Journal of Immunological Methods 487 (2020) 112895

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Journal of Immunological Methods

journal homepage: www.elsevier.com/locate/jim

An algorithmic approach to serological work-up of ABO sub-groups which T

present as ABO discrepancies in resource constraint settings
Aseem K. Tiwari, Divya Setya , Dinesh Arora, Swati Pabbi Mehta, Geet Aggarwal, Subhasis Mitra
⁎

Department of Transfusion Medicine, Medanta-The Medicity, Sector-38, Gurgaon 122001, India

ARTICLE INFO ABSTRACT

Keywords: Background: ABO subgroups or weaker variants of A or B are group A or B subjects whose erythrocytes give a
ABO subgroups weak or negative reaction serologically with anti-A or Anti – B antisera respectively. Occurrence of these sub­
Weaker variants groups may lead to an ABO discrepancy which often puts transfusion services in a quandary. ABO subgroups
Prevalence which present as ABO discrepancies can be missed if reverse grouping is not performed.
Resolution
Aim: This study was planned to estimate the prevalence of different subgroups which can present as an ABO
Discrepancy
discrepancy in Indian population, and provide an insight to transfusion services for identification of subgroups
Algorithm
serologically.
Materials and methods: A cross-sectional, analytical study was performed at a tertiary healthcare based blood
bank on whole blood donors and patients from January 2017 to July 2018. All suspected type II and Type IV
(with Anti-A1) ABO discrepant samples were projected to an algorithmic testing process, to confirm discrepancy
and then narrow down to the probable subgroup.
Results: A total of 33 subgroup discrepancies; 26 of A group and 7 of B group were identified out of 73,380
patient and 35,279 donor samples tested for blood grouping. Following the algorithm, the overall prevalence of
weak subgroups which can present as an ABO discrepancy was found to be 1 in 3293 or 0.03% in our population
by serological testing. Out of the discrepancies caused by subgroups, the prevalence of subgroups of A were
0.0101%, 0.0018%, 0.0009%, 0.0027%, 0.0027% and 0.0018% for A2 with anti-A1, A3, Aend, Ax, Am and Ael
respectively while those of B were 0.009%, 0.0009%, 0.0009% and 0.009% for B3, Bx, Bm and Bel respectively.
Conclusion: Algorithmic approach for resolution of ABO discrepancies caused by subgroups helps in identifying
the subgroup which is important because these individuals may be mistyped as group O individuals.

1. Introduction modification of the type 1 precursor substance in secretions to express

A decade after the discovery of ABO blood group system by Karl
Landsteiner, Dungern and Hirszfeld first identified that anti-A reacted
differently with A red cells from different individuals (Dungern and
Hirszfeld, 1910). This formed the basis of discovery of A1 and A2.
Thereafter, many weak subgroups have been described for A and B
blood groups which are rare and are identified in a minority of in­
dividuals. Any human with ABO subgroup has fewer antigens on their
red cells. ABO blood group subtypes, frequently referred to as sub­
groups or weaker variants of A or B are group A or B subjects whose
erythrocytes give a weak or negative reaction serologically with anti-A
or Anti – B antisera, respectively. Unique to the ABO and Lewis blood
group system, is the fact that ABH-soluble antigens can also be found in
all body secretions except cerebrospinal fluid. Inheritance of Se gene
codes for production of α-2-L-fucosyltransferase that results in
H substance which in turn can then be modified to express A and B
substance in secretions (Svensson et al., 2000; Oriol et al., 2000).
Occurrence of these subgroups due to heterogeneity of A and B al­
leles leads to an ABO discrepancy which often puts transfusion services
in a quandary. ABO discrepancies are categorized broadly into four
types and subgroups present either as a type II (Weak/missing antigen)
or as type IV ABO discrepancy (due to presence of Anti–A1). Many
transfusion services in India still rely only on forward grouping tech­
nique to designate group of a sample. As highlighted by National Aids
Control Organization (NACO), there is lack of standardization in im­
munohematological testing performed by transfusion services across
the country and it is important to ensure that that blood banks dis­
continue the slide/ tile method for blood grouping and opt for direct
and reverse blood grouping by at least tube technique (NACO, 2014).
Donors who possess such phenotypes may present with a false negative

