ABO and H Blood Group

Systems and Secretor

Status
- A blood group system is composed of antigens that are produced by alleles at a single genetic locus or
at loci so, closely linked that genetic crossing over rarely occurs.
- Blood group antigens are molecules located primarily on the red cell membrane. These molecules can
be classified biochemically as proteins and as carbohydrates linked to either a lipid (glycolipid) or a
protein (glycoprotein). With adequate immunologic exposure, a blood group antigen may elicit the
production of its correspond antibody in individuals who lack the antigen.
- The International Society Blood Transfusion (ISBT) has defined 30 blood group systems
- In 1980 to standardize blood group systems and antigen names depends on genetic studies and
serological data. Thus, to provide additional terminology suitable for use with computer software (Table
4-1).
 HISTORICAL OVERVIEW OF ABO BLOOD GROUP
SYSTEM
- Discovery of the ABO blood group system by Landsteiner was in 1900 and this was the marked the beginning of
modern blood banking and transfusion medicine.
-He described the blood groups as A, B, and O after he recognized different patterns of agglutination when human
blood samples were mixed in random pairings.
- Several years later, Landsteiner’s associates, von Decastello and Sturli added group AB to the original
observations.
- Landsteiner’s rule (or Landsteiner’s law) this rule states that normal, healthy individuals possess ABO antibodies
to the ABO blood group antigens lacking on their red cells. Four major phenotypes are derived from the two
major antigens (A and B) of the system. These phenotypes are group A, group B, group AB, and group O (Figure).
- The first blood group system to be described is the ABO blood group system which remains the most important
blood group system for transfusion purposes. Thus, accurate donor and recipient ABO types are fundamental to
transfusion safety because of the presence of ABO antibodies in individuals with no previous exposure to human
red cells.
- The transfusion of ABO-incompatible blood to a recipient can result in intravascular hemolysis and other serious
consequences of an acute hemolytic transfusion reaction(complication of transfusion associated with
intravascular hemolysis, characterized by rapid onset with symptoms of fever, chills, hemoglobinemia, and
hypotension; major complications include irreversible shock, renal failure, and disseminated intravascular
coagulation).
Relationship between ABO antigens and antibodies
 GENERAL CHARACTERISTICS OF ABO ANTIGENS
- ABO antigens are widely distributed and are located on
1- Red cells
2- Lymphocytes (adsorbed from plasma)
3-Platelets (adsorbed from plasma)
4-Most epithelial and endothelial cells
5- Organs such as the kidneys.
- Soluble forms of the ABO blood group system antigens can also be synthesized and secreted by tissue cells which
are detected in secretions and all body fluids except cerebrospinal fluid.
-ABO phenotype frequencies differ in selected populations and ethnic groups. For example, the group B phenotype
has a higher frequency in blacks and Asians compared with whites

- ABO blood group system antigens, which are intrinsic to the red cell membrane, exist as either glycolipid or
glycoprotein molecules, whereas the soluble forms are primarily glycoproteins.

- ABO antigens are detectable at 5 to 6 weeks in utero. A newborn possesses fewer antigen copies per red cell
compared with an adult. Also they lack the fully developed antigen structures of adults’ red cells.

- For Cord blood (whole blood obtained from the umbilical vein or artery of the fetus)blood sample the ABO
phenotyping show weaker agglutination reactions by using blood grouping reagents, anti-A and anti-B. However,
by age 2-4 years these Ag’s become fully expressed as in adults.
 INHERITANCE AND DEVELOPMENT OF A, B, AND H
ANTIGENS
- The inheritance and formation of ABO antigens requires an understanding of the H antigen, which is
inherited independent of the ABO blood group system antigens.
- The production of H antigen is genetically controlled by the H gene, which is located on a different
chromosome from the ABO genetic locus.
- While the expression of soluble ABO antigens in saliva, tears, and other body fluids is influenced by
inheritance of the Se gene.
- So, occurrence and location of the ABO antigens are influenced by three genetically independent loci:
ABO, H, and Se.
