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Rh proteins are encoded by two genes, RHD and RHCE on chromosome 6. Due to the various mutations, Rh is considered one of the most complex blood group system. The additional RHD sequences in RHCE with a normal RHD explain the elevated D (-D-). Such individuals, produce anti-Rh17 antibody (anti-Hro) after the immune stimulus. 
We report one such case and the challenges faced in resolving and providing transfusion support.
A 36-year-old Indian male suffering from chronic liver disease was admitted for a liver transplant at our institute. Owing to a transfusion requirement (Haemoglobin 4.7g/dl), preliminary investigations pertaining to blood bank i.e. blood grouping and antibody screening was sent.
On testing, the blood group was found to be O Rh D positive. The patient had a history of blood transfusion 2 years back. The antibody screen (4 cell panel, Immucor, Norcross, USA) was positive, and the antibody identification was done. The sample reacted with all cells in the 16 cell panel (Capture-R Ready-ID, Immucor Inc., Norcross, USA) and 11 cell panel (ID-DiaPanel, Biorad). The auto-control and direct antiglobulin test (DAT) was negative. On phenotyping (Immucor, Norcross) for the Rh and Kell antigens, it was found that patient was serological -D- K-. It was concluded that the patient was a case of elevated D with anti-Rh 17 antibody (anti- Hro) which is clinically significant. Only Rh null or -D- phenotype red cells will be compatible with the patient.
None of the units in our inventory was -D-. Search for compatible blood among first-degree relatives was made. Patients’ mother and brother had -D- phenotype with the “O” blood group. One unit from each of them was collected, irradiated and transfused. In the meanwhile, search for this rare unit was ongoing and the Japanese Red Cross Society, American Red Cross Society and IBGRL (International Blood Group Reference Laboratory), United Kingdom were contacted. The formalities for the shipment were done and 5 units were imported from the Japanese Red Cross Society. They were transfused to the patient after due processing of the units as per the departmental protocol for the same.
Rare blood groups are those which have a prevalence of <1 in 1000 of the random population . Rarity may vary from country to country depending upon the prevalent phenotypes in a given geographical and ethnic population. Lack of the high-frequency antigen Rh17 is considered among one of the rare phenotypes in India. As per a report by Joshi et al , 4 such cases were found in India. Internationally, there have been few reported cases of HDFN due to anti-Rh17 in the literature, most of them being from Japan. [4-6]
We encountered a case where anti-Rh 17 was developed after an immunizing event (table 1). Negative direct antiglobulin and auto control test excluded the possibility of auto-antibodies.
The patient has two siblings, one of which was -D-. The youngest sibling was CCee phenotypically, which explains why the mother had repeated abortions after the third childbirth. She might have developed the anti-Hro antibody which might have led to HDFN in her subsequent pregnancies which went undiagnosed.
Though the components were available and imported from another country, it consumes time and requires high financial and legal documentary support to arrange the same which might often be limiting. It imposes further psychological, physical and mental stress amidst the already existing combat with life.
Prevalence of -D- in the Japanese population is estimated to be in <1 in 100,000. The Japanese Red Cross maintains an inventory of the rare blood groups and is actively providing many rare phenotype units around the world . Here comes the role of establishing a rare donor registry in India and international collaborations which prove fruitful in such adverse needs. Maintaining an accessible indigenous rare donor programme can go a long way in helping out such cases at the earliest. Though Immunohematology Reference Laboratory at the National Institute of Immunohematology, Mumbai, under the aegis of the Indian Council of Medical Research (ICMR), Government of India has been earmarked for the same and has few rare donor phenotypes identified and registered as delineated by Kaur et al , we required more number of units so the international registries were contacted. India, being the second largest population in the world, the provision for identification and confirmation of the rare phenotypes should be made accessible to most of the blood banks or at least few reference centers need to be earmarked for the same so that the high potential in the country can be well utilized.
Anti-Hro is an alloantibody produced in individuals with –D- phenotype after a sensitizing event. Owing to the rarity of this antigen negative unit, registration in rare donor registries help in procuring blood components at the earliest. We had a case with anti-Hro antibody and who required many units of red cells which were imported from the Japanese Red Cross Society. Accessibility for identification and confirmation of rare blood groups and provision of the same can be centralized and liaison with the international registries can go a long way in the provision of blood components at the earliest.
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