ABO Blood Group System

Marian Helen G. Tecson, RMT

Flow of the Discussion

Introduction History Landsteiner’s Law

Routine ABO
ABO Antibodies ABO Antigens
Testing

Inheritance of ABO Blood Group

ABO Discrepancies
Blood Groups Mythology

Resolution Technical Errors

Introduction
u most important of all blood groups in both transfusion and
transplant medicine

u the only blood group system in which individuals already

have antibodies in their serum to antigens that are absent
from their red blood cells

u occurs without any prior exposure to red blood cells through

transfusion or pregnancy
Introduction
u due to the presence of these antibodies, transfusion of an
incompatible ABO blood type may result in immediate lysis of
donor red blood cells

u this produces a very severe, or even fatal, transfusion reaction

to the patient

u transfusion of the wrong ABO blood group remains the

leading cause of death in hemolytic transfusion reaction
fatalities
History
u Karl Landsteiner discovered the
ABO blood group system

u He classified an individual’s
erythrocytes into 4 types:
Blood Type A, B, AB, and O

u This marked the beginning of the

concept of individual uniqueness
defined by the RBC antigens
present on the RBC membrane
Landsteiner’s Law
u If an agglutinogen (antigen) is present on the red blood cell
membrane, the corresponding agglutinin (antibody) must
be absent in the plasma

u If an agglutinogen is absent on the red blood cell

membrane, the corresponding agglutinin must be present
in the plasma
ABO Blood Group Antigens
u the blood groups are named for the antigens present or
absent on the surface of the red blood cells
u example: group A individuals have the “A” antigen

u presence or absence of these antigens depends on an

individual’s DNA

u DNA express different types of enzymes

ABO Blood Group Antigens
u these enzymes, known as transferases, catalyze a series of
reactions in which they transfer sugar units

u these enzymes are responsible for the type of antigen

expressed on the RBCs
ABO Blood Group Antigens
ABO Blood Group Antigens
u develop early in fetal life

u developed in utero at 5 to 6 weeks of gestation

u expression of A and B antigens on the RBCs is fully

developed by 2 to 4 years of age and remains constant
throughout life
ABH Antigens
u formation of ABH antigens results from the interaction of
genes at three separate loci (ABO, H, and Se)

u these genes do not actually code for the production of

antigens but rather produce specific glycosyltransferases
that add sugars to a basic precursor substance

u a paragloboside or glycan is the same basic precursor

material from which A, B, and H antigens all originate

u specific enzyme transferases elicited by an inherited gene

attach sugars to the paragloboside or glycan
ABH Antigens
u the H antigen is the precursor structure on which A and B
antigens are made

u H antigen acts as the acceptor molecule for the two sugars

that make the A and B antigens

u the H and Se genes are not part of the ABO system

u H gene must be inherited to form ABO antigens on the RBCs
u Se gene must be inherited to form ABO antigens in secretions
u Blood Type A
u H antigen + N-acetylgalactosamine

u Blood Type B
u H antigen + D-galactose

u Blood Type O
u H antigen only (no additional sugars attached)
u O blood group has the highest concentration of H antigen
ABH Antigens
u blood group O individuals inherit at least one H gene and
two O genes

u the H gene elicits the production of an enzyme called ⍺-2-

L-fucosyltransferase that transfers the sugar L-fucose to an
oligosaccharide chain

u L-fucose is the sugar responsible for H specificity

ABH Antigens
u ABH antigens are integral parts of the membranes of RBCs,
endothelial cells, platelets, lymphocytes, and epithelial cells

u ABH-soluble antigens can also be found in all body

secretions
ABO Antibodies
u antibodies are present or found in the serum

u antibodies are formed when our immune system is exposed

to non-self antigens

u antibodies are present against the antigen which is absent

or missing on the cell membrane of the RBCs
ABO Antibodies
ABO Antibodies
u individuals normally produce antibodies directed against
the A or B antigen absent from their RBCs

u these antibodies have been described as naturally

occurring because they are produced without any
exposure to RBCs
ABO Antibodies
u ABO antibody production is initiated at birth, but titers are
generally too low for detection until infants are 3 to 6
months old

u antibody production peaks between 5 and 10 years of age

and declines later in life
u Elderly people usually have lower levels of anti-A and anti-B

u ABO antibodies can cause rapid intravascular hemolysis if

the wrong ABO group is transfused, potentially resulting in
patient death
ABO Antibodies
u Blood type A individual: Anti-B

u Blood type B individual: Anti-A

u Blood type O individual: Anti-A and Anti-B

u Blood type AB individual: None

BLOOD ANTIGENS ANTIBODIES CAN DONATE CAN RECEIVE
TYPE BLOOD TO BLOOD FROM
A A Anti-B A, AB A, O

B B Anti-A B, AB B, O

AB A&B NONE AB A, B, AB, O

O NONE Anti-A, Anti-B A, B, AB, O O

RECAP
ABO ANTIGENS ABO ANTIBODIES
u detectable at 5-6 weeks of u detectable at 3-6 months
gestation old

u fully developed by 2-4 u production peaks at 5-10

years of age years of age

u remain constant u decline later in life

throughout life

u found on the membrane u found in the serum/plasma

of the RBCs
Routine ABO Testing
Forward Typing
u also known as Cell Grouping

u uses known sources of commercial antisera (anti-A, anti-B)

to detect antigens on an individual’s RBCs
Forward Typing
u can be done on a slide or in a test tube at room
temperature

u done by mixing unknown RBC with known typing sera

u use of commercial reagents: Anti-A (blue) & Anti-B (yellow)