- ABO antigens are assembled on a common carbohydrate structure that also serves as the base for the
formation of the H, Lewis, I/i, and P1 antigens. Consequently, this common carbohydrate structure is
capable of antigen expression for more than one blood group system (Figure).
-Thus, it is important to recognize that the action of genes of one blood group system can affect the
expression of antigens in another system.
- Common Structure for A, B and H Antigens
- The common structure (antigen building block) for A, B and H antigens is an oligosaccharide chain
attached to either a protein or a lipid carrier molecule.
- The oligosaccharide chain comprises four sugar molecules linked in simple linear forms or in more
complex structures with a high degree of branching.
- The two terminal sugars, D-galactose and N-acetylglucosamine, may be linked together in two
different configurations.
- When the number 1 carbon of D-galactose is linked with the number 3 carbon of N-
acetylglucosamine, the linkage is described as β1→3. Type 1 oligosaccharide chains are
formed.
- When the number 1 carbon of D-galactose is linked with the number 4 carbon of N-
acetylglucosamine, the linkage is described as β1→4. Type 2 oligosaccharide chains are
formed (Figure).
- Type 2 structures are associated mainly with glycolipids and glycoproteins on the red cell
membrane.
- Type 1 structures are associated primarily with body fluids. Some type 2 glycoprotein
structures are located in body fluids.
- Development of H Antigen
- The H antigen is the only antigen in the H blood group system. This blood group system has
been assigned to a locus on chromosome 19 and is closely linked with the Se locus.
- The H locus has two significant alleles: H and h. The H allele is a dominant allele with high
frequency whereas the h allele is classified as an amorph with rare frequency.
- The gene product of the H allele is a protein classified biochemically as a transferase enzyme.
- formation of H antigen, a glycosyltransferase enzyme transfers a sugar molecule, L-fucose, to either
type 1 or type 2 common oligosaccharide chains. The biochemical name for this enzyme is L-
fucosyltransferase (FUT-1).
- The L-fucose added to the terminal galactose of the type 1 and type 2 chain is called the
immunodominant sugar (sugar molecule responsible for specificity.) for H antigens because the sugar
confers H specificity (Figure). Thus, formation of the H antigen is the end product of an enzymatic
reaction.
Biochemical structures of the H, A, and B antigens.
- This formation is crucial to the expression of A and B antigens because the gene products of
the ABO alleles require that the H antigen be the acceptor molecule.
-The red cells from an h homozygote (hh) are classified as the Bombay phenotype ( rare
phenotype of an individual who genetically has inherited the h allele in a homozygous manner;
the individual’s red cells lack H and ABO antigens.).
-First case was described in 1952 in a family living in Bombay Phenotype. Both red cells and
secretions were deficient in H and ABO antigen expression.
-More than 130 Bombay phenotypes have been reported with a relatively greater incidence in
India.
- The H antigen is not assembled on the red cells. Because H antigen is the building block for the
development of the A and B antigens. So, even though the ABO alleles are inherited. The
resulting phenotype lacks expression of both H and ABO antigens. Thus, these rare individuals
lack both H antigen and ABO antigen expression on their red cells.
- The red cell reactions were characteristic of the group O phenotype in routine ABO testing.
Another related antibody, anti-H, was detected in the family’s serum in addition to the ABO
antibodies.
-The anti-H in the Bombay phenotype is of clinical significance because this antibody is capable of high
thermal activity at 37° C and complement activation with resulting hemolysis.
- Transfusion for these individuals presents an especially difficult problem because they are compatible
only with the Bombay phenotype. If transfusion is necessary, stored autologous units, siblings, and rare
donor files are potential options. (Table)
- Development of A and B Antigens
- Genetic control of A and B antigens has been mapped to chromosome 9.
- Three major alleles exist within the ABO locus: A, B, and O. The A and B alleles, similar to the H allele, are
glycosyltransferases.
- The A allele are N-acetylgalactosamine which transfers the sugar N-acetylgalactosamine
(immunodominant sugar for A) to an oligosaccharide chain; the chain was previously converted to H
antigen.
- The B allele produces D-galactosyltransferase, which transfers the sugar D-galactose
(immunodominant sugar for B) to an oligosaccharide chain; the chain was previously converted to H
antigen.
