence of may reach 100%. Duffy blood group anti-ens are carried on the Duffy glycoprotein.

The Duffy glycoprotein is a promiscuous chemo-ine receptor in RBCs.150 It binds a variety of proin-ammatory cytokines of both the C-X-C class (acute

nflammation) and the C-C class (chronic inflamma-ion), including interleukin-8 (IL-8), melanoma growthtimulatory activity (MGSA), monocyte chemotacticrotein 1 (MCP-1) and a factor regulated on activation,ormal T-expressed and secreted (RANTES).151-154

lthough the Duffy glycoprotein is predicted to haveeven membrane-spanning domains, it does not ap-ear to function as a transport molecule. A majortructural difference compared to other RBC channelorming molecules is that the NH2-terminal region ofhe glycoprotein is oriented on the extracellular sur-ace of the membrane.155 The Duffy glycoprotein ishe receptor for the malarial parasite, Plasmodiumivax.156,157 Because Fy(a�b�) RBCs are refractoryo invasion by P vivax merozoites, likely this pheno-ype, at least in Africa, evolved under selective pres-ure to circumvent the infection.158

The function of Duffy glycoprotein in normal RBChysiology remains to be defined. The lack of Duffylycoprotein in RBCs from black Africans is the resultf a mutation in the promoter region of FYB, whichisrupts a binding site for the erythroid transcriptionactor GATA-1 and prevents expression of the Duffyene in erythroid tissue.159 To date, blacks with autated GATA box have been shown to carry FYB

nd therefore Fyb is expressed on their non-erythroidissues. In one study, Fy(a�b�) African-Americansad decreased allograft survival if they also experi-nced delayed graft function.160 Fy(a�b�) due to anYA allele with a mutated GATA box, has been found

n Papua New Guinea, another malaria-endemic re-ion.161 In Caucasians the Fy(a�b�) phenotype ishe result of premature stop codons that silence the
Y gene, and the Duffy glycoprotein is missing from

ahnnpitikreshodsrhaFld

cFcctsmal

ifdp

TaRdtoeedGafbpbs

pkdR

catcnmidnaLticawmabias(mlGetprthhctrebo

BA

GEctm(ei


ll tissues.162,163 This “true” Duffy null phenotypeas no obvious hematological or immunological ab-ormalities. FY knockout mice show only bluntedeutrophil response on exposure to bacterial lipo-olysaccharide, but the susceptibility to S aureus wasdentical to wild-type. Thus Duffy appears to be func-ionally redundant.164 An increase in inflammatorynfiltrates in the lung and liver was observed in FYnockout mice challenged with lipopolysaccha-ide.165 In studies of patients with sickle cell disease,levated levels of IL-8 were noted in acute chestyndrome; of 20 patients, 19 were Fy(a�b�) and 14ad elevated levels of IL-8.166 Whether the frequencyf Fy(a�b�) in this small group reflects a risk for theevelopment of acute lung syndrome is controver-ial, as the frequency of Fy(a�b�) among West Af-ican blacks is approximately 75%. MCP-1 levels inealthy adults were higher in males versus femalesnd Fy antigen–positive individuals versusy(a�b�) donors.167 Whether variation in MCP-1

evels poses a risk for certain chemokine-associatediseases is unknown.

Another phenotype called Fyx, which is not un-ommon in Caucasians, is due to a mutation in theYB gene (168-171). The resulting amino acidhange (residue 89) is located in the first intracellularytoplasmic loop and decreases the amount of pro-ein in the membrane and results in reduced expres-ion of Fyb, Fy3, and Fy6 antigens and reduced che-okine binding. The weak expression of Fyx is due to

n instability of the mature glycoprotein as it trans-ocates to the plasma membrane (150).

