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ABO Blood Group System

History: Karl Landsteiner

Discovered the ABO Blood Group System in 1901 He and his five co-workers began mixing each others red cells and serum together and inadvertently performed the first forward and reverse ABO groupings

Why is it important?

ABO compatibility between donor cell and patient serum is the essential foundation of pretransfusion testing It is the only system with expected antibodies Whether they are IgG or IgM, ABO antibodies can activate complement readily

This means that incompatibilities can cause life threatening situations (transfusion reactions)

ABO antigens:

Biochemical & Genetic Considerations

ABO and H Antigen Genetics

Genes at three separate loci control the occurrence and location of ABO antigens The presence or absence of the A, B, and H antigens is controlled by the H and ABO genes

The presence or absence of the ABH antigens on the red blood cell membrane is controlled by the H gene The presence or absence of the ABH antigens in secretions is indirectly controlled by the Se gene

ABO Antigen Genetics

H gene H and h alleles (h is an amorph) Se gene Se and se alleles (se is an amorph) ABO genes A, B and O alleles

H Antigen

The H gene codes for an enzyme that adds the sugar fucose to the terminal sugar of a precursor substance (PS) The precursor substance (proteins and lipids) is formed on an oligosaccharide chain (the basic structure)

RBC Precursor Structure


Galactose N-acetylglucosamine Galactose

Precursor Substance (stays the same)

Formation of the H antigen



H antigen

Galactose N-acetylglucosamine Galactose


H antigen

The H antigen is the foundation upon which A and B antigens are built A and B genes code for enzymes that add a sugar to the H antigen

Immunodominant sugars are present at the terminal ends of the chains and confer the ABO antigen specificity

A and B Antigen

The A gene codes for an enzyme (transferase) that adds N-acetylgalactosamine to the terminal sugar of the H antigen


The B gene codes for an enzyme that adds D-galactose to the terminal sugar of the H antigen


Formation of the A antigen


Galactose N-acetylglucosamine Galactose N-acetylgalactosamine


Formation of the B antigen


Galactose N-acetylglucosamine Galactose Galactose



The H antigen is found on the RBC when you have the Hh or HH genotype, but NOT from the hh genotype The A antigen is found on the RBC when you have the Hh, HH, and A/A, A/O, or A/B genotypes The B antigen is found on the RBC when you have the Hh, HH, and B/B, B/O, or A/B genotypes

H antigen

Certain blood types possess more H antigen than others:

Greatest amount of H


Least amount of H

The O allele

Why do Group O individuals have more H antigen than the other groups? The O gene is a silent allele. It does not alter the structure of the H substance.that means more H antigen sites

A A Group O

A A Group A

Many H antigen sites

Fewer H antigen sites

Most of the H antigen sites in a Group A individual have been converted to the A antigen

ABO Antigens in Secretions

Secretions include body fluids like plasma, saliva, synovial fluid, etc Blood Group Substances are soluble antigens (A, B, and H) that can be found in the secretions. This is controlled by the H and Se genes

Secretor Status

The secretor gene consists of 2 alleles (Se and se) The Se gene is responsible for the expression of the H antigen on glycoprotein structures located in body secretions If the Se allele is inherited as SeSe or Sese, the person is called a secretor

80% of the population are secretors


Secretors express soluble forms of the H antigen in secretions that can then be converted to A or B antigens (by the transferases) Individuals who inherit the sese gene are called nonsecretors

The se allele is an amorph (nothing expressed) sese individuals do not convert antigen precursors to H antigen and has neither soluble H antigen nor soluble A or B antigens in body fluids

Secretor Status Summary

The Se gene codes for the presence of the H antigen in secretions, therefore the presence of A and/or B antigens in the secretions is contingent on the inheritance of the Se gene and the H gene
A antigen H antigen in secretions

Se gene (SeSe or Sese) se gene (sese)

B antigen

No antigens secreted in saliva or other body fluids

ABO Group
Secretors (SeSe or Sese):
A B O AB Non-secretors (sese): A, B, O, and AB 0

ABH Substances
+++ 0 0 +++

0 +++ 0 +++

+ + +++ +

Sese + h/h (no H antigen) no antigens in secretions

Type I and Type II Precursors

There are two potential precursors substances for ABH antigens Type I and Type II Both are comprised of identical sugars but the linkage of the terminal sugars differs in the two types Type I precursor has a terminal galactose linked to a subterminal N-acetylgluosamine in a 1-3 linkage These same sugars combine in a 1-4 linkage in type II precursor ABH Ags on red cells are derived from Type II chains whereas the ABH Ags in plasma are made from both types I & II precursors

Type II H

After fucose is added to Type II chains, the structure is termed Type II H Four kinds of Type II H have been identified