- The O allele is considered nonfunctional because the resulting gene product is an enzymatically inactive
protein. As a result, group O red cells carry no A or B antigens but are rich in unconverted H antigens.
- Adult group O red cells have about 1.7 million H-antigen copies per red cell and possess the greatest
concentration of H antigens per red cell.
- Other ABO phenotypes have fewer copies of H antigens because the H antigen is the acceptor molecule
for the A and B enzymes. Group A1B phenotype possesses the lowest number of unconverted H sites.
(Figure)
- The ABH antigens develop as early as the 37th day of fetal life but do not increase much in strength
during the gestational period.
- The RBCs of the newborn have been estimated to carry anywhere from 25 to 50 percent of the
number of antigenic sites found on the adult RBC. As a result, reactions of newborn RBCs with ABO
reagent antisera are frequently weaker than reactions with adult cells
Variation of
H-antigen
concentratio
ns in ABO
phenotypes.
- The expression of A and B antigens on the RBCs is fully developed by 2 to 4 years of age and
remains constant for life.
- Within aging, the phenotypic expression of ABH antigens may vary with race, genetic
interaction, and disease states.
- ABO SUBGROUPS
- Comparison of A1 and A2 Phenotypes
- Subgroups of A make up 1 percent of those encountered in the laboratory
- The ABO phenotypes can be divided into categories termed subgroups. Subgroups differ in the amount
of antigen expressed on the red cell membrane.
- Some subgroups possess more highly branched, complex antigenic structures, whereas others have
simplified linear forms of antigen.
- The group A phenotype is classified into two major subgroups: A1 and A2. These glycosyltransferase
gene products, which are genetically controlled by the A1 and A2 genes differ slightly in their ability to
convert H antigen to A antigen. (Figure)
- The A1 phenotype, encoded by the A1 gene, exists in about 80% of group A individuals. The A1 gene
effectively acts on the H antigens in the production of A antigens.
- The A2 phenotype, encoded by the A2 gene, constitutes about 20% of group A individuals. An
alloantibody, anti-A1, can be detected in 1% to 8% of A2 individuals and in 22% to 35% of A2B
individuals.
- In routine ABO phenotyping, both A1 and A2 red cells agglutinate with commercially available anti-A reagents.
These red cells can be distinguished in serologic testing only with a reagent called Dolichos biflorus lectin which
possesses anti-A1 specificity.
-Thus, this reagent often used to identifying infrequent subgroups of A other than for transfusion purposes.
- In addition to A1 and A2, other A subgroups have been described that involve reduced expression of A
antigens. Thus, result in weak or no agglutination when RBCs tested with commercial anti-A reagents
- The subgroups (Aint, A3, Ax, Am, Aend, Ael and Abantu )are genetically controlled by the inheritance of rare alleles at
the ABO locus and collectively occur at less than 1% frequency.
-Some subgroups may characteristically demonstrate mixed-field agglutination (agglutination pattern in which a
population of the red cells has agglutinated and the remainder of the red cells are un-agglutinated)patterns (e.g.,
A3 subgroup) or possess anti-A1 in the serum (e.g., A3, Ax, and Ael subgroups).
- Antigen present on the weak subgroups of A is usually equivalent to group O red cells. Special techniques of
adsorption (immunohematologic technique that uses red cells (known antigens) to remove red cell antibodies
from a solution (plasma or antisera); group A red cells can remove anti-A from solution). and elution ( process
that dissociates antigen-antibody complexes on red cells; freed IgG antibody is tested for specificity) may also be
necessary to demonstrate the presence of the A antigen.
-The serologic classification of rare A subgroups is determined by the following:
• Weak or no red cell agglutination with anti-A and anti-A,B commercial reagents
• No agglutination with anti-A1
• Presence or absence of anti-A1 in the serum
• Strong agglutination reactions with anti-H
• Presence of A and H in saliva
• Subgroups of B
-B subgroups are rarer than the A subgroups.
-Typically, these subgroups demonstrate weak or no agglutination of red cells with anti-B reagents.