The Duffy glycoprotein may have a role in enhanc-ng leukocyte recruitment to sites of inflammation byacilitating movement of chemokines across the en-othelium (172). It may also function in the lungarenchyma during inflammation (173)

MNS Blood Group System and GPAand GPB

he integral membrane glycoproteins GPA and GPBccount for the majority of the surface charge of theBC. Their extracellular domains contain an abun-ance of sialic acid, which generates a layer of nega-ive charge at the cell surface, preventing adherencef RBCs to each other and to vessel walls. Surfacepitopes of the glycophorins, including variants gen-rated by protein defects, are the basis for a wideiversity of blood group antigens in the MNS system.PA also serves as a receptor for infective agents such

s P falciparum and may function as a chaperone,acilitating the targeting of specific integral mem-rane proteins to the plasma membrane. The glyco-horins belong to the broad family of integral mem-rane proteins that pass through the lipid bilayer as a
ingle �-helix. Because the “single-pass” membrane 3
roteins include growth factor receptors and receptorinases, the glycophorins have been considered can-idate mediators of transmembrane signaling inBCs.

GPA was the first membrane protein to have itsomplete amino acid sequence determined. Aminocids 1 to 61 give rise to the extracellular NH2-erminal domain, which contains a complex oligosac-haride attached to Asn26174 and 15 serine or threo-ine O-linked tetrasaccharides with sialic acidoieties.175,176 The carbohydrate component of GPA

s 60% of its molecular mass. The transmembraneomain of GPA, amino acids 62 to 95, interacts withegatively charged lipids, such as phosphatidylserinend phosphatidylinositol.177,178 Self-association of the75I76XXG79V80XXG83V84XXT87 motif within theransmembrane domain results in homodimerizationnto a right-handed pair of �-helices.179,180 By nu-lear magnetic resonance spectroscopy, Ile76, Val80,nd Val84 on the �-helix of one monomer interfaceith Leu75, Gly79, Gly83, and Thr87 on the secondonomer181; this dimeric interaction resists dissoci-

tion by detergents. A sequence in the transmem-rane domain of GPA is important for horizontalnteractions with band 3,182 and GPA may function aschaperone for membrane targeting of band 3.183 A

pecific role for the cytoplasmic domain of GPAamino acids 96 to 131) has not been defined. Treat-ent of RBCs with antibodies to GPA induces cellu-

ar rigidity on ektacytometry, and the quantity ofPA associated with the membrane skeleton increas-

s.184 Both changes are dependent on the presence ofhe cytoplasmic tail of GPA, suggesting that the cyto-lasmic domain binds to the membrane skeleton inesponse to a transmembrane signal initiated by an-ibody treatment.185 Cellular rigidity induced by ad-erence of pathogens to glycophorins could serve toeighten reticuloendothelial clearance of infectedells.185 GPA has been used as a specific marker forhe erythroid lineage due to its presence in proeryth-oblasts.186 In addition, assays to gauge radiationxposure and consequent somatic mutation haveeen developed based on measuring the frequenciesf variant GPA phenotypes in RBCs.187,188

and 3 and GPA Are Functionallyssociated

PA and band 3 have a physiological association.xpression of the Wrb blood group antigen (the re-eptor for P falciparum) requires the interaction be-ween GPA and Glu658 of band 3. A GPA Ala65Proutation (HAG antigen) and a Glu63Lys mutation

MARS antigen) in GPA cause aberrant Wrb antigenxpression.189 The co-expression of GPA and band 3n Xenopus oocytes facilitates the expression of band
and enhances anion transport. Mutation in band 3

actwGakpa

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trpsio2GasdfieTcc

fiariEOai

actKn

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IGA


t Gly701 leads to impaired protein targeting to theell surface in Xenopus oocytes; the aberrant pheno-ype is rescued by co-expression of the mutant band 3ith GPA, consistent with a chaperone-like role forPA in band 3 targeting.190 RBCs lacking GPA have

ltered band 3 glycosylation. RBCs from band 3nock-out mice are completely deficient in GPA, em-hasizing the potential relevance of band 3-GPA inter-ctions during erythropoiesis and in mature RBCs.191

The gene for GPB lies just downstream of GPA onhromosome 4 and probably arose by gene duplica-ion.192,193 The first 26 amino acids of the extracellu-ar NH2-terminal domain are identical to the N bloodroup form of GPA.194 GPB also carries the S, s, and Ulood group antigens but lacks the N-linked complexligosaccharide. Distally, GPB lacks a portion of thextracellular domain corresponding to exon 3 of GPAnd almost the entire cytoplasmic domain. GPB iseduced in Rhnull RBCs. Because GPB is expressedxclusively in RBCs, the GPB promoter has been theubject of transcriptional regulation studies. Repres-ion of the GPB promoter in nonerythroid cells isccomplished by the binding of a ubiquitous factorhat recognizes a GATA motif centered at position75 of the promoter195; the Ku70 protein may func-

ion as the GPB repressor.196 Erythroid-specific dere-ression of the GPB promoter is mediated by therythroid transcription factor hGATA-1.196

