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The term Rhesus (Rh) blood group system refers to the 5 main Rhesus antigens (C, c, D, E, and e) as well as the many other less frequent Rhesus antigens. The terms Rhesus factor and Rh factor are equivalent and refer to the RhD antigen only.

Rhesus factor

Individuals either have, or do not have, the Rhesus factor (or Rh D antigen) on the surface of their red blood cells. This is usually indicated by "RhD positive" (does have the RhD antigen) or "RhD negative" (does not have the antigen) suffix to the ABO blood type. Unlike the ABO antigens, the only ways antibodies are developed against the Rh factor are through placental sensitization or transfusion. That is, if a person who is RhD-negative has never been exposed to the RhD antigen, they do not possess the RhD antibody. The "RhD-" suffix is often shortened to "D pos"/"D neg", "RhD pos"/"RhD neg", or +/−. The latter is generally not preferred in research or medical situations, because it can be altered or obscured accidentally.

There may be prenatal danger to the fetus when a pregnant woman is RhD-negative and the biological father is RhD-positive. But, as discussed below, the situation is considerably more complex than that.

History of discoveries

The Rhesus system is named after the Rhesus Macaque, following experiments by Karl Landsteiner and Alexander S. Wiener, which showed that rabbits, when immunized with rhesus monkey red cells, produce an antibody that also agglutinates the red blood cells of many humans. Landsteiner and Wiener discovered this factor in 1937 (publishing in 1940). The significance of the Rh factor was soon realized. Dr. Phillip Levine working at the Newark Beth Israel Medical Center made a connection between the Rh factor and the incidence of erythroblastosis fetalis, and Wiener realized adverse reactions from transfusions were also resulting from the Rh factor. Wiener then pioneered the exchange transfusion to combat erythroblastosis fetalis in newborn infants. This transfusion technique saved the lives of many thousands of infants before intrauterine transfusion was invented which enabled much more severely affected fetuses to be successfully treated. Drs. Neva Abelson and L.K. Diamond co-discovered a simple test for the Rh factor which was widely applied.

Rh nomenclature

The Rhesus system has two sets of nomenclatures, one developed by Fisher and Race and one by Wiener. Both systems reflected alternative theories of inheritance. The Fisher-Race system, which is more commonly in use today, uses the CDE nomenclature. This system was based on the theory that control the product of the corresponding antigen (e.g., D gene produces D antigen, and so on). However, the d gene was hypothetical, not actual.

The Wiener system used the Rh-Hr nomenclature. This system was based on the theory that there was one gene at a single locus on each chromosome of the pair which controls production of multiple antigens. In this theory a gene R is supposed to give rise to the “blood factors” Rho, rh’, and hr” and the gene r to produce hr’ and hr”.

Notations of the two theories are used interchangeably in blood banking (e.g., Rho(D)). Wiener’s notation is more complex and cumbersome for routine use. Because it is simpler to explain, the Fisher-Race theory is more widely used.

DNA testing has shown that both theories are partially correct. There are in fact two linked genes, one with multiple specificities and one with a single specificity. Thus, Wiener's postulate that a gene could have multiple specificities (something many did not give credence to originally) has been proven correct. On the other hand, Wiener's theory that there is one gene has proven incorrect, as has the Fischer-Race theory that there are three genes.

Rhesus system antigens

The proteins which carry the Rhesus antigens are transmembrane proteins, whose structure suggest that they are ion channels[305106]. The main antigens are C, D, E, c and e, which are encoded by two adjacent gene loci, the RHD gene which encodes the D antigen [305107] and the RHCE gene which encodes both the C and E antigens [305108]. There is no d antigen. Lowercase "d" indicates the absence of the D antigen (the gene is usually deleted or otherwise nonfunctional).

Rhesus genotypes
Genotype symbol Rh(D) status
cde/cde rr Negative
CDe/cde R1r Positive
CDe/CDe R1R1 Positive
cDE/cde R2r Positive
CDe/cDE R1R2 Positive
cDE/cDE R2R2 Positive

Rh Phenotypes in Patients and Donors
Rh Phenotype CDE Patients (%) Donors (%)
R r CcDe 37.4 33.0
R R CcDEe 35.7 30.5
R R CDe 5.7 21.8
rr ce 10.3 11.6
R r cDEe 6.6 10.4
R R cDe 2.8 2.7
R R cDE 2.8 2.4
rr’’ cEe 0.98
R R CDE 0.03
rr’ Cce 0.8

Hemolytic disease of the newborn

This condition occurs when there is an incompatibility between the blood types of the mother and the baby. These terms do not indicate which specific antigen-antibody incompatibility is implicated. The disorder in the fetus due to rhesus-D incompatibility is known as erythroblastosis fetalis.

  • Hemolytic comes from two words: hemo (blood) and lysis (destruction) or breaking down of red blood cells
  • Erythroblastosis refers to the making of immature red blood cells
  • Fetalis refers to the fetus

When the condition is caused by the RhD antigen-antibody incompatibility, it is called RhD Hemolytic disease of the newborn (often called Rhesus disease or Rh disease for brevity). Here, sensitization to Rh D antigens (usually by feto-maternal transfusion during pregnancy) may lead to the production of maternal IgG anti-RhD antibodies which can pass through the placenta. This is of particular importance to RhD negative females of or below childbearing age, because any subsequent pregnancy may be affected by the Rhesus D hemolytic disease of the newborn if the baby is Rh D positive. The vast majority of Rh disease is preventable in modern antenatal care by injections of IgG anti-D antibodies (Rho Immune Globulin). The incidence of Rhesus disease is mathematically related to the frequency of RhD negative individuals in a population, so Rhesus disease is rare in East Asians, South Americans, and Africans, but more common in Caucasians.