⁎
Corresponding author.
E-mail address: setyadivya@gmail.com (D. Setya).

https://doi.org/10.1016/j.jim.2020.112895
Received 12 July 2019; Received in revised form 11 March 2020; Accepted 6 October 2020
Available online 13 October 2020
0022-1759/ © 2020 Elsevier B.V. All rights reserved.
A.K. Tiwari, et al.
reaction with the corresponding antisera and thus such units can be
mislabeled. Red cells of individuals with subgroups of A or B may er­
roneously be grouped as O and on transfusion to O group patients may
show decreased survival due to naturally occurring anti-A and anti-B
antibodies in the recipient. On the other hand, if a patient possesses a
weak subgroup with an extra antibody like weak A with anti–A1, there
may be delays in providing transfusions and these antibodies can even
cause decreased survival or hemolysis of transfused red cells in the
presence of a clinically significant anti–A1. ABO subgroups may present
as obstacles in typing as well as cross matching and hence prove as a
hindrance in smooth pre-transfusion testing.
A number of strategies have been developed to identify these sub­
groups when an ABO discrepancy (type II or type IV) arises because of
them like differentiating between anti-A or anti-A1, estimation of
transferase activity in serum, presence of A, B, H antigens in saliva,
other serological testing like adsorption-elution techniques, assessing
the relative agglutinability of cells by radio-labelled antibodies and
genotyping.Though there are published reports on ABO sub-groups
including a couple of these from India (Bhatia and Sathe, 1974, Thakral
et al., 2005, Kaur et al., 2014), apparently none of these outline a clean
algorithm with explicit steps to resolve a subgroup discrepancy ser­
ologically which would help in narrowing down the probable subtype
in settings where molecular testing is not available. Such an algorithm
is crucial for any Transfusion Medicine specialist, especially one who is
in the process of setting up a new transfusion service in a developing
country with limited resources in hand. Therefore, a study was planned
to define the scale of the subgroup related ABO discrepancies, to pro­
vide an easy-to-follow algorithmic approach to resolution of these dis­
crepancies and also to provide an accurate blood group report for a
patient or a donor.
2. Materials and methods
2.1. Settings and design
This was a cross-sectional, analytical study performed at a tertiary
healthcare based blood bank on whole blood donors and patients from
January 2017 to July 2018. The blood bank collects 20,000–25,000
whole blood units annually and tests 60,000–70,000 patient samples
annually. A total of 73,380 patient and 35,279 donor samples were
tested during this period.
2.2. Blood sample used
2.2.1. Donors
Sample collected in EDTA pilot tubes (blood sample collected from
sample pouch attached with the blood bag) at the time of donation were
used. Additional sample, if required was obtained from the donor bag in
an aseptic manner.
2.2.2. Patients
Samples sent from the patient bedside in EDTA vacutainers to the
blood bank for blood grouping were used for blood group determina­
tion. Any additional sample if required was obtained by the blood bank
staff from the patient after counselling the patient as to why the sample
was being drawn and obtaining an informed consent.
2.3. Blood grouping test
All donor and patient samples were subjected to a forward and reverse
grouping by an automated Column Agglutination Technology (CAT) based
equipment (AutoVue Innova or Vision, Ortho Clinical Diagnostics, Raritan,
USA). Forward grouping was performed using Anti-A/B/D cassettes with
pre-dispensed antisera while reverse grouping was performed using in-
house pooled cells A cells (Ac), B cells (Bc) and O cells (Oc) in Reverse
