BLOOD GROUPING

Dr. EZE Ejike Daniel, PhD

DEPARTMENT OF PHYSIOLOGY, SCHOOL OF MEDICINE AND

Tel: 0790008358
Watsap : +234-8036254165
Email: [email protected]

JULY, 2023
Hematopoietic System :
- Composition and functions of blood
- Formation of blood cells
- Blood grouping
- Hemostasis : blood coagulation
By the end of this section, you will be able to:
• Explain the ABO and Rh blood groups and their significance in blood transfusions
• Describe the two basic physiological consequences of transfusion of incompatible blood
• Compare and contrast ABO and Rh blood groups
• Identify which blood groups may be safely transfused into patients with different ABO types
• Indications of blood transfusion
• Discuss the pathophysiology of hemolytic disease of the newborn
INTRODUCTION
• Blood transfusions in humans were risky procedures until the discovery of the major human
blood groups by Karl Landsteiner, an Austrian biologist and physician, in 1900.
• Until that point, physicians did not understand that death sometimes followed blood
transfusions, when the type of donor blood infused into the patient was incompatible with
the patient’s own blood.
• Blood groups are determined by the presence or absence of specific marker molecules on
the plasma membranes of erythrocytes (RBCs)
• With their discovery, it became possible for the first time to match patient-donor blood types
and prevent transfusion reactions and deaths.
Antigens, Antibodies, & Transfusion Reactions
Antigens
• Substances that the body does not recognize as
belonging to the “self” and that therefore trigger a
defensive response from the leukocytes (white
blood cells) of the immune system.
• They are also referred to as iso-antigens or
agglutinogens.
• They are generally large proteins, but may include
other classes of organic molecules, including
carbohydrates, lipids, and nucleic acids.
• Following a transfusion of incompatible blood,
erythrocytes with foreign antigens appear in the
bloodstream and trigger an immune response.
Antibodies
• Are proteins called (immunoglobulins).
• They are produced by certain B
lymphocytes called plasma cells.
• They attach to the antigens on the plasma
membranes of the transfused erythrocytes
(BBCs) and cause them to adhere to one
another.
• Antibodies are also referred to as iso-
antibodies or agglutinins.
• But In this lecture, we will use the more
common terms antigens and antibodies.
• Because the arms of the Y-shaped antibodies
attach randomly to more than one non-self
erythrocyte (RBC) surface, they form clumps of
erythrocytes.
• This process is called agglutination.
• The clumps of erythrocytes block small blood
vessels throughout the body, depriving tissues of
oxygen and nutrients.
• As the erythrocyte (RBC) clumps are degraded, in
a process called hemolysis, their hemoglobin is
released into the bloodstream.
• This hemoglobin travels to the kidneys, which are
responsible for filtration of the blood.
• However, the load of hemoglobin released can
easily overwhelm the kidney’s capacity to clear it,
and the patient can quickly develop kidney failure,
hence death.
• More than 50 antigens have been identified on erythrocyte (RBC) membranes,
• But the most significant in terms of their potential harm to patients are classified in two
groups:
- The ABO blood group
- The Rh blood group.
BLOOD GROUPING
• Human beings can be divided into different groups based on the type of antigen on the
surface of their red blood cells and antibodies in their plasma.
• There are two main systems of blood group:
- The ABO system
- The Rhesus system
• There are several other systems such as the kelly, Duffy, Kidd, but these are not widely
distributed and are of lesser importance to man, hence, they will therefore not be
considered in this lecture.
The ABO Blood Group
• Although the ABO blood group name consists of
three letters,
• ABO blood typing designates the presence or
absence of just two antigens A and B on the surface
or membrane of erythrocytes (RBCs)
• Both antigens A and B are glycoproteins.
• People whose erythrocytes (RBCs) have A antigens
on their erythrocyte (RBC) membrane surfaces are
designated blood type A, and those whose
erythrocytes (RBCs) have B antigens are blood
type B.
• People can also have both A and B antigens on
their erythrocytes (RBCs), in which case they are
blood type AB.
• People with neither A nor B antigens are designated
blood type O.
ABO Blood Group: This chart summarizes the
• However, the ABO blood types are genetically characteristics of the blood types in the ABO
determined. blood group.
• Again, normally the body must be exposed to a foreign
antigen before an antibody can be produced.
• This is not the case for the ABO blood group.
