The Lewis System

Justin R. Rhees, M.S., MLS(ASCP)CMSBBCM

University of Utah
• Discuss the genetic interactions of Le genes with ABH and
Se genes.
• Describe the formation and secretion of Lewis antigens and
their adsorption onto the red cell membrane.
• Describe the clinical significance of anti-Lea and anti-Leb

Objectives
• Describe in detail the phenotypes capable of forming Anti-Lea
and Anti-Leb.
• Define the term transitional phenotype as it relates to the age
of the patient.
• Describe the changes in Lewis phenotypes and presence of
Lewis antibodies during pregnancy and clinical significance.
• Given results of a secretor inhibition study, correctly interpret
whether substances are present or not present. Based on these
results, apply your knowledge of gene interaction to identify
the likely Le, Se, and ABH genes present.

Objectives
 The Lewis system is unique.

Lewis system—the liquid

antigen system
Antigen production
The Lewis and ABO systems
Clinical significance
Lewis antibody detection and
identification

Lewis system overview

1. Lea and Leb are NOT alleles of a blood group system.
2. Genes Le and le (amorph)
3. The Le gene must be present for a precursor substance
to be converted to Lea.
4. But, the Se gene must be present for conversion to Leb.

The most important items

 Gene Locus
ABO ABO 9q
 Gene Locus
ABO ABO 9q
H FUT1 19q
 Gene Locus
ABO ABO 9q
H FUT1 19q
Se FUT2 19q

99.99% inherit H (FUT1) gene

~80% inherit Se (FUT2) gene

Secretors in U.S. populations

 Gene Locus
ABO ABO 9q
H FUT1 19q
Se FUT2 19q
Le FUT3 19p

~90% inherit Le (FUT3) gene*

*Lewis gene in U.S. Caucasians

 H antigen on RBC

D-Galactose (GAL)
Fucose
N-acetylglucosamine (GLNAC)
D-Galactose (GAL)
Glucose

RBC Membrane
Ceramide
 A antigen on RBC
N-acetylgalactosamine

D-Galactose (GAL)
Fucose
N-acetylglucosamine (GLNAC)
D-Galactose (GAL)
Glucose

RBC Membrane
Ceramide
 D-Galactose (GAL)
Fucose
N-acetylglucosamine (GLNAC)
D-Galactose (GAL)
Glucose

RBC Membrane
Ceramide
 B antigen on RBC
D-Galactose

D-Galactose (GAL)
Fucose
N-acetylglucosamine (GLNAC)
D-Galactose (GAL)
Glucose

RBC Membrane
Ceramide
• Formation of Lewis and ABO antigens is similar:
• The Le gene produces L-fucosyltransferase to add L-fucose
to the basic precursor substance.
• This acts in competition with ABO, as L-fucose is added to
soluble substances.
L-fucose
D-galactose D-galactose
N-acetylgalactosamine

Protein backbone N-Acetylglucosamine

Formation of Le a
• A person who has inherited the H gene and the Se gene
will have the following in secretions (soluble H):

L-fucose
D-galactose D-galactose
N-acetylgalactosamine

Protein backbone N-Acetylglucosamine

Soluble H substance
• When both Le and Se genes are inherited, the structure is
further modified, producing Leb antigen:

D-galactose D-galactose
N-acetylgalactosamine

Protein backbone N-Acetylglucosamine

Formation of Le b
• Adult with RBC phenotype: Le(a-b-)
• Lack Le gene.
• le/le
• Either secretors (Se) or non secretors (se/se).
• 6% Caucasians, 22% African Americans
• Can form antibodies to Lea and/or Leb without RBC
stimulus.
• What do we call this type of antibody?

Non-RBC
le/le Immune
• Le gene present, non-secretor (se/se):
• Lea antigen produced, present in secretions
• Lea antigen adsorbs onto RBC membrane
• Adult RBC phenotype:
• Le(a+b-)

Le and se/se
• Le gene present, secretor (Se/se):
• Lea antigen produced, present in secretions
• Lea antigen further modified by secretor gene to also
produce Leb antigen (in higher concentrations)
• RBC membrane absorption: Leb antigen competes with Lea
and WINS!!!
• Adult RBC phenotype:
• Le(a-b+)

Le and Se/se
• The formation of Leb substances is only possible with
the inheritance and genetic interaction of both Le and
Se genes.
• Both Lea and Leb substances occur in secretions
• Only Leb substance is absorbed onto the RBC membrane,
Le(a-b+)

