Blood groups

Rh Factor
Blood transfusion

Lecturer – M.D.,Ph.D.,Professor
Mavlet Sh.Vakhitov
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Determination of blood group according to
the ABO system.
• One drop of blood is mixed
with anti-A-anti-B serum
(column 1),
• the second with anti-A
serum,
• the third with anti-B.
• According to the
agglutination reaction
(accumulation of red blood
cells, shown in bright red), a
blood group is judged.
• More than 40% of Central
Europeans have a II group,
40% - I, 10% - III and
6% - IV.
• 90% of American Indians
have blood type I
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Karl Landsteiner
The Nobel Prize
 
      
              
in Physiology and
Medicine 1930

"

"for his discovery of human blood groups"

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 Blood groups
• The differences in human blood are due
to the presence or absence of certain
protein molecules called antigens and
antibodies. The antigens are located
on the surface of the red blood cells and
the antibodies are in the blood plasma.
Individuals have different types and
combinations of these molecules. The
blood group you belong to depends on
what you have inherited from your
parents.
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 Blood Groups
• Blood Groups are the distinguishing of
blood by their antigenic properties.
These properties are determined by the
substances found on the surface of the
red blood cells. There are approximately
200 blood group substances identified
and categorized into 19 distinct
systems. The most common system is
the ABO system.
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 Blood groups
• There are more than 20 genetically
determined blood group systems known
today, but the AB0 and Rh systems are
the most important ones used for blood
transfusions. Not all blood groups are
compatible with each other. Mixing
incompatible blood groups leads to
blood clumping or agglutination, which
is dangerous for individuals.

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Blood groups
• The ABO system is based
on two different antigens,
A and B, found on the
surface of red blood cells.
You may have one, both
or neither of these
antigens.

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 Blood groups
• The ABO system consists of people with blood
groups A, B, AB or O. Individuals may contain
the A, B or both or none of the antigenic
substances. Any individual that lacks any one
of the antigens will develop antibodies
against it at birth. For example, a person with
blood type A will develop anti-B agglutinants.
Agglutinants causes blood to clump together
and can possibly form a blood clot making the
blood extremely viscous.

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 Blood types

• Blood type A  type A agglutinogens are

present on the surface of red blood cells
• Blood type B  type B agglutinogens are
present on the surface of red blood cells
• Blood type AB  both A and B agglutinogens
are present on the surface of red blood cells
• Blood type O  neither A or B agglutinogens
are present on the surface of red blood cells

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Blood group 0
• If you belong to the
blood group 0 (null),
you have neither A or
B antigens on the
surface of your red
blood cells but you
have both A and B
antibodies in your
blood plasma.
•  

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Blood group A
• If you belong to the
blood group A, you
have A antigens on the
surface of your red
blood cells and B
antibodies in your
blood plasma.
•

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Blood group B
• If you belong to the
blood group B, you
have B antigens on the
surface of your red
blood cells and A
antibodies in your
blood plasma.
•

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Blood group AB
• If you belong to the
blood group AB, you
have both A and B
antigens on the surface
of your red blood cells
and no A or B
antibodies at all in
your blood plasma.
•

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Rh factor blood grouping system

• Many people also

have a so called Rh
factor on the red
blood cell's surface.
This is also an
antigen and those
who have it are
called Rh+. Those
who haven't are
called Rh-.

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 Rh factor blood grouping system

• The Rh, or Rhesus, system was first

detected in 1940 by Landsteiner and
Wiener when they injected blood from
rhesus monkeys into guinea pigs and
rabbits. More than 50 antigens have
since been discovered belonging to this
system, making it the most complex red
blood cell antigen system.
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 Blood typing
• Blood typing is a laboratory test done to
determine a person's blood type. If the
person needs a blood transfusion,
another test called crossmatching is
done after the blood is typed to find
blood from a donor that the person's
body will accept.