• Individuals with type A blood-without any prior
exposure to incompatible blood - have preformed
antibodies to the B antigen circulating in their blood
plasma.
• These antibodies, referred to as anti-B antibodies, will
cause agglutination and hemolysis if they ever
encounter erythrocytes with B antigens.
• Similarly, an individual with type B blood has pre-
formed anti-A antibodies.
• Individuals with type AB blood, which has both
antigens, do not have preformed antibodies to either of
these.
• People with type O blood lack antigens A and B on
their erythrocytes (RBCs), but both anti-A and anti-B
antibodies circulate in their blood plasma.
 Phenotypes Blood group
AA A
Inheritance of ABO agglutinogens and AB AB
agglutinins
BB B
• Blood group of a person depends upon the AO A
two genes inherited from each parent. OO O
Gene A and gene B are dominant by OB B
themselves and gene O is recessive.
• The A, B, O blood group is inherited in a
Mendelian fashion.
• The three genes involved are A, B and O.
• The six possible phenotypes with the
corresponding blood groups are
Determination of Blood Group
Requisites for Blood Typing
• To determine the blood group of a person, a suspension of his RBC and testing antisera are
required.
• Suspension of RBC is prepared by mixing blood drops with isotonic saline (0.9%).
Test sera are:
1. Antiserum A, containing anti-A or α-antibody.
2. Antiserum B, containing anti-B or β-antibody.
Procedure
3. One drop of antiserum A is placed on one end of a glass slide (or a tile) and one drop of
antiserum B on the other end.
4. One drop of RBC suspension is mixed with each antiserum. The slide is slightly rocked for 2
minutes. The presence or absence of agglutination is observed by naked eyes and if necessary, it
is confirmed by using microscope.
5. Presence of agglutination is confirmed by the presence of thick masses (clumping) of RBCs
6. While absence of agglutination is confirmed by clear mixture with dispersed RBCs.
Results
1. If agglutination occurs with antiserum A:
• Antiserum A contains α-antibody.
• Agglutination occurs if the RBC contains A antigen &
so, the blood group is A.
2. If agglutination occurs with antiserum B:
• Antiserum B contains β-antibody.
• Agglutination occurs if the RBC contains B antigen &
so, the blood group is B.
3. If agglutination occurs with both antisera A and B:
• RBC contains both A and B antigens to cause
agglutination & so the blood group is AB.
4. If agglutination does not occur either with
antiserum A or antiserum B:
• Agglutination does not occur because RBC does not
contain any antigen (either A or B), therefore, the Determination of blood group
blood group is O.
What is the Relevance of this?
• When the blood types of parents are known, the possible genotypes of their children can be
stated e.g. both parents are B B
• Their children could be BB, BO, OO (genotype).
• When the blood types of a mother and child are known, blood typing can prove that a man
cannot be the father of the child.
• Though can’t prove that he is the father as well.
Rhesus Blood Groups
• This was first discovered in the Rhesus monkey, hence its name.
• In Rhesus blood group, there six types of agglutinogen named C, D, E and c, d, e.
• The first three are dominant and the last three are recessive
• Of the dominant antigens, the main one is the D antigen (agglutinogen) and 85 % of the
population od all white people have the D antigen (agglutinogen)and are said to be Rhesus
positive.
• The remaining 15 % don’t have D antigen (agglutinogen) and are said to be Rhesus negative.
• In American blacks, the percentage of Rh positive is about 95, where as in some African blacks
it is usually 100%
• Unlike in the ABO system, the Rhesus blood group has no naturally occurring antibody in the
plasma to the D antigen.
• The antibody is only developed when a Rhesus negative person is exposed to a Rhesus positive
blood - a process, referred to as sensitization.
• Any of the A,B,O, blood groups can be Rh positive or Rh negative, thus we can have A+, A-,
B+, B- etc.
• Rhesus blood group is of great
importance in women in relation
to pregnancy.
• The problem is mainly in the
Rhesus negative women.
• Usually a process, called
sensitization, occurs following a
transfusion with Rh-incompatible
blood or more commonly, with the
birth of an Rh positive baby to an
Rh negative mother.
• Problems are rare in a first Erythroblastosis Fetalis : First exposure of an Rh− mother to
Rh+ erythrocytes during pregnancy induces sensitization.
pregnancy, since the baby’s Rh Anti-Rh antibodies begin to circulate in the mother’s
positive RBCs rarely cross the bloodstream. A second exposure occurs with a subsequent
placenta (the organ of gas and pregnancy with an Rh+ fetus in the uterus. Maternal anti-Rh
nutrient exchange between the antibodies may cross the placenta and enter the fetal
baby and the mother). bloodstream, causing agglutination and hemolysis of fetal
erythrocytes.