H1, H2 are simple straight chain glycolipids Whereas H3 & H4 have branched chains

ABO Subgroups

ABO subgroups differ in the amount of antigen present on the red blood cell membrane Subgroups have less antigen Subgroups are the result of less effective enzymes. They are not as efficient in converting H antigens to A or B antigens (fewer antigens are present on the RBC) Subgroups of A are more common than subgroups of B

Subgroups of A

The 2 principle subgroups of A are: A1 and A2

Both react strongly with reagent anti-A To distinguish A1 from A2 red cells, the lectin Dolichos biflorus is used (anti-A1) 80% of group A or AB individuals are subgroup A1 20% are A2 and A2B

A2 Phenotype

Why is the A2 phenotype important?

A2 and A2B individuals may produce an anti-A1 This may cause discrepancies when a crossmatch is done (incompatibility)

Whats the difference between the A1 and A2 antigen?

Its quantitative The A2 gene doesnt convert the H3 & H4 to A very well The result is fewer A2 antigen sites compared to the many A1 antigen sites

A1 and A2 Subgroups
Anti-A Anti-A1 Anti-H antisera antisera lectin ABO antibodies in serum # of antigen sites per RBC





Anti-B & anti-A1

900 x103
250 x103

Other A subgroups

There are other additional subgroups of A

Aint (intermediate), A3, Ax, Am, Aend, Ael, Abantu

A3 red cells cause mixed field agglutination when polyclonal anti-A or anti-A,B is used Mixed field agglutination appears as small agglutinates with a background of unagglutinated RBCs They may contain anti-A1

B Subgroups

B subgroups occur less than A subgroups B subgroups are differentiated by the type of reaction with anti-B, anti-A,B, and anti-H B3, Bx, Bm, and Bel

Other ABO conditions

Bombay Phenotype (Oh) Inheritance of hh The h gene is an amorph and results in little or no production of Lfucosyltransferase Originally found in Bombay (now Mumbai) Very rare


The hh causes NO H antigen to be produced Results in RBCs with no H, A, or B antigen (patient types as O) Bombay RBCs are NOT agglutinated with anti-A, anti-B, or anti-H (no antigens present) Bombay serum has strong anti-A, anti-B and anti-H, agglutinating ALL ABO blood groups What blood ABO blood group would you use to transfuse this patient??


Another Bombay

Group O RBCs cannot be given because they still have the H antigen You have to transfuse the patient with blood that contains NO H antigen

ABO Blood Group

ABO Antibodies

Landsteiners Rule:

Normal, Healthy individuals possess ABO antibodies to the ABO antigen absent from their RBCs

ABO Blood Group System

The ABO Blood Group System was the first to be identified and is the most significant for transfusion practice It is the ONLY system that the reciprocal antibodies are consistently and predictably present in the sera of people who have had no exposure to human red cells

Blood Group Systems

Most blood group systems (ABO and others) are made up of:

An antigen on a red cell and the absence of its corresponding antibody in the serum (if youre A, you dont have anti-A)

If you do NOT have a particular antigen on your red cells then it is possible (when exposed to foreign RBCs) to illicit an immune response that results in the production of the antibody specific for the missing antigen



The ABO Blood Group System does NOT require the presence of a foreign red blood cell for the production of ABO antibodies ABO antibodies are non-red blood cell stimulated probably from environmental exposure and are referred to as expected antibodies Titer of ABO Abs is often reduced in elderly and in patients with hypogammaglobulinemia Infants do not produce Abs until 3-6 months of age

ABO antibodies
RBC Phenotype A Frequency (%) 43 Serum Ab

Anti-B Anti-A


4 44


Group O and B individuals contain anti-A in their serum However, the anti-A can be separated into different components: anti-A and anti-A1 Anti-A1 only agglutinates the A1 antigen, not the A2 antigen There is no anti-A2.

Clinically Significant Sometimes
Thermal range 4 - 22

Abs class IgM


Transfusion Reactions
Extravascular Intravascular




Found in the serum of group O individuals Reacts with A, B, and AB cells Predominately IgG, with small portions being IgM Anti-A,B is one antibody, it is not a mixture of anti-A and anti-B antibodies

ABO antibodies

IgM is the predominant antibody in Group A and Group B individuals

Anti-A Anti-B

IgG (with some IgM) is the predominant antibody in Group O individuals

Anti-A,B (with some anti-A and anti-B)

ABO antibody facts

Complement can be activated with ABO antibodies (mostly IgM, some IgG) High titer: react strongly (4+)
Anti-A, Anti-B, Anti-A,B Clinically Significant Yes Thermal range 4 - 37 Transfusion Reactions Extravascular Yes Intravascular Yes Abs class IgM, less IgG HDNB Yes