Diluent cassettes (Ortho Clinical Diagnostics, Raritan, USA).
2
Journal of Immunological Methods 487 (2020) 112895
2.4. ABO discrepancy
ABO discrepancies occur when unexpected reactions occur in the
forward and reverse grouping. They are broadly divided into four ca­
tegories. Type I discrepancies include unexpected reactions in the re­
verse grouping due to weakly reacting or missing antibodies. Type II
discrepancies include unexpected reactions in the forward grouping due
to weakly reacting or missing antigens. Type III discrepancies include
discordant forward and reverse groupings caused by protein or plasma
abnormalities and result in rouleaux formation or pseudoagglutination.
Type IV discrepancies include discordant forward and reverse group­
ings due to miscellaneous reasons such as unexpected ABO antibodies,
unexpected non-ABO antibodies and cold reactive autoantibodies.
(Harmening, 2005).
Any discrepancy between forward and reverse grouping was in­
vestigated. All clerical and technical errors were ruled out and the test
was repeated by Conventional Tube Technique (CTT) after adequate
washing of red cells with Normal Saline (NS). If the discrepancy was
resolved, an attempt was made to find the origin. If the results were still
discrepant, a detailed clinical history was obtained and further eva­
luation was done. If at any point, there was a doubt about whether the
disease state (for e.g. recipient of a peripheral blood progenitor cell
transplant, patient of a gastrointestinal malignancy, pregnancy) was
causing the discrepancy, the discrepancy was solved and the sample
was not included for further analysis in this study.
2.4.1. Type II ABO discrepancies
All suspected type II discrepant samples were projected to an al­
gorithmic testing process (Fig. 1) as per the standard operating proce­
dure of the facility, to confirm type II discrepancy and then identify the
probable subgroup.The tests that were performed by CTT have been
listed in Table 1. For all the cases, monoclonal anti-A and anti-B anti­
sera (Tulip Diagnostics Ltd., Goa, India) and Anti-A1B, Anti-A1 and
Anti-H (Ortho Clinical Diagnostics, Raritan, USA) antisera were used to
confirm the findings by CTT and a careful note of the discrepant results
was noted.
2.4.2. Type IV ABO discrepancies
All type IV ABO discrepancies with an unexpected reaction with A1
cells were screened for subgroups and projected to the same algorithmic
testing process (Fig. 1) for confirmation.
2.4.3. Enhancement studies
Incubation at 4
All the test tubes were placed at 4 °C for 30 min and the results were
re-interpreted.
Increased incubation
A set of test tubes was placed at room temperature for half an hour
before re-centrifugation and re-interpretation.
Increasing cell to serum ratio
On a slide, a 50% suspension of red cells were taken and a drop of
antisera was added. The reaction mixture was kept at room temperature
for 10 min before interpretation. Some agglutination against a back­
ground of free cells was suggestive of a weak reaction which can be
observed with the help of a microscope.
2.4.4. Adsorption-elution study
Pooled human origin polyclonal antisera from group B and and
group A individuals were used for adsorption. Positive control was
prepared by adding 100 μl pooled A/B cells (Eg. If subgroup of A was
suspected then A cells were used for preparing positive control) to
900 μl of pooled O cells. Pooled O cells were used for preparing ne­
gative control. The test cells, A/B cells and O cells were washed before
initiating adsorption to remove plasma or additive solution. The pro­
cedural steps followed have been listed in AABB Technical Manual
(Bethesda, 2014). After adsorption and adequate washing to remove
A.K. Tiwari, et al. Journal of Immunological Methods 487 (2020) 112895

