ABO Blood Group System

Renee Newman Wilkins, PhD, MLS(ASCP)cm CLS 325/435 School of Health Related Professions University of Mississippi Medical Center

History: Karl Landsteiner



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

[Link]

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

Location


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

RBC

Glucose Galactose N-acetylglucosamine Galactose

Precursor Substance (stays the same)

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 an immunodominant 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
N-acetylgalactosaminyltransferase

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

H antigen


Certain blood types possess more H antigen than others:

Greatest amount of H

O>A2>B>A2B>A1>A1B

Least amount of H

Why do Group O individuals have more H antigen than the other groups?

Group O individuals have no A or B genes to convert the H antigen to A or B [Link] 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


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
and/or

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 A +++ 0 0 +++

ABH Substances
B 0 +++ 0 +++ H + + +++ +

Sese + h/h (no H antigen)

no antigens in secretions

Lewis (Le)


The Lewis Blood Group System is mentioned here because it is related to secretor status Lewis antigens are plasma antigens formed by tissues and are released into plasma where they adsorb onto the RBCs (they are not an integral part of the RBC membrane) Consists of 2 antigens
Lea Leb

Lewis


 

Lea and Leb are a single gene (Le) and its amorph (le) Lea is a precursor to Leb The Le gene codes for a transferase, which attaches L-fucose to the precursor chain to form the Lea antigen (designated Le(a+b-) If the H and Se genes are inherited, the Lea is converted to Leb and is designated Le(a-b+) In childhood, both may be on the RBC, Le(a+b+) If a person is lele, they will have no Lewis antigens in plasma or on red blood cells

Frequency of Lewis phenotypes*

Phenotype Le(a+b-) Le(a-b+) Le(a-b-) Whites 22% 72% 6% Blacks 23% 55% 22%

lele

*Adapted from Flynn, J. (1998). Essentials of Immunohematology

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 H 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

A1 A2

4+ 4+

4+ 0

0 3+

Anti-B Anti-B & anti-A1

900 x103 250 x103

*Adapted from Flynn, J. (1998). Essentials of Immunohematology

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 L-fucosyltransferase Originally found in Bombay (now Mumbai) Very rare (130 worldwide)

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??

ANSWER:


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

ABO


Remember:
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

ABO antibodies
   

group A serum contains anti-B group B serum contains anti-A group AB serum contains no antibodies group O serum contains anti-A, anti-B, and anti-A,B

Anti-A1


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.

Anti-A,B
  

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

 

Reactions phase: Room temperature Complement can be activated with ABO antibodies (mostly IgM, some IgG) High titer: react strongly (4+)

ABO Antibodies


  

Usually present within the first 3-6 months of life Stable by ages 5-6 years Decline in older age Newborns may passively acquire maternal antibodies (IgG crosses placenta)
Reverse grouping (with serum) should not be performed on newborns or cord blood

Nature of antibodies


Non-red blood cell stimulated (previously discussed) 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

Laboratory Testing:

ABO typing

ABO Blood Groups

ABO Group A B O AB Antigen Present A B None A and B Antigen Missing B A A and B None Antibody Present anti-B anti-A anti-A, anti-B, anti-A,B None

Forward Grouping


Reaction of patient red blood cells tested with Reagent anti-A and anti-B antisera

Reverse Grouping


Reaction of patient serum with reagent Group A and Group B cells

Forward & Reverse Typing

Reaction of cells Reaction of serum tested with: tested with:

anti-A anti-B A cells

B cells + + 0 0

1 2 3 4

0 + 0 +

0 0 + +

+ 0 + 0

ABO % US % US group white black pop. pop. O 45 49 A B AB 40 11 4 27 20 4