ABO Blood Group System

Importance of ABO system

 ABO compatibility between donor cell and patient
serum is the essential foundation of pre-transfusion
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.
 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)
 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
RBC Precursor Structure

RBC

Glucose

Galactose
Precursor
Substance
(stays the N acetylglucosamine
same)
Galactose
Formation of the H antigen

RBC

Glucose

H antigen Galactose

N-acetylglucosamine

Galactose

Fucose
 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
 A and B Antigen
 The “A” gene codes for an enzyme (transferase) that
adds N-acetylgalactosamine to the terminal sugar of the
H antigen “1-3 N-acetylgalactosaminyltransferase”

 The “B” gene codes for an enzyme that adds D-

galactose to the terminal sugar of the H antigen “ 1-3 D-
galactosyltransferase”.
Formation of the A antigen

RBC

Glucose

Galactose

N-acetylglucosamine

Galactose

N-acetylgalactosamine
Fucose
Formation of the B antigen

RBC

Glucose

Galactose

N-acetylglucosamine

Galactose

Galactose
Fucose
 Genetics
 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.

 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 Group A
A A

Group O Group A

Fewer A
Many H
H antigen
antigen sites
sites

Most of the H antigen sites in a

Group A individual have been
converted to the A antigen
 Other ABO conditions
 Bombay Phenotype (Oh)
 Inheritance of hh
 The h gene is an amorph and results in little or no
production of L-fucosyltransferase
 Very rare
 Bombay
 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 Antibodies
 ABO antibodies
RBC Phenotype Frequency (%) Serum Ab

A 43 Anti-B

B 9 Anti-A

AB 4 --------

O 44 Anti-A,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 Abs class
Yes IgM, less IgG
Thermal range HDNB
4 - 37 Yes
Transfusion Reactions
Extravascular Intravascular
Yes Yes
 The Rhesus (Rh) Blood Group system
 Rh Genetics: The genes that control the system
are autosomal codominant located on the short
arm of chromosome 1.

D antigen – 85% Rh Positive

d antigen – 15%
C antigen – 70% Rh Negative
c antigen – 80%
E antigen – 30%
e antigen – 98%

The presence or absence of D Ag determines if the person is

Rh+ or Rh-
 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

 RH null: individual that appears to have no Rh

antigens ( -, -, -)
 Must use autologous blood products
– No D, C, c, E, e antigens present on the RBC membrane
 Rh antibodies
Rh Abs
Clinically Significant Abs class
Yes IgG
Thermal range HDNB
4 - 37 Yes

Transfusion Reactions
Extravascular Intravascular

Yes No
 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 RH-IG.
 Rh factor
First pregnancy

 Rh factor can cause Placenta

complications in some
pregnancies.
Rh+ antigens

 Mother is exposed to Rh
antigens at the birth of
her Rh+ baby.
 Mother makes anti-Rh+ Possible
antibodies. Anti-Rh+ subsequent
antibodies pregnancies

 During the mother’s next

pregnancy, Rh
antibodies can cross the
placenta and endanger
the fetus.
 Weak D Phenotype
 Most D positive RbC’s 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 rbc’s 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.
 Cross-matching involves mixing a sample of the
recipient's serum with a sample of the donor's red blood
cells and checking if the mixture agglutinates ,or forms
clumps.

 If agglutination is not obvious by direct vision, blood

bank technicians usually check for agglutination with a
microscope .If agglutination occurs, that particular
donor's blood cannot be transfused to that particular
recipient .
 Blood group test
Sample is fresh blood or EDTA blood (anticoagulant)
Put 10 µ of anti A on one side of a slide and put 10 µ of anti
B on the other side
Put 10 µ of blood tested in each side and mix the blood with
the reagent added.
results:
+A & + B = AB
+A & - B = A
-A&+B=B
-A & - B = O