Complete loss of GPA, GPB, or both by gene dele-ion gives rise to En(a�), (S�s�), and MkMk RBCs,espectively. En(a�) RBCs, for example, are com-letely deficient in GPA. The affected cells compen-ate for a potential 60% loss of surface charge byncreasing glycosylation of band 3, such that theverall surface charge is only reduced by about0%.197 Given the proximity and homology of GPA,PB, and GPE genes, hybrid glycophorin molecules

re generated by recombination events during meio-is. None of the GPA and GPB variants produceetectable changes in erythropoiesis or in the shape,unction, or lifespan of affected RBCs. Indeed, rarendividuals with complete absence of GPA and GPBxhibit no apparent erythrocyte abnormalities.198

he major function of GPA could be to confer surfaceharge to the RBC membrane, preventing red cell–redell interactions that are detrimental to blood flow.

GPA is a likely RBC surface attachment site for Palciparum.199,200 Alternative pathways for malarialnvasion of RBCs depend on the strain of P falciparumnd the ability of the parasite to switch its invasionequirements.201 For example, sialic acid–dependentnvasion results from binding of merozoite proteinBA-175 to the Neu5Ac(�2,3)-Gal moiety on the-linked tetrasaccharides of GPA.202 Another sialic

cid–dependent but EBA-175–independent pathways believed to involve merozoite binding to GPB.203

204
GPA binds the C4 component of complement t
nd may provide limited protection to RBCs fromomplement-induced lysis by inhibiting the forma-ion or binding of the C5b-C7 complex.205 In vitro,562 cells transfected with GPA are protected fromatural killer cells.206

Membrane Proteins That Act asAdhesion Proteins

ell adhesion molecules are crucial for many physi-logical processes in embryogenesis, as well as inathological processes such as inflammation, woundealing, and cancer. While adhesion molecules haveo obvious function on mature RBCs, they likely playkey role in cell-to-cell or cell-matrix interaction

uring erythropoiesis or in hematopoietic cell matu-ation. Rare people with Lutheran null or LW nullhenotypes have no known phenotype, and no ge-etic null phenotypes for Indian, Ok, or Xg arenown (Table 1 and 2).

ndian Blood Group Systemntigens of the Indian system are carried on CD44, a

ype I, single-pass, integral membrane protein. CD44ppears to be the major human hyaluronan receptornd also may bind fibrinogen, laminin, some forms ofollagen, and osteopontin.207-209 CD44-hyaluronannteraction may be required for adhesion of lymphoidells and primitive erythroid progenitor cells to bonearrow stroma in lymphopoiesis and erythropoiesis.Isoforms of CD44, the result of alternative splicing

CD44v), are associated with the ability of cancerells to metastasize.210 Soluble forms of CD44 haveeen found in serum of cancer patients; in someon-Hodgkin’s lymphoma, a correlation betweenlinical severity and CD44 levels was observed.211

he In(a�b�) phenotype was described in a patientith a novel form of CDA and CD44 deficiency,212

ut it was not possible to determine if the phenotypeas genetic or related to the patient’s hematologicalisorder.

Positively charged motifs (SRRRC and QKKKL)n CD44, which are homologous to the interactingeptides found in band 3, bind to the membraneinding domain of 4.1R.213 Analogous to band 3,.1R competes with ankyrin for CD44 binding anday thus regulate CD44-ankyrin interactions.213

a2�-dependent and -independent calmodulin bind-ng sites are located within the 4.1R membrane bind-ng domain,214 and 4.1R membrane binding domainnteractions with transmembrane proteins are sub-ect to regulation by Ca2�-calmodulin.