Remember!
And now a quiz!
Nooooooo!
• Lele, Sese, A/B/H genes results in what in secretions, and
what on the RBCs?
Secretions: Lea, Leb, A, B, and H
RBC antigens: A, B, H, Le(a-b+)

Question 1
• Lele, sese, O/O/H genes results in what in secretions, and
what on the RBCs?
Secretions: Lea
RBC antigens: H, Le(a+b-)

Question 2
• What is the following structure?
Soluble H antigen
L-fucose
D-galactose D-galactose
N-acetylgalactosamine

Protein backbone N-Acetylglucosamine

Question 3
• Can a person with the RBC phenotype Le(a-b+) make
anti-Lea?
• No. Le(a-b+) is the result of Lea substance being further
modified to Leb by the action of the Se gene. Both Lea
and Leb antigens are present in secretions. Therefore, the
individual does not normally form anti-Lea.

Question 4
• Regardless of inheritance, “all” neonates type as Le(a-b-)
• If a person has inherited Le and Se, they will eventually
end up typing as Le(a-b+).
• But, this is a process:
• Neonate begins as Le(a-b-)
• RBCs can then transform to Le(a+b-) after 10 days
• Le(a+b+) transitional phenotype.
• Finally, Le(a-b+) phenotype is expressed as the true
phenotype after 6-7 years.

Phenotype development
 Le(a-b-)

Neonate
 Le(a+b-)

After 10 days
 Le(a+b+)

“Transitional phenotype”
 Le(a-b+)

After 6-7 years

• The Lewis system is not implicated in hemolytic disease
of the fetus and newborn (HDFN) Why?
• Regardless of inheritance, fetal blood is Le(a-b-)
 As if this wasn’t already
strange enough!

More strange stuff about

the Lewis system…
• Phenotype can change.
• Lewis antigens can disappear during pregnancy:
• Le(a-b-) phenotype during gestation.
• Anti-Lea and/or anti-Leb present in serum.
• Lack of Lewis antigen expression on RBCs can also
occur in patients with:
• cancer
• alcoholic cirrhosis
• viral and parasitic infections

Changes in Lewis
phenotype
• The Le(a+b+) phenotype in adults is rare in Caucasians
and African Americans
• Asians: 10-40%
• Weaker Se gene, more common in Asia, produces a
fucosyltransferase that competes less effectively with the Le
fucosyltransferase.
• Both Lea and Leb are adsorbed onto the RBC membrane.

Le(a+b+)
Lewis Antibodies
• Non-RBC Immune (naturally occurring)
• Produced without exposure to foreign RBCs
• Generally IgM, cold reactive
• Generally produced by patients with Le(a-b-) phenotype.
• Anti-Lea can be stronger than anti-Leb
• Can cause in vitro/ in vivo hemolysis (rare)

anti-Lea
Hemolysis observed
Ficin (fig)
Papain (papaya)
Trypsin (pig stomach)
Bromelin (pineapple)

Enhanced!

Effect of enzyme treatment?

• Anti-Lea is more commonly encountered than anti-Leb.
• It is produced in approximately 20% of individuals of the
Le(a-b-) phenotype.
• Primarily of IgM class, but some may have IgG
components or be entirely IgG.
• Anti-Lea is frequently detected with saline suspended red
cells at room temperature. However, it sometimes reacts
at 37°C and AHG and is capable of causing hemolytic
transfusion reactions.

anti-Lea
• Anti-Leb is not as common, and generally does not act as
strongly as anti-Lea.
• Like anti-Lea, it is produced by individuals with Le(a-b-)
phenotype.
• However, it can be produced by Le(a+b-) individuals.
(Remember Le, sese inheritors have no Leb present in
secretions, only Lea substance.)

anti-Leb
• Anti-Lea is capable of causing HTR (rare).
• If detected at 37°C or AHG phase, it is considered to be
clinically significant
• Only crossmatch compatible blood should be transfused.

Clinical significance of
Lewis antibodies
• Lewis antibodies are generally considered insignificant
in blood transfusion practices because:
1. Neutralized by soluble Lewis Ag in secretions
2. Ag positive donor cells can become Ag negative in
recipient
3. IgM= do not cross placenta, also Ag not formed on fetal
cells (no HDFN)

Clinical significance of
Lewis antibodies
• Anti-Leab reacts with:
• Le(a+b-)
• Le(a-b+)
• ~90% of cord blood cells, serologically Le(a-b-)

Additional Antibodies
• Anti-LebH reacts with:
• Group O Le(b+)
• Group A2 Le(b+)

Additional Antibodies
• Anti-ALeb reacts with:
• Group A1 Le(b+)
• Group A1B Le(b+)
• Anti-BLeb reacts with:
• Group B Le(b+)
• Group A1B Le(b+)

Additional Antibodies
 Problem Solving:
Secretor Inhibition Studies
• We can use the Secretor Inhibition Test to determine if
Lewis, H, and ABO soluble antigens are present in saliva.
• How the test works:
• Antibody of a known specificity is added to the person’s
prepared saliva specimen.
• If soluble antigen is present in the saliva, it will neutralize
the antibody.

