BLOOD GROUP SYSTEM

BY
AJETUNMOBI I.A
UNIVERSITY OF MEDICAL SCIENCE
ONDO
CODE…512
 OUTLINES
• INTRODUCTION AND HISTORY
• ABO BLOOD GROUP SYSTEMS
• ABO ANTIBODIES
• INHERITANCE OF THE ABO BLOOD GROUPS
• FORMATION (BIOCHEMISTRY) OF A, B, AND H RED
BLOOD CELL ANTIGENS
• INTERACTION OF HH AND ABO GENES
• FORMATION OF A, B, AND H SOLUBLE ANTIGENS
• BOMBAY GROUP
 HISTORY
• In 1875, Landois first noticed clumping/agglutination
when red cells of animals of one species is treated
with serum of another species.
• In 1901 Karl Landsteiner observed similar
phenomena in human being.
• His discovery lead to A, B, O group
• A year later, Decastillo and Sturli (student of
Landsteiner) discovered AB group.
• Other blood group system were discovered 25 years
after A, B, O system.
• Landsteiner law states that there is a reciprocal
relationship between antibody present in the
serum/plasma and antigen on his own red cells.
• In his experiment, he observed that a person’s serum
does not contain the antibody against the antigen
present on his own red cells.
• He further observed that two antigens : A and B were
needed to explain four groups (A,B,AB and O).
• Blood group is phenotypic expression of an individual
but the genetic constitution or genotype is expressed in
a different ways
 PHENOTYPE AND GENOTYPE
NAME OF PHENOTYPE GENENETIC CONSTITUTION OR
GENOTYPE
O OO
A AA OR AO
B BB OR BO
AB AB

The group A is further subdivided in A1 and A2 known as subgroup of A,

and thereby increase the number of phenotypes from four to six-A1, A2,
A1B, A2B, B and O.
 ABO BLOOD GROUP SYSTEMS
• The ABO system is the most important of all
blood groups in both transfusion and
transplant medicine.
• It is the only blood group system in which
individuals already have antibodies in their
serum to antigens that are absent from their
red blood cells (RBCs) without any prior
exposure to RBCs through transfusion or
pregnancy.
• Due to the presence of these antibodies,
transfusion of an incompatible ABO type may
result in immediate lysis of donor RBCs. This
produces a very severe, if not fatal,
transfusion reaction in the patient.
• Testing to detect ABO incompatibility
between a donor and potential transfusion
recipient is the foundation on which all other
pre-transfusion testing is based.
 Historical Perspective and Routine
ABO Testing
• Karl Landsteiner truly opened the doors of blood banking
with his discovery of the first human blood group system,
ABO.
• This marked the beginning of the concept of individual
uniqueness defined by the RBC antigens present on the
RBC membrane.
• Landsteiner drew blood from himself and five associates,
separated the cells and serum, and then mixed each cell
sample with each serum.
• He was inadvertently the first individual to perform
forward and reverse grouping
• ABO grouping is the most frequently performed test
in the blood bank.
• Both ABO forward and reverse grouping tests must be
performed on all donors and patients..
• There is always an inverse reciprocal relationship
between the forward and reverse type; thus, one
serves as a check on the other.
• It has been postulated that bacteria, pollen
particles, and other substances present in nature are
chemically similar to A and B antigens.
• Bacteria are widespread in the environment,
which constantly exposes individuals to A-like and B-like antigens.
• This exposure serves as a source of stimulation of anti-A and
anti-B. All other defined blood group systems do not regularly
have “naturally occurring” antibodies expected in their serum
to antigens they lack on their RBCs.
• Antibody production in most other blood group systems
requires the introduction of foreign RBCs by either transfusion
or pregnancy.
• Performance of serum grouping is, therefore, unique to the
ABO blood group system.
 ABO FORWARD GROUPING
Principle-?
PATIENT RBCS WITH PATIENT RBCS WITH ANTI- INTERPRETATION OF
ANTI-A B BLOOD GROUP
O O O
4+ O A
O 4+ B
4+ 4+ AB

+= Visual agglutination
O= Negative
Note : Reaction grading varies from patient to patient
 ABO REVERSE GROUPING
Principle—Detection of ABO Antibodies (Isoagglutinins) in Serum of
Patient With Known Commercial RBCs
PATIENT SERUM WITH PATIENT SERUM WITH INTERPRETATION OF
REAGENT A1 CELLS REAGENT B CELLS BLOOD GROUP
4+ 4+ O
O 3+ A
3+ O B
O O AB

+= Visual agglutination
O= Negative
Note : Reaction grading varies from patient to patient
 ABO Antibodies
• Individuals normally produce antibodies directed against the
A and/or B antigen(s) absent from their RBCs.
• These antibodies have been described as naturally occurring
because they are produced without any exposure to RBCs.
• The ABO antibodies are predominantly IgM, activate
complement, and react at room temperature or colder.
• ABO antibodies produce strong direct agglutination
reactions during ABO testing.
• ABO antibody production is initiated at birth, but titers are
generally too low for detection until infants are 3-6 month
old.
• Therefore, most antibodies found in cord blood
serum are of maternal origin.
• Results of serum ABO testing before 3 to 6
months of age cannot be considered valid
because some or all of the antibodies present
may be IgG maternal antibodies that crossed
the placenta.
• As a result, it is logical to perform only forward
grouping on cord blood from newborn infants.
• Antibody production peaks between 5 and 10 years of
age and declines later in life.
• Elderly people usually have lower levels of anti-A and
anti-B; therefore, antibodies may be undetectable in the
reverse grouping .
• ABO antibodies can cause rapid intravascular hemolysis
if the wrong ABO group s transfused, potentially
resulting in patient death.
• Although anti-A (from a group B individual) and anti-B
(from a group A individual) contain predominantly IgM
antibody, small quantities of IgG may also be present.
 Inheritance of the ABO Blood Groups

• The theory for the inheritance of the ABO blood groups was first
described by Bernstein in 1924
• He demonstrated that an individual inherits one ABO gene from each
parent and that these two genes determine which ABO antigens are
present on the RBC membrane.
• The inheritance of ABO genes, therefore,follows simple Mendelian
genetics.
• One position, or locus, on each chromosome 9 is occupied by an A,
B, or O gene.
• The O gene is considered an amorph, as no detectable antigen is
produced in response to the inheritance of this gene.
• Therefore, group O phenotype is an autosomal recessive trait with
the inheritance of two nonfunctional O genes
• The designations group A and B refer to
phenotypes,whereas AA, BO, and OO denote
genotypes.
• In the case of an O individual, both phenotype
and genotype are the same because that
individual would have to be homozygous for the
O gene.
• An individual who has the phenotype A (or B)can
have the genotype AA or AO (or BB or BO).
 Formation (Biochemistry) of A, B, and H
Red Blood Cell Antigens
• The formation of ABH antigens results from the
interaction of genes at three separate loci (ABO, Hh, and
Se)
• These genes do not actually code for the production of
antigens but rather produce specific glycosyltransferases
that add sugars to a basic precursor substance.
• A,B and H antigens are formed from the same basic
precursor material called glycan or paragloboside.
• Specific enzyme transferases elicited by an inherited
gene attach sugars to the paragloboside/glycan
NOTE:
• When the terminal galactose on the precursor
substance is attached to the N-acetylglucosamine in a
beta 1 → 4 linkage the precursor substance on
erythrocytes is referred to as type 2.
• ABH antigens on the RBC are constructed on
oligosaccharide chains of a type 2 precursor substance.
• A type 1 precursor substance refers to a beta 1 → 3
linkage between galactose and N-acetylglucosamine of
A, B, and H Soluble Antigens
• The H antigen is the precursor structure on which A and B
antigens are made. Inheritance of the H gene results in
formation of the H antigen.
• The H and Se genes are closely linked and located on
chromosome 19,in contrast to the ABO genes located on
chromosome 9.
• The H and Se genes are not part of the ABO system; yet,
their inheritance influences A and B antigen expression.
• The H gene must be inherited to form ABO antigens on the
RBCs, and the Se gene must be inherited to form ABO
antigens in secretions.
• The ABH antigens develop early in fetal life and do not
increase much in strength during the gestational period.
• Consequently, reactions of newborn RBCs with ABO
reagent antisera are frequently weaker than reactions with
adult cells.
• The expression of A and B antigens on the RBCs is fully
developed by 2 to 4 years of age and remains constant
throughout life.
• In addition to age, the phenotypic expression of ABH
antigens may vary with race, genetic interaction, and
disease states.
 Interaction of Hh and ABO Genes
• Individuals who are blood group O inherit at least one H gene
(genotype HH or Hh) and two O genes.
• The H gene elicits the production of an enzyme called α-2-
Lfucosyltransferase that transfers the sugar L-fucose to an
oligosaccharide chain on the terminal galactose of type 2 chains.
• Sugars occupying the terminal positions of this precursor chain
and conferring blood group specificity are called the
immunodominant sugars. Therefore, L-fucose is the sugar
responsible for H specificity (blood group O)
• The O gene at the ABO locus is sometimes referred to as an amorph
and does not elicit the production of a catalytically active
polypeptide transferase; therefore, the H substance remains
unmodified.
• Consequently, the O blood group has the highest concentration of H
antigen. The H substance (L-fucose) must be formed for the other sugars
to be attached in response to an inherited A and/or B gene.
• The H gene is present in more than 99.99% of the random population. Its
allele, h, is quite rare, and the genotype hh is extremely rare. The term
Bombay has been used to refer to the phenotype that lacks normal
expression of the ABH antigens because of the inheritance of the hh
genotype.
• The hh genotype does not elicit production of α-2-L fucosyltransferase.
Therefore, L-fucose is not added to the type 2 chain and H substance is
not expressed on the RBC.
• Even though Bombay (hh) individuals may inherit ABO genes, normal
expression, as reflected in the formation of A, B, or H antigens, does not
occur.
• In the formation of blood group A, the A gene (AA or AO) codes for
production of α-3-N-acetylgalactosaminyltransferase, which
transfers an N-acetyl-D-galactosamine(GalNAc) sugar to the H
substance. This sugar confers A specificity
• The A-specific immunodominant sugar is linked to a type 2
precursor substance that now contains H substance through the
action of the H gene

• Individuals with blood group B inherit a B gene (BB or BO) that

codes for the production of α-3-D-galactosyltransferase and
attaches D-galactose (Gal) sugar to the H substance previously
placed on the type 2 precursor substance through the action of the
H gene.14 This sugar is responsible for B specificity
 GLUCOSYLTRANSFERASES AND IMMUNODOMINANT
SUGAR RESPONSIBLE FOR A,B,H ANTIGEN SPECIFICITIES
GENE GLYCOSYLTRANSFER IMMUNODOMINA ANTIGEN
ASE NT SUGAR

H α-2-L- L-fucose H
fucosyltransferase

A α-3-N- N-acetyl-D- A
acetylgalatosamiyltr galactosamine
ansferse

B α-3-D- D-galactose B
galactosyltransferas
e
Formation of A, B, and H Soluble Antigens
• ABH antigens are integral parts of the membranes of RBCs,
endothelial cells, platelets, lymphocytes, and epithelial cells.
ABH-soluble antigens can also be found in all body secretions.
• Their presence is dependent on the ABO genes inherited and on
the inheritance of another set of genes called Sese (secretor
genes) that regulate their formation.
• Eighty percent of the random U.S. population are known as
secretors because they have inherited a secretor gene (SeSe or
Sese).
• The inheritance of a Se gene codes for the production of the
transferase α-2-L-fucosyltransferase that modifies the type 1
precursor substance in secretions to form H substance.
• H substance can then be further modified to express A and
B substance in secretions such as saliva. For example, a
group A individual who is a secretor (SeSe or Sese) will
secrete glycoproteins carrying A and H antigens.
• However, the Se gene does not affect the formation of A,
B, or H antigens on the RBC. It is the presence of the Se
gene–specified α-2-L-fucosyltransferase that determines
whether ABH-soluble substances will be secreted
• People who inherit the sese genotype are termed
nonsecretors
 Comparison of ABH Antigens on RBCs with A,B, and H soluble
substances
ABH ANTIGENS ON RBCs A, B, AND H SOLUBLE SUBSTANCES
RBC antigens can be Secreted substances are
glycolipids, glycoproteins, Glycoproteins
or glycosphingolipids

