ABO BLOOD GROUP SYSTEM

DR O.I. AJAYI LECTURE SERIES

 Blood Group Systems
• Most blood group systems (ABO and others) are made up of:
– An antigen on a red cell and the absence of it’s corresponding
antibody in the serum (if you’re A, you don’t 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
 History: Karl Landsteiner
• Discovered the ABO Blood
Group System in 1901
• He and his five co-workers
began mixing each others
red cells and serum together
and inadvertently
performed the first forward
and reverse ABO groupings
http://www.nobelpreis.org/castellano/medizin/images/landsteiner.jpg
 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
 ABO BLOOD GROUP

• History
1. Landsteiners discovered the ABO Blood Group System in 1901

2. He and five co-workers began mixing each others red blood cells
and serum together and accidentally performed the first forward
and reverse ABO groupings.

3. Landsteiners Rule: If an antigen (Ag) is present on a patients red blood

cells the corresponding antibody (Ab) will NOT be present in the patients
plasma, under ‘normal conditions’.
 ABO BLOOD GROUP SYSTEMS

SYSTEM OF:
• ANTIGEN
• ANTIBODY
 ABO BLOOD GROUP

There are two principles:

1-almost all normal healthy individuals above 3-6 months of
age have “ naturally occurring Abs” to the ABO Ags that they
lack - These Abs termed naturally occurring because they
were thought to arise without antigenic stimulation.
2- These “naturally occurring” Abs are mostly IgM class. That means
that, they are Abs capable of agglutinating saline/ low protein
suspended red cell without enhancement and may activate
complement cascade.
 Importance of ABO groups
• 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
• There are four main blood groups:
• A – 42%
• B – 9%
• AB – 3%
• O – 46%.
• There are racial variations in these frequencies.
• The ABO antigens are determined by
carbohydrates (sugars) which are linked either
to polypeptides to form glycoproteins or to
lipids to form glycolipids.
 ABO antigens:

Biochemical & Genetic Considerations

 ABO antigens…
• The expression of ABO antigens is controlled by
3 separate genes: ABO located on the short arm
of chromosome 9, FUT1 (H) and FUT2 (Se) both
located on chromosome 19.
• The genes from each locus are inherited in pairs
as a Mendellian dominant characters.
• Each gene codes for different enzyme
(glycosyltransferases) which attaches specific
sugars(monosaccharides) onto precursor
disaccharide molecules.
 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
 ABO BIOCHEMISTRY
• There are four types of disaccharide
chains known to occur on red cells,
other tissues and body secretions.
• Type1 – found in the plasma and
secretions- are the substrates for FUT2
(Se) gene.
• Types 2,3,4 – only on red cells –
substrate for FUT1 gene (H).
 BIOCHEMISTRY….
• The expression of A and B antigens is determined by the H and
Se genes which both give rise to glycosyltransferases that add L-
fucose to produce the H-antigen.
• The presence of an A or B gene (or both) results in the
production of further glycosyltransferases which convert the H-
substance into A and B antigens by the terminal addition of N-
acetyl-D-galactosamine and D-galactose respectively.
 BIO……..
• The O gene does not encode for any functional enzyme
production, therefore, it results in premature
termination of the translated polypeptide and the
production of an enzyme with no catalytic activity – the
H substance persists unchanged and result in Zero
antigenic conversion, hence the term ‘O’.
• Their red cells have no antigens but their plasma
contains anti-H in addition to anti A and anti B
antibodies.
 Genetics
• The H antigen is found on the RBC with the Hh or HH
genotype, but NOT from the hh genotype
• The A antigen is found on the RBC with the Hh, HH, and A/A,
A/O, or A/B genotypes
• The B antigen is found on the RBC with the Hh, HH, and B/B,
B/O, or A/B genotypes
 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

 Inheritance

• Definition
Isoagglutinins: are defined as antibodies that agglutinate blood cells
of some individuals of the same species

Glycosyltransferases: are enzyme that facilitate the transfer of

carbohydrate (sugar) molecules onto carbohydrate precursor
molecules

Immunodominant sugar: is the sugar molecule that complete the

antigenic determinant when combined with the precursor substance
ABO inheritance
 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
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 an
immunodominant sugar to the H antigen
– Immunodominant sugars are present at the terminal ends of the
chains and confer the ABO antigen specificity
 H Antigen
The H gene codes for an enzyme (fucosylytranferase) that adds a
Fucose to the terminal sugar of a Precursor Substance (PS*).
The biochemical structure below constitutes the H Antigen. (h
gene is an amorph.)

H gene acts on
a Precursor
substance(PS)*
by adding
*PS = oligosaccharide chain
Fucose attached to either glycosphingo-
lipid, Type 2 chain (on RBC) or
glycoprotein, Type 1 chain (in
secretions)
 ABO Genetics

• 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.
 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
A Antigen

The A gene codes

for an enzyme that
adds GalNAc
(N-Acetyl-D
galactosamine)
to the terminal
sugar of the
H Antigen. The biochemical structure
constitutes the A antigen.
Formation of the B antigen
RBC

Glucose

Galactose

N-acetylglucosamine

Galactose

Galactose
Fucose
 Formation of the
B Antigen

B gene codes for an

enzyme that adds
D-Galactose
to the terminal sugar
of the H Antigen.

The biochemical structure

constitutes the B Antigen.
The H antigen is found on
the RBCs when there is an
Hh or HH genotypes but
NOT with the hh genotype.

The A antigen is found on

the RBCs when there is
Hh, HH, and A/A, A/O or
A/B genotypes.