ABO Antibodies

Usually present within the first 3-6 months of life Stable by ages 5-6 years Decline in older age & in hypogammaglobulinemia Newborns may passively acquire maternal antibodies (IgG crosses placenta)

Nature of antibodies

Non-red blood cell stimulated ABO antibodies Red blood cell stimulated Antibodies formed as a result of transfusion, etc Usually IgG Active at 37C Can occur in group O (may occur in group A or B) These antibodies also occur in the other Blood Group Systems

Auto-Anti-H Clinically Significant No Thermal range 4 - 15 Abs class IgM HDNB No Allo-Anti-H Clinically Significant Yes Thermal range 4 - 37 Abs class IgM, IgG HDNB Yes

Transfusion Reactions

Transfusion Reactions





RH System

The Rh(D) Antigen

Rh is the most complex system, with over 45 antigens The complexity of the Rh blood group Ags is due to the highly polymorphic genes that encode them. Discovered in 1940 after work on Rhesus monkeys The 2nd most important after ABO in the crossmatch test Only the most clinically significant Ags will be discussed
M. Zaharna Blood Bank 2009

Rh Genetics

The genes that control the system are autosomal codominant located on the short arm of chromosome 1.

Rh blood group antigens are proteins

The antigens of the Rh blood group are proteins. The RhD gene encodes the D antigen, which is a large protein on the red blood cell membrane, & the most important.


RHD gene

RHCE gene

M. Zaharna Blood Bank 2009

Chromosome 1

Rh Antigen Frequency

D antigen 85% d antigen 15% C antigen 70% c antigen 80% E antigen 30% e antigen 98%

Rh Positive

Rh Negative

The presence or absence of D Ag determines if the person is Rh+ or RhM. Zaharna Blood Bank 2009

Weak D Phenotype

Most D positive rbcs react macroscopically with Reagent anti-D at immediate spin

These patients are referred to as Rh positive Reacting from 1+ to 3+ or greater

HOWEVER, some D-positive rbcs DO NOT react (do NOT agglutinate) at Immediate Spin using Reagent Anti-D. These require further testing (37oC and/or AHG) to determine the D status of the patient.
M. Zaharna Blood Bank 2009

Rh Deleted

Red cells that express no Ags at the C & E loci ( D ) Number of D Ags greatly increase Anti-D IgG Abs can agglutinate these cells

M. Zaharna Blood Bank 2009

Rh null

RH null: individual that appears to have no Rh antigens ( , , ) RBC has fragile membrane- short lived Must use autologous blood products

No D, C, c, E, e antigens present on the RBC membrane

Demonstrate mild hemolytic anemia (Rh antigens are integral part of RBC membrane and absence results in loss of membrane integrity)

When transfusion is necessary ONLY Rh Null blood can be used to transfuse.

M. Zaharna Blood Bank 2009


Rh antibodies

Result from the exposure to Rh antigens IgG form Bind at 37C Form agglutination in IAT phase

Rh Abs
Clinically Significant Yes Abs class IgG

Thermal HDNB range Yes 4 - 37 Transfusion Reactions

Extravascular Intravascular

M. Zaharna Blood Bank 2009


Clinical Significance of Rh antibodies

Related to Hemolytic transfusion reactions Re-exposure to antigen cause rapid secondary response Always check patients history for previous transfusion or pregnancy to avoid reexposure.

M. Zaharna Blood Bank 2009

Hemolytic disease of the Newborn (HDN)

Usually related to D antigen exposure and the formation of anti-D Usually results from D negative female and D positive male producing and offspring.

The baby will probably be D positive.

1st pregnancy not effected, the 2nd pregnancy and on will be effected-results in still birth, severe jaundice, anemia related to HDN. To prevent this occurrence the female is administered RHIG.
M. Zaharna Blood Bank 2009

Rh factor
Rh factor can cause complications in some pregnancies. Mother is exposed to Rh antigens at the birth of her Rh+ baby.
M. Zaharna Blood Bank 2009

First pregnancy Placenta Rh+ antigens

Mother makes antiRh+ antibodies. During the mothers next pregnancy, Rh antibodies can cross the placenta and endanger the fetus.

Anti-Rh+ antibodies

Possible subsequent pregnancies

M. Zaharna Blood Bank 2009


After ABO, the Rh system is the second most important system. This is because: The D antigen is extremely immunogenic. It causes the production of anti-D in 50 - 70% of Rh(D) negative people who are exposed to the D antigen. Moreover, anti-D is the most common cause of severe HDN and can cause in Utero death. Because of this, in blood transfusion, the patient and donor are matched for Rh(D) type as well as ABO groups. The C and E Ags are not as immunogenic as D, routine typing for these Ags is not performed
M. Zaharna Blood Bank 2009