mmunoglobulin Superfamily oflycoproteinst least six proteins in the RBC membrane belong to

he immunoglobulin superfamily of glycoproteins:

tSCmtm

LTtpdpboksicctbldmaw�crtemc

igtngLbdmoco5mr(gCbflit

ectvilIirfIIdrsm

L

Thcwt(edLgigGcic

lIaIets

iT1fihl

pnne


hese are the glycoproteins carrying Lutheran, LW,cianna, and Ok blood groups, as well as CD47 andD58, which have no known polymorphisms in hu-ans. The immunoglobulin superfamily glycopro-

eins primarily function as receptors and adhesionolecules.215,216

utheran Blood Group Systemhe Lutheran blood group glycoprotein is the recep-

or on erythroid cells for the extracellular matrixrotein, laminin. The glycoprotein consists of fiveisulfide-bonded extracellular, immunoglobulin su-erfamily domains, a single hydrophobic transmem-rane domain, and a cytoplasmic tail. Two isoformsf this type I membrane protein (85 kd [Lu] and 78d [BCAM] isoforms) are expressed by alternativeplicing of a single gene; both bind laminin. The twosoforms are distinguished by differences in theirytoplasmic domains; the 78-kd isoform has a trun-ated cytoplasmic tail.217-221 While the function ofhe Lutheran glycoprotein in normal RBCs remains toe defined, it mediates adhesion of sickle red cells toaminin.222-225 RBCs from patients with sickle cellisease express approximately one and a half timesore Lutheran glycoprotein than do normal RBCs,

nd the level of laminin binding to RBCs correlatesith the level of Lutheran expression. Laminin �-5/� mice have a dramatic decrease in Lutheran gly-

oprotein in diverse tissues.226-228 Lutheran glycop-otein is expressed late during erythroid differentia-ion and it may play a functional role in mediatingrythroblast-extracellular matrix interactions in thearrow that regulate egress of reticulocytes into the

irculation.The cytoplasmic region of Lutheran glycoprotein

nteracts with the membrane cytoskeleton.229 Threeenetic backgrounds generate the Lu(a�b�) pheno-ype: homozygosity for a recessive gene Lu, a domi-ant supressor gene InLu, and an X-linked recessiveene XS. Only the autosomal recessive type ofu(a�b�) can be considered a true null phenotype,ecause weak expression of Lutheran antigens can beemonstrated for the two other types. A nonsenseutation generating a stop codon was identified in

ne Lu(a�b�) individual who was therefore almostertain to lack the Lu glycoproteins, yet there were nobvious disease manifestations.230 About 1 person in,000231,232 inherits In(Lu), which is located on chro-osome 11p. The In(Lu) gene product has broad

egulatory functions: it inhibits expression of CD44an adhesive protein carrying the Indian bloodroup), MER2 (a common RBC antigen), CR1 (the3b/C4b complement receptor carrying the Knopslood group), AnWj (the erythroid Haemophilus in-uenzae receptor), and the glycolipid antigens P1 and

, as well as the Lutheran antigens.233 Second, al-
hough some of these proteins (like CD44) are widely h
xpressed, the action of In(Lu) is limited to erythroidells.234 Patients with the In(Lu) Lu(a�b�) pheno-ype have abnormally shaped RBCs; the morphologyaries from normal or mild poikilocytosis (bumpy,rregular cells) to marked acanthocytosis. No hemo-ysis or anemia is evident. Osmotic fragility of freshn(Lu) Lu(a�b�) RBCs is normal but during in vitroncubation RBCs lose K� and become osmoticallyesistant.231 The molecular mechanisms responsibleor this cation loss and for the regulatory effects of then(Lu) protein are not known, mostly because then(Lu) gene has not been cloned. Whether the re-uced Lu glycoprotein, some other protein, or dis-uption of a complex on the RBC membrane is re-ponsible for the maintenance of normal red cellorphology is yet to be determined.

W Blood Group System

he LW glycoprotein (also termed intracellular ad-esion molecule-4 [ICAM-4]) consists of two extra-ellular immunoglobulin superfamily domains,hich show strong sequence homology with the pro-

ein superfamily of intracellular adhesion moleculesICAMs).235 The 40- to 42-kd LW glycoprotein isncoded by a gene on chromosome 19. Extracellularomains of LW glycoprotein interact with integrinsFA1 (CD11/CD18)236 and �4�1 and �V inte-rins.237 In contrast to Lutheran glycoprotein, whichs expressed late during erythroid development, LWlycoprotein appears early in erythropoiesis beforePA and about the same time as RhAG.238 LW gly-

oprotein may function in erythroblast-macrophagenteractions (in erythroblastic islands) that are criti-al for erythropoiesis.239

LW also binds to a similar integrin, �IIb/�3. Plate-ets adhered better to ICAM-4–positive than toCAM-4–negative (LWnull) cells; immobilized RBCsnd platelets deficient in GPIIb/IIIa did not bind toCAM-4–coated microtiter wells.240,241 There is novidence that platelets and RBCs interact in vivo, buthese molecules may participate in pathological statesuch as vaso-occlusion in sickle cell disease.