Forward Typing
u mixed on a slide with an applicator stick and then tilted
back and forth & observed over a period of 2 minutes for
agglutination

u longer periods of incubation should be avoided because

the effects of drying may be interpreted as agglutination
(pseudoagglutination)
Forward Typing Results
Routine ABO Testing
Reverse Typing
u also known as Serum Testing

u detecting ABO antibodies in the patient’s serum by using

known reagent RBCs, namely A and B cells

u patient’s serum is tested with suspensions of known group A

& B cells

u done to crosscheck the results of forward typing

Routine ABO Testing
u ABO blood grouping is the most frequently performed test
in blood bank

u both ABO forward and reverse typing tests must be

performed on all donors and recipients

u there is always an inverse reciprocal relationship between

the forward and reverse type; thus, one serves as a check
on the other
Reverse Typing Results
Expected Results:
(+)agglutination (-)no agglutination
FORWARD TYPING REVERSE TYPING
BLOOD TYPE Anti-A Anti-B A Cells B Cells
A + - - +
B - + + -
AB + + - -
O - - + +
RECAP
FORWARD TYPING REVERSE TYPING
u aka Cell Grouping u aka Serum Testing

u detects antigens u detects antibodies

u sample: patient’s RBCs u sample: patient’s serum

u reagents: anti-A & anti-B u reagents: known A & B cells

typing sera
Inheritance of the ABO Blood Groups
u an individual inherits one ABO gene from each parent and
that these two genes determine which ABO antigens are
present on the RBC membrane

u the inheritance of ABO genes follows simple Mendelian

genetics

u codominant in expression
Punnett Square
A B
A AA AB
O AO BO

A O
B AB BO
O AO OO
Inheritance of the ABO Blood Groups
u one position, or locus, on each chromosome 9 is occupied
by an A, B, or O gene

u the O gene is considered an amorph

u no detectable antigen is produced in response to the
inheritance of this gene

u the group O phenotype is an autosomal recessive trait with

the inheritance of two nonfunctional O genes
Inheritance of the ABO Blood Groups
Quick Guide
u Genotype – an individual’s actual genetic make-up
u example: AA, BO, OO, AB
u two genes are the same = homozygous
u two genes are different = heterozygous

u Phenotype – the outward expression of genes

u mostly composed of serologically demonstrable antigens
u example: blood type A or blood type B
Blood Group Mythology
u Blood Group A: more pronounced “hangover”

u Blood Group B: “criminality”

u Blood Group O: “good teeth”

ABO Discrepancies
u occur when unexpected reactions are obtained in the
forward and/or reverse typing

u can be due to problems with the patient’s RBCs or patient’s

serum, or problems with both the serum and cells

u all ABO discrepancies must be resolved prior to reporting a

patient or donor ABO blood group
ABO Discrepancies
u due to weakly reacting or missing antibodies

u newborns
u ABO antibody production is not detectable until 3 to 6 months
of age

u elderly patients
u production of ABO antibodies is depressed
Technical Errors
u can also cause ABO discrepancies

u Examples:
u incorrect or inadequate identification of blood specimens,
test tubes, or slides
u blood sample and test tube labeling errors
u failure to add reagents or failure to add sample
u contaminated reagents
u addition of incorrect reagents or sample
u clerical errors or incorrect recording of results
u failure to follow manufacturer’s instructions
Resolution
u serum and antiserum should always be added first,
followed by the patient or reagent RBCs to avoid:
u reagent contamination
u potential omission of either patient sample or reagent

u results must be recorded immediately after obtaining them

to avoid transcription errors

u always examine reagent vials concurrently while

performing ABO testing and quality control testing for
possible contamination
Resolution
u make sure any and all technical factors that may have
given rise to the ABO discrepancy are reviewed and
corrected

u obtain adequate information regarding the patient’s age,

diagnosis, transfusion history, medications, and history of
pregnancy

u if the discrepancy persists and appears to be due to an

error in specimen collection or identification, a new sample
must be drawn from the patient and all RBC and serum
testing must be repeated
Reference
u Harmening, D. (2019). Modern Blood Banking and Transfusion Practices,
7th Ed. F.A. Davis Company.