RBC antigens are synthesized Secreted substances are

only on type 2 precursor chains primarily synthesized on
type 1 precursor chains

Type 2 chain refers to a Type 1 chain refers to a

beta 1→4 linkage in which beta-1→3 linkage in which
the number one carbon the number one carbon of the
of the galactose is attached to galactose is attached to the
the number four carbon of number three carbon of
the N-acetylglucosamine sugar the N-acetylglucosamine sugar
of the precursor substance. of the precursor substance

The enzyme produced by The enzyme produced by

the H gene (α-2-Lfucosyltransferase) the Se gene (α-2-Lfucosyltransferase)
Acts primarily on type 2 chains, preferentially
which are prevalent on the acts on type 1 chains in
RBC membrane. secretory tissues.
 BOMBAY GROUP
• Another important blood group and more in indian context is Bombay
group discovered by Bhende and Bhatia in 1952.
• The phenotype results from the inheritance of a double dose of the h
gene, producing the very rare genotype hh.
• The (Oh) Bombay phenotype is inherited as an autosomal recessive trait.
The underlying molecular defect is most often a mutation in the gene H
gene, producing a silenced gene incapable of coding for the enzyme, α-2-
L-fucosyltransferase (H transferase).
• As a result, the ABO genes cannot be expressed and ABH antigens cannot
be formed, since there is no H antigen made in the Bombay phenotype
• The Bombay phenotype (oh) individual are therefore devoid of antigens
present in ABO system.
• This can be observed invitro by lack of reaction oh phenotype red cells
with antisera-A,B,AB and H.
• In RBC testing using Anti-A and Anti-B, the Bombay would phenotype as an O blood
group.
• However, RBCs of the Bombay phenotype (Oh) do not react with the anti-H lectin (Ulex
europaeus), unlike those of the normal group O individual, which react strongly with anti-
H lectin
• Bombay serum contains anti-A, anti-B, anti-A,B, and anti-H. Unlike the anti-H found
occasionally in the serum of A1 and A1B individuals, the Bombay anti-H can often be
potent and reacts strongly at 37°C. It is an IgM antibody capable of binding complement
and causing RBC lysis.
• Transfusing normal group O blood (with the highest concentration of H antigen) to a
Bombay recipient (anti-H in the serum) would cause immediate cell lysis.

• For transfusion purpose, Bombay phenotype individual can only receive blood from
another Bombay phenotype individuals.
• The Oh individuals are non-secretor of ABH substances
 General Characteristics of Bombay Oh (Hnull)
Phenotypes
• Absence of H, A, and B antigens; no agglutination with anti-A, anti-B, or anti-
H lectin
• Presence of anti-A, anti-B, anti-A,B, and a potent wide thermal range of
anti-H in the serum
• A, B, H nonsecretor (no A, B, or H substances present in saliva)
• Absence of α-2-L-fucosyltransferase (H enzyme) in serum and H antigen on
red blood cells
• Presence of A or B enzymes in serum (depending on ABO genotype)
• A recessive mode of inheritance (identical phenotypes in children but not in
parents)
• RBCs of the Bombay phenotype (Oh) will not react with the anti-H lectin
(Ulex europaeus)
• RBCs of the Bombay phenotype (Oh) are compatible only with the serum
from another Bombay individual
 ABH Antigens and Antibodies
in Disease
• Associations between ABH antigens and practically any disorder known to
man can be found throughout medical literature.
• It has been observed that certain diseases condition has the capacity to
influence or modify the antigens particularly A and B antigens.This may lead
to pseudoantigens.
• Leukaemia for example reduces the antigenic strength of individual of A
group.
• Hodgkin’s lymphoma disease also has been reported to weaken or depress
ABH red cell antigens resulting in variable reactions during forward
grouping.
• Acquired B antigen are usually of bacteria origin, it has been observed in
persons particularly those who are suffering from gut infection due to E.coli.
• A lack of detectable ABO antigens can occur in patients with carcinoma of
stomach or pancreas.
• CONCLUSION