The proband and her brother who have the rarenherited LWnull phenotype are apparently normal.he gene responsible for this LWnull phenotype has a0 –bp deletion and a premature stop codon in therst exon.242 Transient loss of LW antigen from RBCsas been reported in pregnancy and in lymphoma,

eukemia, sarcoma, and other malignancies.243

The LW protein is part of the Rh complex and isresent on D-negative RBCs at about half the copyumber as on D-positive RBCs. In cord blood theumber of copies of LW glycoprotein per red cell isqual in D-positive and D-negative RBCs and is
igher than in adults.

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k Blood Group Systemhe RBC antigen, Oka, is located on the Ok glycop-otein, a leukocyte activation antigen with two im-unoglobulin superfamily domains.244 The function

f the Ok glycoprotein (synonyms: CD147, neu-othelin, basigin) in RBCs is unknown, although con-erved sequence homologies within the cytoplasmicnd transmembrane domains suggest that it could becomponent of a signal transduction complex.245,246

nockout mice show that basigin is required formbryo implantation and expressed during spermat-genesis.247 Basigin is expressed in testes duringpermatogenesis but it is also present in azoospermicen with the Sertoli cell–only syndrome.248 Basiginay bind mannoside-containing glycoconjugates.249

The Oka antigen occurs with a high incidence andhe only known Ok(a�) individuals (eight pro-ands) are Japanese. The Ok(a�) phenotype is theesult of a single amino acid substitution in the Oklycoprotein.245

cianna Blood Group Systemuman erythrocyte membrane-associated protein

ERMAP) is expressed exclusively on erythroid cellsnd carries Scianna blood group antigens.250 ERMAPs predicted to have one extracellular transmembranemmunoglobulin-like domain; the intracellular re-ion has a conserved B30.2 domain and multipleinase-dependent phosphorylation consensus mo-ifs.251 Therefore, ERMAP is likely a receptor/signalransduction molecule specific for erythroid cells.252

g Blood Group Systemhe Xg glycoprotein is homologous with CD99,hich has adhesion properties and is thought to be

mportant in hemopoietic cell differentiation. CD99lso may mediate apoptosis of immature thymo-ytes.253-255 The function of Xg glycoprotein in RBCss not known.

The difference between the Xg(a�) and Xg(a�)lood groups is associated with the level of the Xga

ntigen and, presumably, Xg glycoprotein on theBC surface rather than a different gene product. Xga

ntigen escapes X-chromosome inactivation due tohe expression of a duplicate gene, MIC2, which lieselomeric and in the pseudoautosomal region of the Xhromosome. MIC2 (synonyms: CD99, E2) is ex-ressed on all cells and is an adhesion molecule on Tells.256 A portion of CD99 activates a caspase-inde-endent apoptosis pathway in T cells.257

MH Blood Group Systemhe JMH antigen is carried on the GPI-linked proteinD108, expressed on RBCs, some activated lympho-

257,258
ytes, neurons, epithelia, and testes. CD108 e
olecules are part of plasma membrane complexeshat are associated with intracellular protein ki-ases.257 Like other GPI-linked molecules, CD108 onBCs may be a receptor that plays a role in signal

ransduction.

Membrane Proteins That Functionas Enzymes

ell Blood Group Systemell glycoprotein is a 93-kd, single-pass type II mem-rane protein encoded by a gene on chromosomeq33.259 It has sequence homology with a family ofeutral endopeptidases and is an endothelin-3–con-erting enzyme; in addition to this activity, Kell gly-oprotein can also cleave the precursors of endothe-in-1 and endothelin-2, but much less effectively.260

ndothelins are potent vasoactive peptides involvedoth in the regulation of vascular tone and in devel-pmental processes. The Kell glycoprotein may par-icipate in the early stages of hematopoiesis or cellineage determination.261

The Kell glycoprotein carries the antigens in theell blood group system. In contrast to the pathology

een in Xk-deficient RBCs, Kell glycoprotein defi-iency does not result in RBC alterations107 (Tables 1nd 2).