Fig. 1. : Algorithm for solving a subgroup discrepancy.

Table 1 2.4.5. Saliva testing (Hemagglutination saliva inhibition testing)

. Initial tests performed by CTT in case of a suspected subgroup discrepancy.
Test tube Contents Comment
A Anti-A + Patient/donor red cell suspension
B Anti-B + Patient/donor red cell suspension
C Anti-D + Patient/donor red cell suspension
D Anti-A1 + Patient/donor red cell suspension For suspected weak
A only
E Anti-A1B + Patient/donor red cell suspension
F Anti-H + Patient/donor red cell suspension
G In-house pooled A1 cells + Patient/donor
plasma
H In-house pooled B cells + Patient/donor
plasma
I In-house pooled O cells + Patient/donor
plasma
J Patient/donor red cell suspension + patient/ Autocontrol
donor plasma
unbound antibody, last wash was preserved as a control and then gentle
heat elution using 6% bovine serum albumin (Ortho Clinical Diag­
nostics, Raritan, USA) was done at 56 °C for 10 min. The eluate ob­
tained was tested with 3 different un-pooled reagent cells (A or B) by
CAT at room temperature phase. However, if the reaction was not well
appreciated in this phase, reaction was also looked for in the indirect
antiglobulin phase. Results of this test were also recorded.
This test was performed to check the secretor status in saliva. The
procedural steps followed have been listed in AABB Technical manual
(Bethesda, 2014). In this study, the transfusion service possessed pooled
human origin polyclonal Anti-H from Bombay group donors. However,
a backup of commercial Anti-H was kept if human origin could not be
obtained. Presence of H substance indicated that the subject was a se­
cretor and vice versa. Presence or absence of substance A and B were
recorded. Saliva testing helped distinguish between those subgroups
which could be identified only by adsorption elution studies. For ex­
ample, Bm and Bel. If the individual was a non-secretor, no conclusion
could be drawn.
2.4.6. Interpretation
Subgroup classification was determined according to the char­
acteristics of weak ABO groups listed in Tables 2 and 3 (Harmening,
2005). Samples were tested by the same performer using the above
mentioned algorithm with the same reagents to avoid any inter-op­
erator variations.
All the subjects who participated in the study were offered blood
group evaluation for the next of kin by the transfusion service to look
for other family members with weaker variants of A and/or B antigens.
This was done to increase awareness about their rare blood type and
also because some of these members could present as blood donors to
transfusion services who do not have the expertise for techniques like
adsorption-elution or saliva testing, where these donors might be

Table 2
Characteristics of Weak A Phenotypesa (Harmening, 2005).
Sub group Anti – A Anti – B Anti – A1B Anti – H Anti – A1 A1 cells B cells Substance in saliva

A3 ++ MF 0 ++MF 3+ Sometimes No Yes A,H

Ax Weak/0 0 2+ 4+ Almost always +/− Yes A(trace), H
Aend Weak/MF 0 Weak/MF 4+ Sometimes No Yes H
Am 0/Weak 0 0/+ 4+ No No Yes A,H
Ay 0 0 0 4+ No No Yes A,H
Ael 0 0 0 4+ Yes Some Yes H

a
MF - Mixed field

3
A.K. Tiwari, et al. Journal of Immunological Methods 487 (2020) 112895

Table 3
Characteristics of Weak B Phenotypes (Harmening, 2005).a
Sub group Anti – A Anti – B Anti – A1B Anti – H Anti – A1 A1 cells B cells Substance in saliva

B3 0 ++ MF ++ MF 3+ Sometimes Yes No B,H

Bx 0 Weak Weak 3+ Almost always Yes Weak Anti-B H
Bm 0 0/Weak 0/Weak 3+ No Yes No B,H
Bel 0 0 0 3+ Yes Yes Sometimes a weak anti-B H

