I don’t think there is a well-defined mechanism for this.
The natural keys are assigned at the ItemGroupDef/ItemRef level, and the supplemental qualifier variables do not appear there.
The reason is that SDTM and the FDA still refuse us to put such variables in the domain/dataset itself (i.e. where they belong) and just mark them as “supplemental” in the define.xml.
For the stylesheet, please remember that the stylesheet delivered by CDISC is just an example stylesheet, and that it is the sponsor’s responsibility to provide an appropriate stylesheet. So you can (and should in this case) extend the stylesheet in order to make this possible. I have a lot of experience in developing stylesheets, so if you need help with this, please contact me by e-mail (address can easily be found).
In SDTMIG Section 4.1.1.9 Assigning Natural Keys in the Metadata , it shows how to specify key variables when it spans across to supplemental qualifiers.
Does the current P21 engine 2508.0 allow the use of QNAM.xxxxx as key variable in the define without causing additional issue while trying to resolve the duplicate records issue?