“ BLOOD GROUPS & THEIR

CLINICAL SINGIFICANCE ’’

- DR KIRAN THORAT
• Biomedical importance of Blood Groups -

1) In blood transfusion
2) In pregnancy
3) In cases of paternity disputes
4) Medico legal value
• Blood group or blood type – Definition –

• It is the classification of blood based on the presence or absence of

inherited antigenic substances on the membrane of RBCs

• Antigens may be - proteins, carbohydrates, glycoproteins

or glycolipids
• ISBT blood group systems -

ISBT NO. COMMON NAME OFFICIAL

ABBREVIATION
001 ABO ABO
002 MNS MNS
003 P P1
004 Rhesus RH
005 Lutheran LU
006 Kell KEL
007 Lewis LE
008 Duffy FY
ISBT NO. COMMON NAME OFFICIAL
ABBREVIATION
009 Kidd JK
010 Diego DI
011 Yt or Cartwright YT
012 XG XG
013 Scianna SC
014 Dombrock DO
015 Colton CO
016 Landsteiner- LW
Weiner
ISBT NO. COMMON NAME OFFICIAL
ABBREVIATION
017 Chido/Rodgers CH/RG
018 Hh H
019 Ky XK
020 Gerhich GE
021 Cromer CROM
022 Knops KN
023 Indian IN
024 Ok OK
ISBT NO. COMMON NAME OFFICIAL
ABBREVIATION
025 Raph MER2
026 JMH JMH
027 Ii I
028 Globoside P
029 GIL GIL
• Chief blood group systems

1. ABO or ABH blood group system

2. Rhesus or Rh blood group system

• ABO / ABH blood group system -

• Most important system in human blood transfusion &

• Also present in some animals – Cows, Sheep &

Apes like Chimpanzees & Gorillas
• History of Discovery -

• Landsteiner,s law – two components

- exception to the 2nd component
Landsteiner’s law
• Antigens of the ABO blood group system – A & B (Agglutinogen)
• Blood groups of ABO system –

Blood Ag Ab India U.S.

groups present present % %
A A Anti-B 21 42
B B Anti-A 39 09
AB AB - 09 03
O - Anti-A 31 46
Anti-B
• In addition to RBC,s A & B antigens are present in – salivary glands,
saliva, pancreas, kidney, liver, lungs, testes, semen & amniotic fluid.
• A & B Ags - are derived from a common precursor called `H’ antigen/`H’
substance

- are complex oligosaccharides that differ in their terminal sugar

• `H’ antigens – On RBC’s – Glycosphingolipids

On other tissues – Glycoproteins

 Structure of `H’ antigen
• An ‘H’ gene codes for a fucose transferase
Fucose ---–----Galactose
• This puts fucose on the ends of these |
Glycosphingolipids & Glycoproteins,
forming ‘H’ Ag Acetylgalactosamine
|
Galactose
• H Ag is present in individuals of all blood
groups |
Glucose
|
Ceramide
• Blood Group A –

- individuals have gene coding for

transferase that catalyzes placement of a
terminal sugar N-acetylgalactosamine on
‘H’ Ag
 STRUCTURE OF `B’ ANTIGEN

GALACTOSE
|
• Blood Group B – FUCOSE---–-- GALACTOSE
|
N-
- individuals have gene coding for ACETYLGALACTOSAMINE
transferase that catalyzes placement of a |
terminal sugar galactose on ‘H’ Ag
GALACTOSE
|
GLUCOSE
|
CERAMIDE
 STRUCTURE OF `AB’ ANTIGEN

N-acetylgalactosamine
|
• Blood Group AB – GALACTOSE
- individuals have gene coding for |
both the transferases FUCOSE---–-- GALACTOSE
|
N-
ACETYLGALACTOSAMINE
• Blood Group O – |
GALACTOSE
- individuals have none of the |
transferase, so ‘H’ Ag persists GLUCOSE
|
CERAMIDE
 STRUCTURE OF `A’ ANTIGEN

N-ACETYLGALACTOSAMINE
|
FUCOSE---–-- GALACTOSE
|
N-ACETYLGALACTOSAMINE
STRUCTURE OF `AB’ ANTIGEN |
GALACTOSE
STRUCTURE OF `H’ ANTIGEN
N-ACETYLGALACTOSAMINE |
| GLUCOSE
GALACTOSE FUCOSE ---–-- GALACTOSE |
| CERAMIDE
|
FUCOSE---–-- GALACTOSE N-ACETYLGALACTOSAMINE
|
| STRUCTURE OF `B’ ANTIGEN
N-
ACETYLGALACTOSAMINE GALACTOSE
| | GALACTOSE
GALACTOSE |
GLUCOSE
| FUCOSE---–-- GALACTOSE
| |
GLUCOSE
CERAMIDE N-ACETYLGALACTOSAMINE
|
CERAMIDE |
GALACTOSE
|
GLUCOSE
|
CERAMIDE
 • Antibodies / Agglutinins of ABO system