The Kell system consists of five sets of high-inci-ence and low-incidence antigens (K/k; Kpa/Kpb/pc; Jsa/Jsb; K11/K17; K14/K24), three low-incidencentigens (Ula; K23; VLAN), and 10 high-incidencentigens (Ku; Km; K12; K13; K16; K18; K19; K22;OU, RAZ). The antigens are associated with a singlemino acid substitution of the Kell glycoprotein. Theto K substitution of Thr to Met disrupts the motif

or N-glycosylation and may explain the relativelyigh immunogenicity of the K antigen.262

t Blood Group Systemt antigens reside on acetylcholinesteraseAChE).263,264 The RBC isoform of AChE is GPI-inked and is present in the membrane as a dimer. Itsunction in RBCs is not known but the molecule isnzymatically active; the Yta/Ytb polymorphismwhich results from a single amino acid substitu-ion)265 does not affect the enzymatic activity ofchE.264 Yt(a�b�) RBCs have no obvious abnormal-

ties. AChE is a conventional type I transmembranerotein on neuronal cells, likely from alternate splic-ng of the mRNA.263

ombrock Blood Group Systemhe Dombrock blood group antigens reside on ADP-ibosyltransferase, a GPI-linked glycoprotein. This
nzyme (ART4) acts as a regulator of protein function

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hrough post-translational modification of the addi-ion of adenosine diphosphate (ADP)-ribose to a tar-et molecule.266 Despite extensive investigation, theBC Dombrock glycoprotein has yet to be shown toave enzymatic activity. The polymorphism leadingo the Doa/Dob antigens was identified as an aminocid substitution when the candidate gene was se-uenced.267 Various mutation events lead to theonull phenotype with no obvious deleterious effectn RBC structure or function.268

Complement Elementsand Regulatory Proteins

romer Blood Group System

ntigens in the Cromer blood group system are lo-ated on decay accelerating factor (DAF, CD55),hich is attached to the RBC membrane through aPI anchor. The DAF glycoprotein is arranged into

our extracellular short consensus repeat domains,ach with about 60 amino acid residues. The Cromerystem has two sets of antithetical antigens: Tca/Tcb/cc and WESa/ WESb. Nine of the antigens (Cra, Tca,ra, Esa, IFC, WESb, UMC, GUTI and SERF) are ofigh incidence and three (Tcb, Tcc, and WESa) are of

ow incidence. The amino acids required for expres-ion of these antigens have been determined, andith the exception of Dra are due to a single amino

cid change.269,270

DAF is present on all cells that are in contact withlasma (including blood cells and vascular endothe-ium), on epithelia of the gastrointestinal and urinaryracts, and in the nervous system. DAF is stronglyxpressed on the apical surface of trophoblasts271 andill absorb antibodies in the Cromer system fromaternal serum, explaining the lack of HDN due toromer antibodies. Although DAF is not expressedn paroxysmal nocturnal hemoglobinuria (PNH) IIIBCs, this deficiency is not the cause of their suscep-

ibility to hemolysis.DAF functions to accelerate the decay of both C3

nd C5 convertases regardless of whether they are theroducts of the classical or alternative pathways.hus, DAF inhibits the amplification stage of comple-ent activation and protects cells from complement-ediated damage. DAF is a receptor for Escherichia

oli and enterovirus.140,272,273 DAF is also found inlasma and other body fluids and prevents the acti-ation of C4b2a by inhibiting the deposition of C3bn the surface of RBCs.274 Together with membraneofactor protein (MCP), DAF catalyzes factor I–me-iated cleavage of C3b that binds to RBCs.275-277

RBCs from individuals with the Inab phenotype,he null phenotype of the Cromer system, do not haveignificant complement-induced lysis in vivo.278 Al-
hough protein-loosing enteropathy has been re- p
orted with the Inab phenotype, there is no clearisease association with this phenotype. The Dr(a�)ariant RBCs express inherited Cromer antigens veryeakly.