• However, during or immediately
after birth, the Rh negative mother
can be exposed to the baby’s Rh
positive cells where foetal and
maternal blood mixed together at
parturition.
• This occurs in about 13-14 % of
such pregnancies
• After exposure, the mother’s
immune system begins to
generate anti-Rh antibodies.
• If the mother should then Erythroblastosis Fetalis : First exposure of an Rh− mother to
Rh+ erythrocytes during pregnancy induces sensitization.
conceive another Rhesus positive Anti-Rh antibodies begin to circulate in the mother’s
baby, the Rh antibodies she has bloodstream. A second exposure occurs with a subsequent
produced can cross the placenta pregnancy with an Rh+ fetus in the uterus. Maternal anti-Rh
into the fetal bloodstream and antibodies may cross the placenta and enter the fetal
destroy the fetal RBCs. bloodstream, causing agglutination and hemolysis of fetal
erythrocytes.
• This condition, known as hemolytic disease of the newborn (HDN) or erythroblastosis
foetalis, may cause anemia in mild cases, but the agglutination and hemolysis can be so severe
that without treatment the fetus may die in the womb or shortly after birth (hydrops-foetalis).
• There is also kernicterus Form of brain damage in infants caused by severe jaundice. If the
baby survives anemia in erythroblastosis fetalis, then kernicterus develops because of high
bilirubin content.
• The blood-brain barrier is not well developed in infants as in the adults.
• So, the bilirubin enters the brain and causes permanent brain damage.
• Most commonly affected parts of brain are basal ganglia, hippocampus, geniculate bodies,
cerebellum and cranial nerve nuclei.
• A Rhesus positive mother does not have such a problem.
• Hyper-immune globulin injection is now available to combat the problem of Rhesus
incompatibility.
• A single dose of this Rhesus immune globulin is given during the post-partum period after
each child birth in an Rhesus negative mother.
• This prevents sensitization from occurring.
CLINICAL SIGNIFICANCE OF Rhesus – antigen
1. In Blood Transfusion
• If Rh – negative person is transfused with Rhesus –positive blood, anti-Rh antibodies
(agglutinins) develop in his plasma.
• Later on, if he needs a second blood transfusion and is given Rh – positive blood, agglutination
of the donor’s RBCs would occur inside the blood vessels of the recipient.
2. In Marriage
• If Rhesus-positive male married Rh-negative female, the fetus will be Rhesus-positive in most
cases.
• During delivery, some fetal RBCs containing the Rhesus-antigen may cross the placenta to reach
the mother’s blood.
• The mother becomes sensitized and anti-Rhesus antibodies (anti-D antibodies) are formed.
• If this mother becomes pregnant again with a Rhesus-positive fetus, the Rhesus-antibodies
already formed in her plasma cross the placenta to the fetus and cause the following disorders:
Importance of knowing Blood Group
1. Medically, it is important during blood transfusions and in tissue transplants.
2. Socially, one should know his or her own blood group and become a member of the Blood
Donor’s Club so that he or she can be approached for blood donation during emergency
conditions.
3. In general among the couples, knowledge of blood groups helps to prevent the complications
due to Rhesus incompatibility and save the child from the disorders like erythroblastosis fetalis.
4. Medico-legal importance:
• Judicially, it is helpful in medico-legal cases to sort out parental disputes.
• Blood groups are inherited from father and mother.
• Blood group determination can exclude but cannot prove that a certain person is the father of a
certain child i.e. it is a good negative test.
• If both parents are of the phenotype A (Possible phenotypes (AA or AO), they could have children
of the genotypes (AA, AO or OO), but never (BO, BB or AB).
Blood Transfusion
• Process whereby one person gives blood to be passed into the body of another person.
• The person who gives blood for someone else’s use is called ‘donor’ and the person to whom
blood is given is called ‘recipient’.
Indication for blood transfusion
1. Incases of excessive blood loss
2. Severe anemia
3. Surgical operation
4. When there is decreased WBCs (leucopenia).
5. When there is decreased blood platelets (thrombocytopenia purpura).
6. When there is decreased coagulation factors VIII, IX and XI in hemophilia.
7. In erythroblastosis fetalis: In exchange transfusion to replace the infant’s blood with Rhesus-
negative group O blood.