• Antibodies against red cell antigens are called as agglutinins – anti- A &
anti- B

• These antibodies are usually produced in the first year of life

• These are of IgM type & can not cross the placenta

• These are the cold antibodies

• Subgrouping of blood group A (A1 & A2) & AB (A1B & A2B) –

• To determine this Kulith extract is used which contain anti-A1 substance

• Procedure – 2 drops of cell suspension + 2 drops of Kulith extract

- observed after 5 minutes

- If agglutination – A1 or A1B (75%)

- If no agglutination – A2 or A2B (25%)
• Difference between A1 & A2 is only quantitative

• A1 – cell having about 1 lac copies of ‘A’ Ag on its surface

• A2 - cell having about 2.5 lac copies of ‘A’ Ag on its surface

• Kulith / horse gram - is a type of legume, generally grown in dry agricultural
areas

• Used as a staple food for horses in India, hence the name

• Preparation of Kulith extract – is prepared by soaking 10 gms of seeds in

100 ml of 0.9% saline overnight in a refrigerator, next day solution is filtered
& extract is prepared
• Secretor and non-secretor -

• Non-secretor (15%) – in whom Ags are absent in body secretions

• Secretor (85%) - in whom Ags are present in body secretions like saliva,
semen, tears, amniotic fluid etc.

• If you are a secretor, you express more of your blood type in your body
 Inheritance of ABO blood groups

• Blood groups are inherited from both the parents

• For example – blood group `B’ individual whose PHENOTYPE is `B’ may
have GENOTYPE `BB’ (homozygous) or `BO’ (heterozygous)

• Both parents with B blood group could have children with genotype – BB,
BO, OO
Possible Blood group Genotypes

Parent A B O
Allele
A AA AB AO

B AB BB BO

O AO BO OO
• When blood grp of mother & child are known, typing can prove that the
man can not be the father, although it can not prove that he is the father
• Rhesus blood group system –

- first described in Rhesus monkeys in 1940 by Landsteiner & Alexander S

Weiner, hence the name

- second most important blood group system in transfusion medicine

- Rabbits when injected with Rhesus monkey red cells produce Abs that also
agglutinate RBCs of many humans

- This led to the discovery of Rh system in humans

• Ags of Rh System –

- Mainly six - C, D, E, c, d & e along with many other less frequent Ags

- Out of these six immunologically most active is the D antigen

- Rh positive (D antigen present) & Rh negative (D antigen absent)

- found in red cell membrane, not in any other tissues

• Inheritance - Rh antigen is inherited as dominant gene

- Rh +ve individual - homozygous (DD) or heterozygous (Dd) genotypes

- Usually, 60% of Rh +ve individuals have Dd genotype and 40% have DD

genotype

- The genotype of Rh –ve person is dd

• If one of the parents is homozygous positive and the other is homozygous
negative, all offsprings will be heterozygous positives
- Similarly, if the father & mother are homozygous negatives all offsprings
will be homozygous negatives &

Parents Father (dd) Mother (dd)

d d d d

Offspring dd dd dd dd
- when one of the parents is heterozygous positive & other homozygous
negative

Parents Father (Dd) Mother (dd)

D d d d

Offspring Dd Dd dd dd

- 50% of offsprings will be heterozygous positive and 50% will be

homozygous negatives
• Antibodies of rhesus system

• Anti-D Abs do not develop without exposure of Rh-D negative individuals to

Rh-D positive cells

• These Abs are of IgG type & can cross placenta

• Warm Ab
 ABO Abs Rh Abs
IgM type IgG type
Can’t cross placenta Cross placenta
Cold Abs Warm Abs
Distribution of Rh D positive & Rh D negative blood

Rh D Positive % Rh D Negative%
Asians 99 O1
Caucasians 85 15
J&K 88 – 90 10 – 12
Punjab 95 – 96 05 – 06
Delhi 95.16 O4.84
South India 97.70 02.30
• The MNS System - first described in 1927 (MN in 1927; S in 1947)

• Antigens - M, N & S expressed in RBCs & endothelial cells of renal

capillaries

• The common phenotypes are - M, N, MN & S

• This system is helpful for solving the paternity dispute, anthropological &
genetic studies
• M & N factors depend on 2 minor genes

• Each individual carries 2 genes of M & N groups

• M + M = M; N + N = N; M + N = MN
• Paternity Dispute –
If baby’s group Parents must So if mother Father could
is have given it was not have been
O (M) O + O (M + M) No matter which AB (N)
AB (N) A + B (N + N) No matter which O (M)