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Blood typing and crossmatching tests

• Blood typing and crossmatching tests are

based on the reaction between antigens and
antibodies. An antigen can be anything that
causes the body to launch an attack, known
as an immune response, against it. The
attack begins when the body builds a special
protein, called an antibody, that is uniquely
designed to attack and make ineffective
(neutralize) the specific antigen that caused
the attack. A person's body normally doesn't
make antibodies against its own antigens,
only against antigens that are foreign to it. 28
 Blood typing
• Blood typing is a way to categorise different
types of antigens found on the surface of red
blood cells. The antigens on the surface of
red blood cells have a special nametag:
agglutinogens. The ABO blood group
describes just one set of agglutinogens
(antigens), which are genetically determined
carbohydrate molecules carried on the
surface membranes of the red blood cells
(there are over 100 different ways to type
blood). Blood type is a description of what
kind of agglutinogens are present on the
surface of the red blood cells.

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 Blood typing is done:

• Before a person receives a blood transfusion.

• Before a person donates blood.
• Before a person donates an organ for
transplantation.
• Before surgery.
• When a woman is planning to become
pregnant or first becomes pregnant.
• To determine whether two people could be
blood relatives.
• To identify a person suspected of committing
a crime.
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 RBC - Antigens SERUM- Antibodies

0 (I) 0 αβ
A (II) A β
B (III) B α
AB (IV) AB 0

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 Blood typing with typing sera
st.serum αβ β α 0
RBC
0(I) _ _ _ _

A(II) + _ + _

B(III) + + _ _

AB(IV) + + + _
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 Blood typing using Colyclons
Colyclons
Anti -A Anti -B Anti -AB

0 (I) - - -
A (II) + - +
B (III) - + +
AB (IV) + + +

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Blood typing using Colyclons

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Blood typing

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What blood group is it ?

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 Rh factor blood grouping system

• A person with Rh- blood does not have Rh

antibodies naturally in the blood plasma (as
one can have A or B antibodies, for instance).
But a person with Rh- blood can develop Rh
antibodies in the blood plasma if he or she
receives blood from a person with Rh+ blood,
whose Rh antigens can trigger the production
of Rh antibodies. A person with Rh+ blood can
receive blood from a person with Rh- blood
without any problems.

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Rh Blood Factor

                                              

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Blood transfusion

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 Blood transfusion
• Blood transfusion is a procedure in which
the blood or blood components from one
person, called a donor, is given to another,
called a recipient. Depending on the reason
for the transfusion, the person may be given
whole blood or a blood component

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• The first historical attempt at blood transfusion
was described by the 15th-century chronicler
Stefano Infessura. Infessura relates that, in 1492,
as Pope Innocent VIII sank into a coma, the blood
of three boys was infused into the dying pontiff's
veins at the suggestion of a physician. The boys
were ten years old, and had been promised a ducat
each. All three died. Roman Catholic authors take
pains to discredit Infessura's account, accusing
him of anti-papalism.

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 General indications for blood
trans-fusion:
• acute blood loss, when 20-30% of the total blood
volume has been lost and bleeding is continuing
• severe anaemia (Hb level below 80)
• septic shock (if IV fluids are insufficient to
maintain adequate circulation and in addition to
antibiotic therapy)
• to provide plasma and platelets for clotting
factors.

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Blood products
• Whole blood
• Packed red cells
• Granulocyte concentrates
• Platelet concentrates
• Human plasma - fresh
frozen plasma / freeze-
dried plasma
• Plasma protein fraction
• Human albumin 25%
• Cryoprecipitate
• Clotting factors - Factor
VIII / IX
• Immunoglobulins

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 Different types of blood
collection
• Homologous - whole blood is collected from the
donor, separated into different components, and
transfused into compatible recipients.
• Aphaeresis - only the necessary components, such
as plasma or platelets, are taken from the blood of
the donor by a special machine; the bulk of the
blood is given back.

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 Different types of blood
collection
• Autologous - prior to a scheduled operation or
transfusion, the patients donate blood specifically
for their own use. This reduces the possible risks
of incompatibility or infection.
• Directed or designated - prior to a scheduled
transfusion, the patient requests that only blood
collected from family members or friends be used
for transfusion.