Precautions Before Blood Transfusion
1. Donors blood should be compatible with that of the recipient as regards the ABO system and
Rh factor.
• That is, to ensure that there is no agglutination, it is desirable that a recipient should be given
blood of the same group as his own.
• Since this is not always possible a recipient can be given blood from another group provided the
agglutinins in the recipients plasma will not react with the agglutinogen on the donors RBCs.
• For instance, a recipient who is group A cannot be given a group B blood since the Anti-B in the
group A plasma will react with the B- agglutinogen on the group B donor RBCs.
2. Cross matching test (to find out whether the person’s body will accept the donor’s blood or not)
should be done before transfusion. Cross-matching = Recipient’s serum + Donor’s RBC.
3. Hemoglobin of transfused blood should be normal.
4. Transfused blood should be free from diseases e.g syphilis, malaria, viral hepatitis or AIDS.
5. Transfused blood must be fresh or recently stored at (4 0C up to 21 days). Sodium citrate
(anticoagulant) and dextrose (nutrient) are added. Prolonged storing leads to:
a) Intracellular K+ leaves the RBCs to the plasma. Excess K+ in plasma may stop the heart
in diastole.
b) Decreased coagulation factors VII, VIII and IX.
c) Decreased platelet count .
d) Decreased hemoglobin concentration due to hemolysis of RBCs.
e) Decreased dextrose and increased lactic acid due to glycolysis.
Dangers or hazards of blood transfusion
• Transfusion can be associated with some hazards, although with great care such hazards are
indeed uncommon.
• The possible dangers are :
1. Danger of incompatibility
• Agglutination (Clumping) of the donors RBCs.
• And This:
a) Blocks the capillaries and causes severe pain.
b) Blocks the blood vessels e.g. of the heart causing myocardial infarction or the brain
causing paralysis.
• Hemolysis of the donors RBCs leading to jaundice due to excess formation of bilirubin.
• Hypotension: Fall in arterial blood pressure due to vasodilation caused by histamine released
from hemolyzed RBCs.
• Increased neuromuscular excitability due to decreased calcium level in plasma. It may occur
due to excessive amount of citrate in the transfused blood.
• Decreased urine volume (oliguria) or even anuria and death may occur from renal failure
a) Hypotension
b) Precipitation of hemoglobin (acid hematin) and blocking of renal tubules causing anuria.
c) Fatal hyperkalemia may result from hemolysis of RBCs and failure of K+ excretion due to
renal failure. Fatal hypokalemia may occur during recovery since K+ filtered from the
glomeruli is not reabsorbed by damaged renal tubules.
2. Transmission of Diseases: Such as syphilis, malaria, viral hepatitis or AIDS.
3. Allergic reactions: Rigors and fever may occur due to presence of pyrogens.
4. Transfusion of excessive amount of blood (over loading of the circulation):
• This happens if large volume of blood is given too rapidly and this may lead to heart failure.
5. Tetany:
• Which is increased neuromuscular excitability due to decreased calcium level in plasma and
may occur due to excessive amount of citrate in the transfused blood.
Critical Thinking Questions
Q1. Following a motor vehicle accident, a patient is rushed to the emergency Department
with multiple traumatic injuries, causing severe bleeding. The patient’s condition is critical,
and there is no time for determining his blood type. What type of blood is transfused, and
why?
Answer to critical thinking questions
• In emergency situations, blood type O− will be infused until cross matching can be done.
• Blood type O− is called the universal donor blood because the erythrocytes have neither A
nor B antigens on their surface, and the Rh factor is negative.
Q2. In preparation for a scheduled surgery, a patient visits the hospital laboratory for a blood
draw. The technician collects a blood sample and performs a test to determine its type. She
places a sample of the patient’s blood in two wells. To the first well she adds anti-A antibody. To
the second she adds anti-B antibody. Both samples visibly agglutinate. Has the technician made
an error, or is this a normal response? If normal, what blood type does this indicate?
Answer to critical thinking question
• The laboratory technician has not made an error.
• Blood type AB has both A and B surface antigens, and neither anti-A nor anti-B antibodies
circulating in the plasma.
• When anti-A antibodies (added to the first well) contact A antigens on AB erythrocytes, they
will cause agglutination.
• Similarly, when anti-B antibodies contact B antigens on AB erythrocytes, they will cause
agglutination.