nops Blood Group Systemntigens of this system are carried on complement

eceptor 1 (CR1; CD35). CR1 is a type I single-passembrane glycoprotein and a member of a large

amily of proteins known as the complement controlrotein (CCP) family. The CR1 glycoprotein consistsf up to 30 repeated and disulfide-bonded domainsalled CCP modules. These modules, also termedhort consensus repeats, are organized into four re-ions called long homologus repeats (LHRs), eachegion consisting of seven short consensus repeats.279

ost importantly, CR1 copy number on RBCs variesreatly among healthy individuals. Less than 100opies per RBC are not detected using conventionallood group antibodies for the antigens expressed onhis receptor molecule. Knops antigen expression isariable among different individuals, as is the num-er of CR1 molecules per RBC.280 Like DAF, the CR1ene is located within the regulation of complementctivation (RCA) cluster on chromosome 1 at 1q32.R1 has four allotypes, A, B, C, and D. The most

requent allotypes are A (82%) and B (18%); thethers are exceedingly rare.

Soluble CR1 (sCR1) is present in low levels inlasma.281 CR1 protects RBCs from autohemolysis bynhibiting the classical and alternative complementathways through cleavage of C4b and C3b. CR1inds immune complexes, which are removed by theeticuloendothelial system in the liver and spleenithout damaging RBC integrity.140,273,282

Acquired deficiencies of CR1 have been describedn patients with systemic lupus erythromatosis, rheu-

atic diseases, and other malignant and inflamma-ory disorders. Low levels of CR1 on RBCs may causeeposition of immune complexes on blood vesselalls with subsequent damage to the vessels.283

Kna and McCa are common antigens with a similarrevalence (�90%) in different populations. How-ver, the Sla antigen is of high prevalence in whites98%) but of much lower occurrence among blacks60%). In vitro rosetting of P falciparum is reduced inninfected cells that are Sl(a�) or have low CR1

evels, suggesting that the Sl(a�) phenotype mightonfer resistance to malaria.284

hido/Rodgers Blood Group Systemhe complement elements C4A and C4B carry theodgers and Chido antigens, respectively, and aredsorbed onto RBCs from plasma. C4, the fourthomponent of complement, is involved in classical
athway activation. Functionally, C4A is more effec-

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ive than C4B in solubilizing immune complexes andnhibiting immune precipitation. C4B binds morefficiently to the RBC, thus causing hemolysis.

Of 18 cases with total C4 deficiency (Ch/Rgnull),4 had lupus; C4A null occurs in numerous otherutoimmune diseases such as Graves’ disease, rheu-atoid arthritis, and Sjorgen syndrome.285 C4B null

ene has been associated with IgA nephropathy andheumatoid arthritis as well as increased susceptibil-ty to bacterial meningitis in children.286

BO Blood Group SystemBO antigens are the most clinically significant hu-an alloantigens in transfusion medicine, yet their

hysiology remains to be elucidated. The antigens ofhe ABO system, which are not the primary generoduct, require the sequential action of glycosyl-ransferases for expression. Lack of A, B, and H anti-ens on RBCs, as in individuals with the Bombayhenotype (Oh), does not affect erythrocyte function,ntegrity, or survival,287 nor are there reports of in-reased propensity to infection or disease in thesendividuals.

The carbohydrate antigens A, B, H, Le, and P1re present on many human cells other than RBCsnd are also found in animals, bacteria, and even inome plants. On red cells, these antigens contrib-te to glycocalyx but otherwise their function isnknown.85

ewis Blood Group Systemewis antigens (Lea and Leb) on RBCs are derived

rom plasma and not synthesized by the RBC.289

ewis antigens are expressed in many human tissuesncluding gastric surface mucous cells. Helicobacterylori, the major causative agent of gastric ulcers,inds to gastric surface mucous cells that containucose, specifically Leb and H (type 1 chain) antigens,ith Leb the predominant receptor for the organ-

sm.290 H pylori mimics cell surface glycomolecules

Table 4. Components Carrying Blood Group Antigens That Serveas Receptors for Infectious Agents