• Criteria used for differentiation of weak B phenotypes include the following:
1- Strength/type of agglutination with anti-B, anti-A,B, and anti-H
2- Presence or absence of ABO isoagglutinins in the serum
3- Adsorption-elution studies with anti-B
4- Presence of B substance in saliva
- Importance of Subgroup Identification in Donor Testing
- Failure to detect a weak subgroup could have serious consequences.
- If a weak subgroup is missed in a recipient (the individual receiving the transfusion), the
recipient would be classified as group O. Classification as a group O rather than a weak
subgroup would probably not harm the recipient. However, an error in donor phenotyping and
the subsequent labeling of the donor unit as group O (rather than group A) might result in the
decreased survival of the transfused cells in a group O recipient cause these recipients would
possess ABO antibodies capable for reacting with the weak subgroup antigens in vivo.
 GENETIC FEATURES OF ABO BLOOD GROUP
- SYSTEM
An individual inherits two ABO genes (one from each parent). The three major alleles of the
ABO blood group system are A, B and O. The A gene subsequently can be divided into the A1
and A2 alleles. The A1 allele is dominant over the A2 allele and both alleles are dominant
over the O allele.
- The A and B genes express a codominant mode of inheritance, whereas the O allele is
recessive.
 ABO BLOOD GROUP SYSTEM ANTIBODIES
-These ABO antibodies, present in individuals with no known exposure to blood or blood products but,
from the environment in bacteria, plants, and pollen. So, individuals respond immunologically to these
antigens and produce ABO antibodies detectable in plasma and serum. Another term is used for these
antibodies is non–red blood cell stimulated (immunologic stimulus for antibody production is unrelated
to a red cell antigen) is more appropriate for describing the ABO antibodies.
-Newborns do not produce their own ABO antibodies until they are 3 to 6 months of age. ABO antibodies
detected prior to this time are maternal in origin (IgG have crossed the placenta), it can be done just
forward ABO typing test for the newborns.
-Maximal ABO titers (extent to which an antibody may be diluted before it loses its ability to
agglutinate with antigen) have been reported in children 5 to 10 years old.
- As a person ages, the ABO titers tend to decrease and may cause problems in ABO
phenotyping specifically for the reverse ABO typing test. This dangerous cause when wrong
blood typing transfused, it will cause intravascular hemolysis.
-In addition to newborns and older patients, other situations exist where ABO antibody titers
may be weak or not demonstrable in testing (Table).
• Acquired hypogammaglobulinemia: lower than normal levels of gamma globulin in the blood associated with
malignant diseases (chronic leukemias and myeloma) and immunosuppressive therapy.

• Congenital agammaglobulinemia: genetic disease characterized by the absence of gamma globulin and
antibodies in the blood.

• Acquired agammaglobulinemia: absence of gamma globulin and antibodies associated with malignant diseases
such as leukemia, myeloma, or lymphoma.
 GENERAL CHARACTERISTICS OF HUMAN ANTI-A AND
ANTI-B
• Immunoglobulin Class
- The anti-A produced in group B individuals and the anti-B produced in group A individuals contain
primarily antibodies of the IgM class along with small amounts of IgG.
- In contrast, anti-A and anti-B antibodies found in the serum of group O individuals are composed
primarily of IgG class.
• Hemolytic Properties and Clinical Significance
- IgG and IgM forms of anti-A and anti-B are capable of the activation and binding of complement and
eventual hemolysis of red cells in vivo or in vitro. Because of their ability to activate the complement
cascade with resultant red cell hemolysis, the ABO antibodies are considered of clinical significance
(antibodies capable of causing decreased survival of transfused cells as in a transfusion reaction; have
been associated with hemolytic disease of the fetus and newborn.) in transfusion medicine where
clinical signs and symptoms of an acute hemolytic transfusion reaction occur.
• In Vitro Serologic Reactions
- ABO antibodies directly agglutinate a suspension of red cells in a physiologic saline
environment and do not require any additional potentiators.
• They are optimally reactive in immediate-spin phases at room temperature (15° C to 25° C).