a
MF - Mixed field

labelled as group O. A total of 17 such individuals were tested out of decreased amounts of A and B antigens on red cells. A and B antigens
which 14 possessed a subgroup of A and/or B antigen. The subgroup are synthesized on the same common fucosylated precursor, the H an­
type of these relatives has not been included in this data because in the tigen. Group A shows more variations than group B. Serological dis­
present study only those samples which present as an ABO discrepancy tinction between subgroups of A and B is based on the variation in
were considered. agglutination reactions with anti-A and anti-B respectively. Varying
antigenic density accounts for the different strengths of agglutination
3. Results reaction with monoclonal antigen typing reagents. In 1926, A, B and H
antigens were discovered in saliva (Putkonen, 1930).
Between January 2017 and June 2018 a total of 33 type II and type Most studies in the published literature including a couple of reports
IV ABO discrepancies were identified out of 73,380 patient and 35,279 from India, have described prevalence of subgroups in healthy donors.
donor samples tested for blood grouping. Eleven discrepancies were This is possibly the first study in India which describes prevalence of
found in donors whereas 22 were found in patient samples. 18 of these subgroups in patients as well. Phenotypic frequencies of subgroups is
22 samples were from health check-up samples of healthy individuals different for various ethnic regions. Lee et al., reported a prevalence of
while the rest four were from admitted patients. Out of these 33 dis­ 0.05% in Korean blood donors (Lee et al., 2010) whereas, an Indian
crepancies, 26 were confirmed as subgroups of A and seven were con­ study conducted by Thakral et al. reported an overall prevalence of
firmed as subgroups of B. Four discrepancies could not be completely weak subgroups as 1:5100 or 0.02% in Indian donor population
resolved because either a sample of saliva could not be obtained for (Thakral et al., 2005). The present study reports a frequency of sub­
testing or the individual was a non-secretor. Following the algorithms groups which present to the transfusion service as a discrepancy as 1 in
described above, the following prevalence given in Table 4 were ob­ 3293 individuals or 0.03%; 1 in 3207 donors and 1 in 3335 patients.
tained for various subgroups which present to the transfusion service as After A2, A3 subgroup is most common among all the subgroups. Its
an ABO discrepancy. frequency has been found to be 9 in 150,000 French donors and 2 in
The overall prevalence of weak subgroups which are identified due about 180,000 Canadian blood donors (Daniels, 2002; Lin, 1997). The
to a discrepancy by serological testing was found to be 1 in 3,293 or present study reports a prevalence of A3 which present as an ABO
0.03% in our population; 1 in every 3,207 donors and 1 in every 3,335 discrepancy as 1 in 54,330 individuals. Aend cells behave like weak A3
patients. Subgroups of A causing an ABO discrepancy were more fre­ cell. The most important serological characteristic of Ax is that the red
quently found than subgroups of B in our population; the frequency for cells are not agglutinated by anti-A, but agglutination can be observed
the former being 0.023% or 1 in 4,179 while that of the latter being with anti-A1B. The prevalence of Ax and Aend in French donors has
0.006% or 1 in 15,523. Among discrepancies, A2 was the most frequent been estimated to be about 1:40,000–1:77,000 and 2 in 1,50,000 do­
type, identified only when anti - A1 presented with an ABO discrepancy. nors respectively (Daniels, 2002). The present study found the pre­
A2 was followed by Ax and Am. Among the seven subgroups of B, three valence of Ax, Aend and Am which present as an ABO discrepancy as 1
could not be identified due to non-secretor status of the subject and in 36,220, 1 in 108,659 and 1 in 36,220 individuals respectively. Most
unavailability of saliva, rest of the four belonged to B3, Bx, Bm, Bel re­ Am red cells are not agglutinated by anti-A. Its frequency has been
spectively. Table 4 gives an overview of the subgroups identified due to found to be one in 150,000 French donors and one in 4,00,000 Chinese
an ABO discrepancy. (Daniels, 2002; Reed, 1964). Though anti – A does bind to Ael red cells,
as demonstrated by adsorption and elution studies but these cells are
not agglutinatd by anti-A. No donors belonging to Ael subgroup were
4. Discussion
found in testing 150,000 French blood donors whereas five were found
among 400,000 Chinese (Daniels, 2002; Reed, 1964). The prevalence of
As discussed earlier, subgroups of ABO are distinguished by
Ael which present as an ABO discrepancy was found to be 1 in every
54,330 individuals in our study.
Table 4
Weak variants of B are rare; much rarer than weak A subgroup.
Percentage and prevalence of subgroups presenting as an ABO discrepancy.
Subgroups of B are commoner in our population than in French
Blood group Sub group Number Percentage Frequency 1:116,667 due to higher prevalence of B blood group in Indians. (Reed,
A A2 (with Anti-A1) 11 0.0101 1 in 9,878
1964; Lin, 1997; Harmening, 1999; Daniels, 2002) The frequency of B
A3 2 0.0018 1 in 54,330 subgroup presenting as an ABO discrepancy in our population was found
Aend 1 0.0009 1 in 108,659 to be 1 in 15,223. Jain et al. reported ABO discrepancies and their further
Ax 3 0.0027 1 in 36,220 distribution according to standard classification into Group I, II and IV
Am 3 0.0027 1 in 36,220
discrepancies. The most common cause of ABO discrepancies was weak
Ael 2 0.0018 1 in 54,330
InconclusiveϮ 1 0.0009 1 in 108,659 anti-B antibody (35.5%), followed by weak anti-A antibody and weak
B B3 1 0.0009 1 in 108,659 subgroups of A (25.8% each), agglutination with O cells in reverse
Bx 1 0.0009 1 in 108,659 grouping i.e. group IV discrepancy (7.5%) and weak subgroups of B
Bm 1 0.0009 1 in 108,659 (5.4%). (Jain et al., 2020) Weak agglutination is observed with Bx red
Bel 1 0.0009 1 in 108,659
InconclusiveϮ 3 0.0027 1 in 36,220
cells and anti-B whereas Bm and Bel cells are not agglutinated by anti-B
and detection is only possible by adsorption and elution studies. Our
Ϯ
Inconclusive - Saliva not available for testing or the patient/donor was a study found one subject each with Bx, Bm and Bel subgroups.
non-secretor on saliva testing.