Receptor Infectious Agent/Micro-organism

roteinsDuffy Plasmodium vivaxGlycophorin A Plasmodium falciparumAnWj Hemophilus influenzaeCromer Escherichia coli, enterovirusesKnops (S1a) Plasmodium falciparumarbohydratesLewis Helicobacter pyloriP (Globoside) Parvovirus B19P1, Pk Escherichia coli

resent in gastric mucosa through the expression of R

ewis antigens, facilitating H pylori infection. Mosttrains of H pylori express Lex and Ley (the type 2hain structures) and a small minority of strainsxpress Lea and Leb antigens on type 1 chains. Theinding moiety of H pylori, Bab A (blood group anti-en binding adhesin), has been purified and Bab Aay mediate H pylori adherence to gastric epithelium

s an important bacterial virulence factor.291 In trans-enic mice expressing a human receptor for H pylorin their gastric mucosa, H pylori attachment resultedn production of autoantibodies directed at Lex. Lex

pitopes are common to both H pylori and gastricarietal acid–secreting cells. Chronic type B gastritiss well as gastric and dudenal ulcers may develop dueo an autoimmune process or through an inflamma-ory response to H pylori colonization.292 Lewis de-erminants on H pylori, the host Lewis phenotypeype, and the severity of the inflammatory responseave been correlated.293 Factors other than Lewisxpression must influence disease progression, be-ause isolates of H pylori that do not express Lewisntigens colonize gastric mucosa and cause infection,nd individuals with the Le(a�b�) phenotype canecome infected with H pylori and develop ulcers.arbohydrate chains expressing Leb in blood group� and B� individuals, unlike those of group O

ndividuals, are frequently substituted with the A or Bctive sugar; these substituted chains do not permitinding of H pylori. This biochemical difference mayxplain earlier observations that group O individualsave a higher incidence of ulcers than those of groupor B.290

Lewis antigens may act as receptors for other in-ectious pathogens. Lex (an isomer of Lea) and Ley (ansomer of Leb) were found as neoantigens on malig-ant tissues294; their presence and the density appar-ntly correlated with tumor metastatic potential.

loboside Blood Group Systemhe P antigen is the receptor for parvovirus B19,hich specifically infects erythroid progenitors. B19

auses erythema infectosum (fifth disease) in normalhildren and adults, and worsening of anemia asransient aplastic crisis in patients with hemolysis,nd chronic hypoplastic anemia if the host is unableo mount an effective neutralizing antibody re-ponse.295,296 P-fimbriated strains of E coli, often re-ponsible for pyelonephritis, express both P-bindingnd Pk-binding molecules at the tips of their pili,hich bind to P and Pk antigens through the disac-

haride Gal�1-4Gal.297

aph Blood Group SystemER2 was first identified as a blood group antigen

sing monoclonal antibodies. More than 92% of
BCs are MER2�. When the human antibody was

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ound, the antigen was renamed Raph. Anti-MER2ound in three Raph-negative individuals with renalailure suggests that MER2 might be required forormal renal function.298

nfectious Diseases and Blood Groupntigensome blood group antigens are expressed on tissuesther than RBCs, including the epithelium of theastrointestinal and urogenital tracts and lungs,hich are exposed to multiple micro-organisms. Sev-

ral carbohydrate and protein antigens have beenhown to act as adhesion or receptor molecules fornfectious agents (Table 4).

Conclusion

n this review we have described the function of many ofhe protein components of the RBC membrane. Theame protein or homologous proteins in other tissuesay have defined functions, beyond the scope of this

eview and described elsewhere.140,273,299 It is impor-ant to consider that a component in the RBC mem-rane does not exist in isolation and interactions withinicroenvironments of the membrane may be important

o functionality.Blood group polymorphisms generally do not af-

ect the biological function of the component and inact usually occur in the relatively nonconserved re-ions—thus, variations can be tolerated. Notable ex-eptions are Leb and Sla, which bind Helicobacterylori and Plasmodium falciparum, respectively,here the specific antigen is required for the bindingf the microbe. Some blood group phenotypes appearo confer a selective advantage: an example is they(a�b�) in areas where certain forms of malaria arendemic. Other components, like CR1 and GPA, maye present in the RBC membrane to efficiently re-ove microbes from the circulation, thereby protect-

ng the host from infection.

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Red Blood Cell (RBC) Membrane Proteomics

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