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 Cross Matching
• Blood grouping
• Patient’s red cells grouped for ABO and
Rhesus antigens
• Serum tested to confirm patients ABO group
• Antibody screening
• Detects atypical red cell antibodies in
recipients serum
• Crossmatching
• Tests donor red cells against patient’s serum
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 Cross Matching
• To begin the crossmatch, blood from a donor
with the same ABO and Rh type as the
recipient is selected. In a test tube, serum
from the patient is mixed with red blood cells
from the donor. If clumping occurs, the blood
is not compatible; if clumping does not occur,
the blood is compatible. If an unexpected
antibody is found in either the patient or the
donor, the blood bank does further testing to
make sure the blood is compatible.

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Cross Matching

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 Cross Matching
• Before blood from a donor and the recipient
are crossmatched, both are ABO and Rh
typed. In addition, antibody screening is done
to look for antibodies to certain Rh, Duffy,
MNS, Kell, Kidd, and P system antigens. If an
antibody to one of these antigens is found,
only blood without that antigen will be
compatible in a crossmatch. This sequence
must be repeated before each transfusion a
person receives.

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Blood transfusion

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 Donor Blood Transfusion
Algorithm
• 1. Diagnosis (history, examination, palpation, auscultation,
laboratory and instrumental methods);
• 2. Determination of indications and contraindications for
blood transfusion in this patient;
• 3. Determination of blood type and Rh factor;
• 4. Obtain blood from the blood bank of the corresponding
group and Rh factor;
• 5. To determine the suitability of the received donor blood
for transfusion to this patient;

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 Donor Blood Transfusion
Algorithm
• 6. Check donor’s blood group;
• 7. Determine the compatibility of the blood of the donor
with the blood of the recipient (Crossmatching –
compatibility in vitro);
• 8. Carry out a biological test (compatibility in vivo) before
beginning of transfusion;
• 9. Blood transfusion (approximately 60 drops per minute)
under the supervision of a physician

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 Complications of blood transfusion

• Early
• Haemolytic reactions (immediate or
delayed)
• Bacterial infections from contamination
• Allergic reactions to white cells or
platelets
• Pyogenic reactions
• Circulatory overload
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 Complications of blood transfusion

• Air embolism
• Thrombophlebitis
• Citrate toxicity
• Hyperkalaemia
• Clotting abnormalities

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 Complications of blood transfusion

• Late
• Infection - cytomegalovirus / hepatitis
• Immune sensitisation
• Iron overload

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 Complications of Blood Transfusion
Complications of blood transfusion

•Immune complications •Non-immune complications

•Hemolytic (acute and •Complications

delayed) associated with
•Non-Hemolytic (includes massive blood
febrile, urticarial, transfusion
anaphylactic, purpura,
etc.) •Infectious
complications

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 Hemolytic reactions
• Hemolytic reactions usually involve
the destruction of transfused blood cells
by the recipient's antibodies. Less
commonly, the transfused antibodies
can cause hemolysis of the recipient's
blood cells. There are acute (also known
as intravascular) hemolytic reactions
and delayed (also known as
extravascular) hemolytic reactions.

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 Symptoms of acute
hemolytic reactions
• Symptoms of acute hemolytic reactions
include chills, fever, nausea, chest pain
and flank pain in awake patients. In
anesthetized patients, you should look
for rise in temperature, unexplained
tachycardia, hypotension,
hemoglobinuria, oozing in the surgical
field, DIC, shock and renal shutdown.

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 Delayed hemolytic
reactions
• Delayed hemolytic reactions are
generally mild in comparison.
These are caused by antibodies to
non-D antigens of the Rh system
or to foreign alleles in other
systems such as the Kell, Duffy or
Kidd antigens.

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 Symptoms of Delayed
hemolytic reactions
• Symptoms are generally mild and
include malaise, jaundice, fever, a
fall in hematocrit despite
transfusion, and an increase in
unconjugated bilirubin. Diagnosis
may be facilitated by the direct
Coombs test which can detect the
presence of antibodies on the
membranes of red cells.
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 Non-Hemolytic reactions
• Non-Hemolytic reactions are due to
sensitization of the recipient to donor white
cells, platelets or plasma proteins. These
reactions include:
• Febrile
• Urticarial
• Anaphylactic
• Pulmonary Edema (non-cardiogenic)
• Graft vs. Host(Graft-vs.-host disease is an immune
attack on the recipient by cells from a donor)
• Purpura
• Immune Suppression
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 Non-Immune Complications

• Massive Transfusion is usually

defined as the need to transfuse from
one to two times the patient's normal
blood volume. In a "normal" adult, this
is the equivalent of 10-20 units.
Potential complications from this include
coagulopathy, citrate toxicity,
hypothermia, acid-base disturbances
and changes in serum potassium
concentration.