4
A.K. Tiwari, et al.
This study suggests an algorithmic approach with easy to under­
stand steps for resolution of a subgroup discrepancy. Any transfusion
service under setup needs to estimate the prevalence of subgroups
which can present as a discrepancy in the local population for inventory
management (reagents and equipment for performing saliva testing and
adsorption elution studies) and writing down their Standard Operating
Procedure (SOP), as well. This study would help new setups in devel­
oping an insight about the frequency of subgroups as well as tailoring
serological work up algorithms for their laboratories.
The secretion of soluble forms of antigens is genetically determined
independent of the ABO system. This property has been used in saliva
inhibition testing to confirm the presence or absence of A, B and H
antigens in secretors. This study provides meaningful data on the fre­
quency and distribution of the ABO subgroups in Indians. Though, in
four cases (1 in 27,165) the exact subgroup could not be determined
because of non-secretor status or inability of the testing facility to
procure a saliva sample; yet 29 out of the 33 subgroups (87.88%) could
be determined using the algorithm (which includes saliva testing)
mentioned in Fig. 1.
Genotyping is valuable for easier and accurate determination of
ABO blood group status but in resource constraint settings of a devel­
oping country like India, the use of genotyping or determination of
serum transferase activity is not readily available for routine use and
pose a financial concern. The alternative strategy for narrowing down
to a particular subgroup is determination with the help of serological
and saliva testing. Molecular genetics makes it possible to define an
individual's ABO genotype without laborious family studies. It is a
useful tool for resolution of typing discrepancies and valuable for dis­
tinguishing acquired variant phenotypes from inherited ones. Hence,
for now, serological determination of subgroup seems feasible for a
country such as ours, till we have easily accessible molecular tests.
According to the Rapid Situation Assessment of Blood Transfusion
Services in India, 2014; it was observed that there are huge variations in
immunohematology testing across facilities. In District level blood
banks, primitive techniques such as, slides and tile method are used for
blood grouping (NACO, 2014). By means of this study, the authors want
to emphasize the significance of performing both forward and reverse
blood grouping for detection of subgroups as firstly, undetected donor
subgroups which may pose as group ‘O' on forward typing and may
have appalling consequences in patients who possess a corresponding
naturally occurring antibody in their plasma. For example, Am and Ael
donor units when typed as ‘O' and transfused to patients with anti-A in
their plasma may lead to decreased survival of transfused cells. Sec­
ondly, as a Transfusion Medicine physician, one bears the responsibility
of providing a complete blood grouping report to the individual being
tested, be it a donor or a patient. This study would help transfusion
services in resolving ABO discrepancies caused by subgroups of A or B.
5. Conclusion
The prevalence of ABO subgroups which present as an ABO dis­
crepancy has been calculated. An algorithmic approach for serological
determination as described in the text helps in resolution of ABO dis­
crepancy and identification of the type of subgroup in any resource
constraint setting where molecular typing is not available for routine
use.
Journal of Immunological Methods 487 (2020) 112895
Compliance with ethical standards
No source of funds.
Ethical approval
This was an observational study where all tests performed on blood
samples were “standard-of-care”. All personal identifiers of patients
were masked and only laboratory procedures with algorithmic ap­
proach were discussed. The study was approved by the Institutional
Review Board (IRB) and Institutional Ethics Committee (IEC).
Informed consent
Informed consent for testing was obtained from all patients and
blood donors as per standard hospital protocol.
Declaration of Competing Interest
Authors declare no conflict of interest.
Acknowledgements
AKT was the guarantor for the study. Concept, design and in­
tellectual content was defined by SPM, GA. Literature search, experi­
mental studies, data acquisition, data analysis and statistical analysis
was done by DS, SM. Manuscript was prepared by DS. AKT reviewed the
manuscript.
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