  • Symptoms and signs in the fetus:
    • Enlarged liver, spleen, or heart and fluid buildup in the fetus' abdomen seen via ultrasound.

  • Symptoms and signs in the newborn:
    • Anemia which creates the newborn's pallor (pale appearance).
    • Jaundice or yellow discoloration of the newborn's skin, sclera or mucous membrane. This may be evident right after birth or after 24–48 hours after birth. This is caused by bilirubin (one of the end products of red blood cell destruction).
    • Enlargement of the newborn's liver and spleen.
    • The newborn may have severe edema of the entire body.
    • Dyspnea or difficulty breathing.

Population data

The frequency of Rh factor blood types and the RhD neg allele gene differs in various populations.

Population data for the Rh D factor and the RhD neg allele
Population Rh(D) Neg Rh(D) Pos Rh(D) Neg alleles
European Basque approx 35% 65% approx 60%
other Europeans 16% 84% 40%
African American approx 7% 93% approx 26%
Native Americans approx 1% 99% approx 10%
African descent less 1% over 99% 3%
Asian less 1% over 99% 1%


The Rh(D) antigen is inherited as one gene (RHD) (on the short arm of the first chromosome, 1p36.13-p34.3) with two alleles, of which Rh+ is dominant and Rh- recessive. The gene codes for the RhD polypeptide on the red cell membrane. Rh- individuals who lack a functional RHD gene (dd genotype) do not produce the D antigen, and may be sensitized to Rh+ blood.

Two very similar epitopes are encoded on the same protein on the adjacent related RHCE gene, Cc and Ee. It is believed that the RHD gene arose by duplication of the RHCE gene during primate evolution. Mice have just one RH gene.

The Rhesus system is much more complex than the ABO blood type system because there are more than 30 combinations possible.


The structure homology data suggest that the product of RHD gene, the RhD protein, acts as an ion pump of uncertain specificity (CO2 or NH3) and unknown physiological role . Two recent studies have reported a protective effect of the RhD-positive phenotype, especially RhD heterozygosity, against the negative effect of latent toxoplasmosis on psychomotor performance of infected subjects. RhD-negative compared to RhD-positive subjects without anamnestic titres of anti-Toxoplasma antibodies have shorter reaction times in tests of simple reaction times. And conversely, RhD-negative subjects with anamnestic titres (i.e. with latent toxoplasmosis) exhibited much longer reaction times than their RhD-positive counterparts. The published data suggested that only the protection of RhD-positive heterozygotes was long term in nature; the protection of RhD-positive homozygotes decreased with duration of the infection while the performance of RhD-negative homozygotes decreased immediately after the infection.

Origin of RHD polymorphism

For a long time, the origin of RHD polymorphism was an evolutionary enigma. Before the advent of modern medicine, the carriers of the rarer allele (e.g. RhD-negative women in a population of RhD positives or RhD-positive men in a population of RhD negatives) were at a disadvantage as some of their children (RhD-positive children born to preimmunised RhD-negative mothers) were at a higher risk of fetal or newborn death or health impairment from hemolytic disease. The higher tolerance of RhD-positive heterozygotes against Toxoplasma-induced impairment of reaction time could counterbalance the disadvantage of the rarer allele and could be responsible both for the initial spread of the RhD allele among the RhD-negative population and for a stable RhD polymorphism in most human populations. Differences in the prevalence of Toxoplasma infection between geographical regions (0–95%) could also explain the striking variation in the frequency of RhD-negative alleles between populations. It is possible that the better psychomotor performance of RhD-negative subjects in the Toxoplasma-free population could be the reason for spreading of the “d allele” (deletion) in the European population. In contrast to the situation in Africa and certain (but not all) regions of Asia, the abundance of wild cats (definitive hosts of Toxoplasma gondii) in the European territory was very low before the advent of domestic cat.

Weak D

In testing, Rh positive blood is easily identified. Units which are Rh negative are often retested to rule out a weaker reaction. This was previously referred to as Du, which has fallen out of favor. In some cases, this phenotype occurs because of an altered surface protein that is more common in people of African descent. The testing is difficult, since using different anti-D reagents, especially the older polyclonal reagents, may give different results.

The practical implication of this is that people with this sub-phenotype will have a product labeled as "Rh positive" when donating blood. When receiving blood, they are sometimes typed as a "Rh negative", though this is the subject of some debate. Most "Weak D" patients can receive "Rh positive" blood without complications. This is important, since most blood banks have a limited supply of "Rh negative" blood. Patients who test as "Rh negative" and whose "Rh positive" status is detectable with an IAT are commonly given "Rh negative" blood, but this is also debated.

Other Rh group antigens

43 other Rh group antigens have been described, but they are either much less frequently encountered or are rarely clinically significant. Each is given a number, though the highest assigned number (Rh56 or CENR) is not an accurate reflection of the antigens encountered since many (e.g. Rh38) have been combined, reassigned to other groups, or otherwise removed.


  1. Wsutoday Test for Rh factor
  2. Genetics of Rhesus Factor

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