The B antigen is found on

the RBCs when there is
Hh, HH, and B/B, B/O or
A/B genotypes.
• 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
antigens….that means more
H antigen sites
Amount of H Antigen According to Blood Group

 Blood Group O
people have Neither the A or B genes have
converted the H antigens to A or B
red blood cells antigens - just a whole bunch of H!

rich in H O allele at the ABO locus

antigen. Why? (amorph) It does not
alter the structure of H
substance.

Greatest O > A2 > B > A2B > A1 > A1B Least

Amount of H Amount of H
 Donor Nucleotides & Immundominant Sugars responsible
for H, A, and B Ags specificity

Gene Glcosyltransferase Nucleotide Immunodominant sugar Antigen

Guanosine
H L- fucosyl trnsferas L-fucose H
GDP-FUC

N acetylgalactosaminyl Uridine
A N-acetyl-D- A
transferase UDP- galactoseamine
GALNAC

Uridine
B D- galactosyl D-galactose B
transferase UDP-GAL
 A A

A A
Group O Group A

Many H Fewer A
antigen sites H antigen
sites

Most of the H antigen sites in a

Group A individual have been
converted to the A antigen
 ABO INHERITANCE

Dad = A/O Mom

and
B O
Mom = B/O
A A/B A/O
Dad
O O/B O/O
 Possible ABO matings
Phenotypes Genotype offspring
AxA AAxAA A (AA)
AAxAO A (AA or AO)
AOxAO A (AA or AO),O(OO)

BxB BBxBO B (BB or BO)

AxAB AAxAB AB (AB) or A (AA)

AOxAB AB (AB), A (AA, AO), B(BO)
ABO Blood antibodies
 Landsteiner’s Rule:
• Normal, Healthy individuals
possess ABO antibodies to the
ABO antigen absent from
their RBCs in their serum.
 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)
 Characteristics of antibodies
• Non-red blood cell stimulated (previously discussed)
– ABO antibodies –naturally occuring.
• Red blood cell stimulated
– Antibodies formed as a result of transfusion, etc
– Usually IgG
– Active at 37°C
– 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
REACTION PATTERNS.

Fig 13.6
Tube test
 Antibodies of Rh system
• Naturally occurring
• Anti- E
• Occasionally anti-D and anti C
• Immune antibodies
• D antibodies are more immunogenic
• Other are anti c, E, e, C.
• Most common is anti- E
• After anti- D, anti- c is the common cause of HDN
• (The vast majority of Rh antibodies are IgG and do not fix complement)
 Major ABO Blood Group

Forward blood grouping using anti-sera and red blood cells

ABO Antigen Antigen Antibody

Group Present Missing Present
A A B Anti-B
B B A Anti-A
O None A and B Anti-A&B
AB A and B None None
If an antigen (Ag) is present on a patients red blood cells the
corresponding antibody (Ab) will NOT be present in the patients
plasma, under ‘normal conditions’.
 Rh Blood Groups

▪ There are eight different Rh agglutinogens, three of which (C, D, and

E) are common
▪ Presence of the Rh agglutinogens on RBCs is indicated as Rh+
▪ Anti-Rh antibodies are not spontaneously formed in Rh– individuals
▪ However, if an Rh– individual receives Rh+ blood, anti-Rh antibodies
form
▪ A second exposure to Rh+ blood will result in a typical transfusion
reaction

Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings

 Hemolytic Disease of the Newborn

▪ Hemolytic disease of the newborn – Rh+ antibodies of a sensitized Rh– mother

cross the placenta and attack and destroy the RBCs of an Rh+ baby
▪ Rh– mother becomes sensitized when Rh+ blood (from a previous pregnancy of an
Rh+ baby or a Rh+ transfusion) causes her body to synthesis Rh+ antibodies
▪ The drug RhoGAM can prevent the Rh– mother from becoming sensitized
▪ Treatment of hemolytic disease of the newborn involves pre-birth transfusions and
exchange transfusions after birth

Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings

HEMOLYTIC DISEASE OF THE NEWBORN AND FETUS

• Hemolytic disease of the new born and fetus (HDN) is a

destruction of the red blood cells (RBCs) of the fetus and
neonate by antibodies produced by the mother

• It is a condition in which the life span of the fetal/neonatal red

cells is shortened due to maternal allo-antibodies against red
cell antigens acquired from the father
 ANTIBODIES
Five classes of antibodies
• IgM
• IgG
• IgA
• IgD
• IgE
• Blood groups specific antibodies are
• IgG and
• IgM
 Disease mechanism - HDN

• There is destruction of the RBCs of the fetus by antibodies

produced by mother
• If the fetal red cells contains the corresponding antigen, then
binding of antibody will occur to red cells
• Coated RBCs are removed by mononuclear phagocytic system
 Clinical features
Less severe form
• Mild anemia
Severe forms
• Icterus gravis neonatorum (Kernicterus)
• Intrauterine death
• Hydrops fetalis
• Oedematous, ascites, bulky swollen & friable placenta
Pathophysiology
• Extravascular hemolysis with extramedullary erythropoiesis
• Hepatic and cardiac failure
 HDN…
BEFORE BIRTH

• Anemia (destruction of red cells)

• Heart failure
• Fetal death

AFTER BIRTH

• Anemia (destruction of red cells)

• Heart failure
• Build up of bilirubin
• Kernicterus
• Severe growth retardation
 Transfusion Reactions

▪ Transfusion reactions occur when mismatched blood is infused

▪ Donor’s cells are attacked by the recipient’s plasma agglutinins
causing:
▪ Diminished oxygen-carrying capacity
▪ Clumped cells that impede blood flow
▪ Ruptured RBCs that release free hemoglobin into the bloodstream
▪ Circulating hemoglobin precipitates in the kidneys and causes renal
failure

Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings