Blood Groups & Red Cell

Antigen & their

Significance.
https://www.ncbi.nlm.nih.gov/books/NBK2263/
VISHANT MALIK 19SBAS2060001 MSC BIOCHEMISTRY.
Most important clinically significant of Blood Group System is for transfusion
practice.

 Becouse, this is the only blood group system in which antibodies are consistently,
predictably, and naturally present in the serum of people who lack the antigen.
Therefore ABO compatibility between donor and recipient is crucial since these
strong, naturally occurring A and B antibodies are IgM and can readily activate
complement and cause agglutination. If ABO antibodies react with antigens in
vivo, result in acute hemolysis and possibly death.
 ABO grouping is required for all of the following individuals:

 Blood Donors-since it can be life threatening to give the wrong ABO

group to the patient.
 Transfusion recipients-since we need to know the donor blood is ABO
compatible.
 Transplant Candidates and Donors-ABO antigens are found in other
tissues as well. Therefore the transplant candidates and donors must
be compatible.
 Prenatal Patients-To determine whether the mothers may have babies
who are suffering from ABO-HDN. It is also beneficial to know the ABO
group should she start hemorrhaging.
 Newborns (sometimes) If the baby is demonstrating symptoms of
Hemolytic Disease of the Newborn, the ABO group needs to be
determined along with Rh and others.
 Paternity testing Since the inheritance of the ABO Blood Group
System is very specific, this serves as one of the first methods to
determine the likelihood that the accused father is the father or
not.
 Discovery of the ABO system:

 In 1900 Karl Landsteiner reported a series of tests, which identified the ABO
Blood Group System. In 1910 he won Nobel prize for medicine for this
discovery. He mixed the serum and cells of all the researchers in his lab and
found four different patterns of agglutination. From those studies he developed
what we now know as Landsteiner's rules for the ABO Blood Group:
 A person does not have antibody to his own antigens
 Each person has antibody to the antigen he lacks (only in the ABO system)
 Below are the four blood groups and the antigens and the expected, naturally-
occurring antibodies present.
 ABO Typing
 ABO typing involves both antigen typing and antibody detection. The antigen typing is referred to
as the forward typing and the antibody detection is the reverse typing.
 The forward typing determines antigens on patient's or donor's cells
I. Cells are tested with the antisera reagents anti-A, anti-B, (and in the case of donor cells anti-
A,B).
II. Reagents are either made from hyperimmunized human sources, or monoclonal antibodies.
III. One advantages of the monoclonal antibodies are the antibody strength.
IV. Another advantage of monoclonals: human source reagents can transmit infectious disease
(hepatitis).
V. Reverse typing determines antibodies in patient's or donor's serum or plasma
a. Serum tested with reagent A1 cells and B cells
b. Reverse grouping is also known as backtyping or serum confirmation
Characteristics of ABO antigens(agglutinogen):

 ABO antigens are glycolipid in nature, meaning they are oligosaccharides

attached directly to lipids on red cell membrane. These antigens stick out from
red cell membrane and there are many antigen sites per red blood cell
(approximately 800,000)
 Besides their presence on red blood cells, soluble antigens can be present in
plasma, saliva, and other secretions. These antigens are also expressed on tissues
other than red cells. This last fact is important to consider in organ
transplantation.
 ABO antigens are only moderately well developed at birth. Therefore ABO-
HDN not as severe as other kinds of Hemolytic Disease of the Newborn. .
 Characteristics of ABO
antibodies(agglutinin):
 These are expected naturally occurring antibodies that occur without exposure to red cells
containing the antigen. (There is some evidence that similar antigens found in certain
bacteria, like E.coli, stimulate antibody production in individuals who lack the specific A
and B antigens.)
 Immunoglobulin M antibodies, predominantly
 They react in saline and readily agglutinate. Due to the position of the antigen and the IgM
antibodies it is not necessary to overcome the zeta potential.
 Their optimum temperature is less than 30oC, but reactions do take place at body
temperature
 Not only are these antibodies expected and naturally occurring, they are also commonly
present in high titer, 1/128 or 1/256.
 They are absent at birth and start to appear around 3-6 months as result of stimulus by
bacterial polysaccharides. (For this reason, newborn blood is only forward typed.)
 ABO Genes

 The A and B genes found on chromosome #9. We inherit one gene (allele) from
our father and one from our mother. The two co-dominant alleles are A or B.
Anytime an individual inherits an A or B gene it will be expressed.
 The O gene signifies lack of A or B antigens. It is not expressed unless this gene
is inherited from both parents (OO). Therefore the O gene is recessive.
Structure of abo
 Clinical Examination

 There are 2 types of abo grouping detection:-

I. Forward grouping(antigens are used)
II. Reverse grouping (antibodies are used):-
 Hemolytic Transfusion Reaction
 Hemolytic Disease of the Fetus and Newborn
 Drugs
 Disease
 History of the Rh System

 Levine and Stetson(1939) described a hemolytic transfusion reaction in an

obstetric
 patient following delivery of stillborn infant.
 An antibody was isolated from the mother’s serum. It was postulated that the fetus
and the
 father possessed a common factor that the mother lacked.
 While the mother carry the fetus, the mother was exposed to this factor and
developed
 antibody against the transfused red cells from the father and resulted in
transfusion
 reaction.
 At that time ,the responsible antibody was not named.
 Landsteiner and Wiener(1940) injected RBC’s of rhesus monkeys in rabbits-
developed
 antibodies.
 The antibody was named as anti-Rh.
 When resulting antiserum was mixed with human RBC’s, then agglutination
occurred.
 The RBC antigen responsible for this reaction was called as Rh factor.
 The antibody discovered by Levin and Stetson in the mother was subsequently
reexamined and found identical in activity as the anti-Rh antibody found by
Landsteiner and
 Weiner.
 So this work led to discovery of Rh system.
 Anti-rhesus formed by the animals was renamed anti-LW (Landsteiner and
Wiener).
 Fisher and Race(1943 and 1944) discovered C, E, c, e Ag and their corresponding
antibodies
 anti-C , anti -E ,anti- c ,anti -e
 Rh antigen

 Integral membrane proteins with an active phoshpholipid

component.
 Present on red blood cells.
 D antigen is commonest and most immunogenic.
 Pathophysiology

I. Erythroblastosis fetalis-
II. Icterus gravis neonatorum
III. Kernicterus
IV. Hydrops fetalis
V. Haemolytic disesase on new born
Erythroblastosis fetalis
Erythroblastosis fetalis
kernicterus
Hemolytic disease of newborn

 The term Hemolytic disease of the newborn 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 maternal allo-
antibodies fetal/neonatal RBC is shortened against due to red cell
antigens acquired from the father.
 Rate of RBCs destruction is accelerated but ability of bone
marrow to respond is normal. It was a major cause of fetal loss
and death among newborn babies.
Etiology of HDN
 investigation
 Coombs test:
I. Direct Coombs test: for diagnoses HDN.
 The direct Coombs test detects maternal anti-D antibodies that have
already bound to fetal RBCs.
 This is called the direct Coombs test because the anti-Ig binds "directly" to
the maternal anti-D Ig that coats fetal RBCs in HDN.
II. Indirect Coombs test: used in the prevention of HDN.
 Finds anti-D antibodies in mother's serum. If these were to come into
contact with fetal RBCs they would hemolyse them and hence cause HDN.
 This is called the indirect Coombs test because the anti-Ig finds "indirect"
evidence of harmful maternal antibodies, requiring the addition of fetal
RBCs to show the capacity of maternal anti-D to bind to fetal RBCs
Management
 Prevention

 Determine Rh status of the mother.

 If the mother is not sensitized, reduce the risk of future
sensitization
 If the mother is sensitized, determine whether the fetus is at risk
and monitor accordingly
 To prevent Isoimmunization of yet unimmunized mother give Anti
Rh D IgG (Rhogam) Intra Muscular at28 weeks of gestation.
Antigens of blood grouping

 Blood grouping antigens:-

I. Abo antigens
II. Rh/D antigen
III. Lewis antigen
IV. Duffy antigen
V. Kell antigen
 Lewis antigen system
 It is based upon two genes on chromosome 19: FUT3, or Lewis
gene; and FUT2, or Secretor gene.
  FUT 2 (fucosyltransferase2 coding gene) has a dominant allele
which codes for an enzyme (designated Se) and a recessive allele
which does not produce a functional enzyme (designated se).
 FUT3 has a functional dominant allele (Le) and a non-functional
recessive allele (le).
 The product of these genes produce an oligosaccharides chain that
forms lewis antigen.
 Two types of Lewis antigen.
 Lewis a
 Lewis b.
 Hence three resultant phenotypes: Le(a+b-), Le(a-b+), and
Le(a-b).
 FUT2 adds fucose to the oligosaccharide precursor in a different
position from the FUT3 enzyme.
 This makes the basis of difference in both alleles.

Clinical significance
The transfused red cells shed their Lewis antigens and acquire
the Lewis phenotype of the recipient. So it do not cause any
hemolysis.
 Duffy antigen system

 Itis named after the patient in which it was discovered.

 It is encoded by the DARC( Duffy antigen/chemokine receptor)
gene.
 The protein encoded by this gene is a glycosylated membrane
protein and a non-specific receptor for  chemokines and human
malarial parasites.

Clinical significance
 Transfusion reactions are usually caused by anti-Fya or anti-Fyb.
 Anti-Fy3 may cause acute or delayed hemolytic transfusion
reactions (HTRs).
 Hemolysis reactions are very rare but fatal
Duffy antigens plays important role in –
 HEMATOPOIESIS - nucleated RBC present in the bone marrow
have high expression of DARC, which facilitates their direct
contact with hematopoietic stem cells.
  HIV :- absence of the DARC receptor appears to increase the
susceptibility to infection by HIV. 
 CANCER:- cytokine receptor DARC on adjacent vascular cells
suppresses tumor metastasis.
Clinical significance
 In renal transplant, these antigens can cause hemolysis and are fatal.
 JK (a-b-) do not cause hemolysis as no urea transporter is present. While jk (a)
and jk(b) forms antibodies against donated blood resulting in hemolysis.
 Role of Blood transfusions and the
immune system
 The immune system never rests—its cells constantly patrol the circulation.
Without the immune system, the body would be overwhelmed with infections.
With it, blood transfusions must be performed with great care
 A blood transfusion is a procedure that restores blood to the body
 A healthcare professional will pass blood through a rubber tube into a vein using a
needle or thin tube
 The sections below will cover the different types of blood transfusion procedures
available, as well as the different types of blood
 Types of blood transfusions
 According to the American Red Cross, there are four common types of blood
transfusions:
 Red blood cell transfusions: A person may receive a red blood cell transfusion if they
have experienced blood loss, if they have anemia , or if they have a blood disorder
 Platelet transfusions: A platelet transfusion can help those who have lower platelet
counts, such as from chemotherapy or a platelet disorder
 Plasma transfusions: Plasma contains proteins important for health. A person may
receive a plasma transfusion if they have experienced severe burns, infections, or
liver failure
 Whole blood transfusion: A person may receive a whole blood transfusion if they
have experienced a severe traumatic hemorrhage and require red blood cells, white
blood cells, and platelets.
 Why are blood transfusions necessary?
 Blood transfusions are necessary when the body lacks enough blood to function
properly
 For example, a person may need a blood transfusion if they have sustained a severe
injury or if they have lost blood during surgery
 Some people need blood transfusions for certain conditions and disorders, including:
 Anemia: This occurs when a person’s blood does not have enough red blood cells. It
can develop for a number of reasons, such as if a person does not have enough iron in
their body. This is known as iron deficiency anemia
 Hemophilia: This is a bleeding disorder wherein the blood is unable to clot properly.
 Cancer.
 Kidney disease.
 Liver disease.
 How to launch an immune response
against transfused red blood cells
 Antigen detection
• The red blood cells (RBCs) from one person may enter into the circulation of another
person in two different ways, either by a blood transfusion or by pregnancy
• The RBCs will appear foreign if they contain antigens that are not found on the patient's
own RBCs
 Antigen processing
• When the macrophage encounters an antigen, it engulfs it, digests it, and then presentsthe
antigenic fragments on its cell surface together with MHCII (Major Histocompatibility
Complex II)
• A T helper cell binds to the antigen/MHCII on the macrophage, and the two cells interact.
• The macrophage secretes cytokines to stimulate the T cell, which in turn secretes cytokines
to stimulate the growth and production of more T cells.
• The T helper cell, now activated, leaves to activate a third type of cell, the B cell
• Existing B cells are stimulated by the T cell to grow, divide, and produce genetically
identical daughter cells
• Some of the daughter cells become plasma cells that produce antibodies that are specific
for the antigen that stimulated their production.
• The amount and type of antibody produced results from the interaction of T helper cells
(which stimulate antibody production) and T suppressor cells (which inhibit antibody
production)
• Other daughter cells remain as B cells in the circulation for many years. They serve as
"memory cells", remembering the encounter with the antigen that stimulated their
production.
 Immune response

• If this is the first time the antigen has been encountered, a primary immune
response is mounted
• Usually there is a delay of several days, then IgM antibody is produced, followed
by a switch to IgG antibody production
• The initial IgM molecules bind the antigen weakly, but the subsequent IgG
molecules are much better targeted
• IgG continues to be produced long after the encounter with the antigen, providing
long-lasting immunity
• If the immune system has encountered the antigen before, it will already be armed
with primed B cells (memory cells) that accelerate the production of larger amounts
of IgG (rather than IgM).This is called the secondary immune response
• It is faster, more specific, and the production of the specific antibody may remain
high for years
• B cells may also undergo changes to further improve how the antibodies they
produce bind to the antigen
• There are two main arms of immune response: humoral (using antibodies) and
cellular (using immune cells)
• Severe immune-mediated transfusion reactions usually involve the humoral arm
• In the case of a foreign red blood cell antigen, the patient's preexisting antibodies
bind to the antigen, coating the donor RBCs
• Some types of antibody may activate the complement cascade, a series of enzyme-
driven reactions involving protein fragments
• The cascade ends with the formation of a "membrane attack complex“ , a large
molecule that punches a hole in the cell membrane
• Other antibodies simply bind to the donor RBCs and cause them to clump together
(agglutinate)
• The agglutinated cells may survive or may be prematurely removed from the
circulation by the macrophages