The agglutination reactions do not require an incubation period and react without delay on
centrifugation.
-The procedure is straightforward and is divided into two components:
1-Testing of the red cells for the presence of ABO antigens (or forward grouping)
2- Testing of serum or plasma for the expected ABO antibodies (or reverse grouping).
-Donor and recipient red cells must be tested using anti-A and anti-B reagents. Donor and recipient
serum or plasma must be tested for the expected ABO antibodies using reagent A1 and B red cells.
-Testing of cord blood and samples from infants younger than 4 months requires only red cell testing
in ABO phenotyping because ABO antibody levels are not detectable.
-The ABO phenotype is determined when the red cells are directly tested for the presence or absence of
either A or B antigens. Serum testing provides a control for red cell testing because ABO antibodies.
-An ABO discrepancy occurs when red cell testing does not agree with the expected serum testing. Any
discrepancy in ABO testing should be resolved before transfusion of recipients or labeling of donor
units.
 SELECTION OF ABO-COMPATIBLE RED BLOOD CELLS AND PLASMA
PRODUCTS FOR TRANSFUSION
- In routine transfusion practices, donor products (RBCs and plasma) with identical ABO
phenotypes are usually available to the recipient. This transfusion selection is referred to as
providing ABO-identical (ABO group–specific) blood for the intended recipient.
- In situations where blood of identical ABO phenotype is unavailable, ABO-compatible (ABO
group–compatible) blood which means (the serologic compatibility between the ABO
antibodies present in the recipient’s serum and the ABO antigens expressed on the donor’s
red cells.)
- ABO compatibility applies to RBC transfusions but not to transfusions of whole blood (table).
When whole blood is transfused, ABO-identical donor units must be provided because both
plasma and red cells are present in the product.
- Group AB recipients are considered universal recipients (group AB recipients may receive
transfusions of RBCs from any ABO phenotype; these recipients lack circulating ABO antibodies
in plasma.)because these individuals lack circulating ABO antibodies and can receive RBCs of
any ABO phenotype.
- Persons with group O red cells are called universal donors (group O donors for RBC
transfusions; these RBCs may be transfused to any ABO phenotype because the cells lack both
A and B antigens.) because the RBC product lacks both A and B antigens and could be
transfused to any ABO phenotype. Group O donor RBCs can be used in times of urgency for
emergency release of donor units.
When plasma products are transfused, the selection of an ABO-identical phenotype is the ideal
situation.
- For the transfusion of plasma, group AB is considered the universal donor and group O is the
universal recipient
- ROUTINE ABO PHENOTYPING
-A fundamental procedure of immunohematologic testing is the determination of the ABO phenotype
(table).
- SECRETOR STATUS
-There are two allelic genes at this locus: Se and se. The gene product of the Se allele, FUT2, is an L-
fucosyltransferase that preferentially adds L-fucose to type 1 oligosaccharide chain structures in
secretory glands.
- The FUT2 gene may also act on type 2 chains in the secretory glands. The H gene, FUT1,
preferentially adds fucose to type 2 chains.
-The FUT2 gene is directly responsible for regulating the expression of soluble A, B, and H antigens on
the glycoprotein structures by the A and B glycosyltransferases. located in body secretions such as
saliva , urine, tears, bile, amniotic fluid, breast milk, exudate, and digestive fluids.
- An individual who inherits the Se allele in either a homozygous (SeSe) or a heterozygous (Sese)
manner is classified as a secretor (ndividual who inherits Se allele and expresses soluble forms of H
antigens in secretions).
-About 80% of the random population inherits the Se allele and is classified as secretors.
-An individual with the genotype sese is classified as a nonsecretor (ndividual who inherits the
genotype sese and does not express soluble H substance in secretions).
- About 20% of the random population can be considered nonsecretors.
-The allele, se, is an amorph. A homozygote does not convert glycoprotein antigen precursors to
soluble H substance and has neither soluble H antigens nor soluble A or B antigens present in body
fluids (Figure)
-The application of the presence of ABH substances in body secretions such as: saliva, urine, tears, bile
and milk helps in forensic medicine.