Secretor Inhibition
 • Red blood cells with the corresponding antigen are then
added to the test.
• If “+” reaction, the antibody was NOT neutralized (soluble
antigen NOT present in saliva).
• If “0” reaction, the antibody WAS neutralized (soluble antigen
IS present in saliva).

Secretor Inhibition
 O Cells
A1 B O Cells
Le(a-)
Cells Cells Le(a+)
(Control)
Saliva +
Anti-A
Saliva+
Anti-B
Saliva +
Anti-Lea
Saliva +
Anti-H

For this test, assume NO individuals are Oh Bombay phenotype h/h

 O Cells
A1 B O Cells
Le(a-)
Cells Cells Le(a+)
(Control)
Saliva +
Anti-A
Saliva+
Anti-B
Saliva +
Anti-Lea
Saliva +
Anti-H
 O Cells
A1 B O Cells
Le(a-)
Cells Cells Le(a+)
(Control)
Saliva +
Anti-A +
Saliva+
Anti-B
Saliva +
Anti-Lea
Saliva +
Anti-H
Saliva + Anti-A + A1 Cells = Positive Reaction
This means the Anti-A in the tube was NOT neutralized
Therefore, the saliva does NOT have A substance
 O Cells
A1 B O Cells
Le(a-)
Cells Cells Le(a+)
(Control)
Saliva +
Anti-A +
Saliva+
Anti-B +
Saliva +
Anti-Lea
+ 0
Saliva +
Anti-H
0 0
B Substance NOT present
Lea Substance NOT present
H substance is present
Remember, O cells are RICH in H antigen
 O Cells
A1 B O Cells
Le(a-)
Cells Cells Le(a+)
(Control)
Saliva +
Anti-A +
Saliva+
Anti-B +
Saliva +
Anti-Lea
+ 0
Saliva +
Anti-H
0 0
No A, B, or Lea, in saliva, but the person secretes H substance. Which genes are present?
H gene, Se gene, le/le
And, we know the person is O/O
If they are secreting H substance, but no A or B, they must be type O
 O Cells
A1 B O Cells
Le(a-)
Cells Cells Le(a+)
(Control)
Saliva +
Anti-A +
Saliva+
Anti-B 0
Saliva +
Anti-Lea
0 0
Saliva +
Anti-H
0 0
No A substance in saliva
Have B substance, Lea substance, and H substance in Saliva
Genes present?
H, B, Le, and Se
 O Cells
A1 B O Cells
Le(a-)
Cells Cells Le(a+)
(Control)
Saliva +
Anti-A +
Saliva+
Anti-B +
Saliva +
Anti-Lea
+ 0
Saliva +
Anti-H
+ +
No A, B, Lea, or H in saliva
Negative Control Anti-Lea with Le(a-) cells produced no reaction
Genes present?
No Le, No Se. Because this person is a non-Secretor, can’t make assumptions about ABO
 O Cells
A1 B O Cells
Le(a-)
Cells Cells Le(a+)
(Control)
Saliva +
Anti-A 0
Saliva+
Anti-B 0
Saliva +
Anti-Lea
0 0
Saliva +
Anti-H
0 0

Practice Problem: What substances are present in saliva?

Based on this information, what gene(s) might be present?
• Substances present: A, B, Lea, and H
• Genes present: Se, Le, H, A/B

Answer
• Based upon this information, can you make assumptions
about what antigen(s) is/are present on the person’s
RBCs?
• H, and A/B genes: Person’s RBC type is AB
• Le and Se genes: Person’s RBC type is likely Le(a-b+)

Thank you!

Follow-up Question
1. Reid ME, Lomas-Francis C. Blood Group Antigens and
Antibodies. SBB Books. New York. 2007.
2. Harmening DM, Ed. Modern Blood Banking and
Transfusion Practices, 5th and 6th Editions. F.A. Davis
Company. Philadelphia. 2005, 2012.
3. Roback, JD, Ed. AABB Technical Manual, 17th Edition
4. Nosferatu (1922) FW Murnau, starring Max Schreck,
Greta Schröder. Images lovingly downloaded from
Flickr Creative Commons.

References