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 Massive Transfusion.
• Is defined as significant bleeding as
seen in trauma and some surgeries,
where 10 or more units of red blood
cells have been transfused within 24
hours. Massive transfusion of red blood
cells and other fluids causes a dilution
of platelets and clotting factors and may
result in further blood loss due to a
dilution coagulopathy.

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 Massive Transfusion
• Therefore, other blood products such as
platelets, fresh frozen plasma, and
cryoprecipitate may be required to restore
normal levels of these clotting factors.
Because red blood cells are stored at 4°
Celsius, hypothermia can occur with
massive transfusions despite the utilization
of fluid warmers. Hypothermia below 34
degrees Celsius is associated with a
coagulopathy and a poorer outcome in
trauma patients.

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 Non-Immune Complications

• Infectious Agents can be passed

along with blood transfusion as
well.
• Hepatitis
• AIDS
• Other viral agents (CMV, EBV,
HTLV)
• Parasites and bacteria
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Transfusion related acute lung injury

• Occurs following administration of plasma-

containing blood components
• Due to interaction of donor antibodies with
recipient white cells
• The clinical pictures is similar to ARDS
• Occurs 30 minutes to several days after
transfusion
• Clinical features include fever, cough and
shortness of breath
• Chest x-ray shows perihilar shadowing
• Treat as ARDS (Acute respiratory distress
syndrome)
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 Acute haemolytic or bacterial transfusion
reactions

• Due to acute haemolysis or bacterial contamination

• Difficult to differentiate on clinical grounds
• May occur after infusion of small volume of
incompatible or infected blood
• Associated with high morbidity and mortality
• In unconscious patient bleeding due to DIC
(Disseminated Intravascular Clotting) may be the only
sign
• Most ABO mismatched transfusions are due to human
error
• Usually occurs soon after start of transfusion

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 Acute haemolytic or bacterial transfusion
reactions

• Patient feels unwell and agitated

• Symptoms include back pain and pain at
infusion site
• Associated with shortness of breath, rigors
• Examination will show hypotension, oliguria
and bleeding from venepuncture sites
• Urinalysis will show haemoglobinuria
• Usually occurs soon after start of transfusion

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 Acute haemolytic or bacterial
transfusion reactions

• Due to acute haemolysis or bacterial

contamination
• Difficult to differentiate on clinical grounds
• May occur after infusion of small volume of
incompatible or infected blood
• Associated with high morbidity and mortality
• In unconscious patient bleeding due to DIC
may be only sign
• Most ABO mismatched transfusions are due
to human error
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 Management
of acute haemolytic or bacterial
transfusion reactions
• Discontinue transfusion immediately and remove
giving set
• Check unit of blood against patients identity
• Give intravenous crystalloid
• Consider transfer to the intensive care unit
• Take blood for FBC(Full Blood Count), plasma
haemoglobin, clotting, blood cultures and repeat
grouping
• Give broad spectrum antibiotics
• Monitor urine output and ECG

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Non-haemolytic transfusion febrile
reaction
• Usually occurs more than 30 minutes
after start of transfusion
• Patient feels generally well but may be
shivering
• Temperature is usually less than 38.5C
• Blood pressure is usually normal

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 Management
• Stop transfusion and assess possibility
that this may be a more significant
reaction
• Restart transfusion at a slower rate
• Consider the use of paracetamol
• Hydrocortisone should not be routinely
used during a transfusion

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 Anaphylaxis

• Usually occurs soon after start of transfusion

• May be seen in IgA deficient patients reacting
to transfused IgA
• Presents with circulatory collapse and
bronchospasm
• Management
• Discontinue transfusion and remove giving set
• Maintain airway and give oxygen
• Administer adrenaline, chlorpheniramine,
salbutamol
• If the patient is IgA deficient any further
transfusion must be carefully planned
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 Hemolytic Reactions
• Sometimes there is incompatibility
between a unit of donor blood and the
recipient’s blood, which can cause a
breakdown of red blood cells in the
recipient. It’s necessary to use a testing
method before the transfusion, called
“cross-matching” to ensure that this
does not take place. Despite this, various
factors including clerical error have led
to incompatible units being transfused.

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 Non-Hemolytic Reactions
• Febrile or pruritic reactions occur in up to
1 per cent of transfusions. These
reactions are due to the presence of
trace proteins such as white blood cells
(WBC) and platelets in the unit of red
blood cells. Usually these reactions can
be treated and the transfusion allowed to
continue. The recent introduction of WBC
leukocyte-depleting filters should further
reduce the incidence of these reactions.

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 Immunomodulation
• Some studies have suggested that
blood transfusions may increase the
chances of infection or malignancy
occurrence by altering the recipient’s
immune system. While such studies are
inconclusive, the introduction of
leukocyte-reducing filters may be
protective.

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 Effects of Aging Donor Blood.

• Red blood cells can be kept in

refrigerated storage for up to 35 days.
However, over this time, changes in the
binding of oxygen to hemoglobin and
potassium levels contained in this
blood, can occur. This can effect the
ability of the red blood cells to release
oxygen once transfused, an important
reason to replace hemoglobin using a
blood transfusion.

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 Effects of Aging Donor Blood

• However, the blood transfusion

can also increase potassium levels,
which can be associated with
cardiac complications, including
palpitations, and in extreme cases,
cardiac arrest (heart failure).

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• Not require special handling
• Not require special storage
• Be free of infectious risks
• Be Non-immunogenic
• Not alter immune response
• Be readily available in large quantities
• Be low cost
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 Classification of the 'blood
substitutes'.
1. Haemoglobin solutions
1). Ultrastructural modification of the
haemoglobin molecule
a) Intramolecularly cross-linked haemoglobin - The
tetramic structure is maintained by an
intramolecular cross-link between the two alpha
or the two beta sub units.
b) Polymerised haemoglobin - The formation of
fumerate bridges between alpha molecules can
result in oligomes or polymers of haemoglobin.
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 Classification of the 'blood
substitutes'.
c) Conjugated haemoglobin - The linkage of free
haemoglobin molecules to a soluble non-
haemoglobin polymer.
d) Microsphere haemoglobin - Haemoglobin
molecules are exposed to a high intensity
ultrasound which creates 'shells' of
approximately one million haemoglobin
molecules cross linked by the superoxides
formed during the sonication process.

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 Classification of the 'blood
substitutes'.
2)Liposome-encapsulation of haemoglobin - The
typical form of synthetic liposome is a
phospholipid bilayer, with molecules of
cholesterol added for increased rigidity and
mechanical stability. This liposome then
encloses a stroma free haemoglobin solution and
2,3 DPG(2,3-diphosphoglycerate) or
inositol hexaphosphate as a gelatinous fluid.

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 Classification of the 'blood
substitutes'.
2. Perfluorocarbons - florinated organic
solutions with a high solubility
co-efficient for oxygen

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 Advantage characteristics of
Blood substitutes

• Blood Substitutes have universal compatibility

therefore typing and cross matching is not
required.
• The blood substitute must eliminate disease
transmission such as HIV, Mad Cow Disease, and
Hepatitis.
• Blood substitutes have longer shelf lives than
regular blood, therefore can be stored longer,
whereas blood only lasts for 42 days.
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 Advantage characteristics of
Blood substitutes

• Blood substitutes are more robust than

regular blood and can withstand more harsh
environments such as not requiring
refrigeration and can be used in the pre-
hospital environment.
• Synthetic blood delivers oxygen to the body
faster than real blood which can limit bodily
injury, particularly during heart attack.
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 Advantage characteristics of
Blood substitutes

• There are more operations today than in the

past, many of which are elective and require
large amounts of blood, on average 6 pints.

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