A (MN) A + O or A + A B or O (N) B or O (N)

(M + N)
B (MN) B + O or B + B A or O (M) A or O (M)
(M + N)
• Bombay blood group –

- Discovered In 1952 by Y M Bhende, Bhatia & Deshpande in Bombay

- These individuals lack the H gene & therefore the basic precursor
substance can not be converted into H substance

- This in turn results in failure to form A or B antigen

- When their blood sample is tested for routine AB grouping, they will be
labeled as blood group O

- However, their serum contains anti A & anti B and anti H antibodies

- These individuals therefore, should be transfused with only Bombay blood

group (Phenotype - hh).
• Applied significance –

1. Blood transfusion - Indications – any condition →alter blood in quantity or

quality
- Hemorrhages

- Blood disorders (severe anemia, leukemia, hemophilia etc)

- Pre & post operatively to build up blood loss

- Hemorrhagic shock etc

• Prerequisites for blood transfusion -

a) Cross matching – compatibility of a donor’s blood with recipient’s blood

Types – Serological &

- Electronic
Serological cross matching - Types – Direct / Major & Indirect / Minor

Donor Recipient
↓ ↓
Ags (RBC) Abs (Plasma)

If mismatched
↓
Severe Ag-Ab reaction
↓
Hemolysis of donors RBCs
(Direct / Major)
Serological cross matching - Types – Direct / Major & Indirect / Minor

Donor Recipient
↓ ↓
Abs (Plasma) Ags (RBCs)

Even mismatched
↓
Negligible Ag-Ab reaction
↓
No / negligible hemolysis of
Recepient’s RBCs
(Indirect / Minor)
Serological cross matching - Types – Direct / Major & Indirect / Minor

Donor Recipient
Donor Recipient
↓ ↓
↓ ↓
Abs (Plasma) Ags (RBCs)
Ags (RBC) Abs (Plasma)

Even mismatched
If mismatched
↓
↓
Negligible Ag-Ab reaction
Severe Ag-Ab reaction
↓
↓
No / negligible hemolysis of R RBCs
Hemolysis of donors RBCs
(Indirect / Minor)
(Direct / Major)
• Electronic cross matching – determines ABO & Rh typing of donor &
recipient & Ab screen of recipient

- indicated only when patient has negative Ab screen or Abs are below the
detectable levels
b) No Rh negative female at any age before menopause should be given Rh
positive blood transfusion
 c) Inter group transfusion

Blood Antigens Antibodie Can give Can

Group s blood to receive
blood
from
AB

O
Blood Antigens Antibodies Can give Can
Group blood to receive
blood
from
AB A and B None AB AB, A, B,
O
A A B A and AB A and O

B B A B and AB B and O

O None A and B AB, A, B, O

O
2. Hemolytic disease of newborn(HDN) - Various forms of HDN

1) Hydrops foetalis –
- a serious fetal condition defined as abnormal accumulation of fluid in two
or more fetal compartments, including ascites, pleural
effusion, pericardial effusion & skin edema

- Anemia → heart failure → heart lose its ability to pump blood effectively
→ back pressure in vasculature of legs, ankles & feet → edema
2) Erythroblastosis foetalis / Icterus gravis neonatorum –

- Infant born at term is jaundiced or become so within 24 hrs

- no anemia at birth, but develops within few days, as at birth ↑ed

hemolysis is compensated by an intense normoblastic response of BM
→ high retuculocyte count & many immature RBCs → erythroblastemia

3) Kernicterus
• Prevention of HDN –

• Sensitization of Rh – ve mother during 1st pregnancy can be prevented by –

- Giving a single dose of anti-D Abs (Rh immunoglobulin IgG) within 72 hours
of the delivery

- Doing fetal Rh typing with material obtained by amniocentesis / chorionic

villus sampling, if fetus is Rh +ve, a single dose of anti-D Abs is given to
mother during pregnancy
3. Transfusion Reactions – any adverse event occurring due to blood
transfusion

Types –

a) Febrile non-hemolytic transfusion reaction - most common, fever,

dyspnea & violent pain in back, occurs within 1 – 6 hours
b) Bacterial infection - risk is highest in platelet transfusion( 1 in 50,000)
than the RBC transfusion( 1 in 500,000)

c) Acute hemolytic reaction - occurs within minutes of transfusion causing

fever, chills, back pain & hemoglobinuria, may
lead to ARF

d) Anaphylactic reaction - 1 in 30,000 – 50,000 cases, laryngospasm,

hypotension
e) Transfusion associated acute lung injury -
- it is a syndrome of acute respiratory distress associated with fever, non-
cardiogenic pulmonary edema ( incidence – 1 in 2000)

f) Volume overload / transfusion associated circulatory overload (TACO) –

- patients with impaired cardiac function become volume overloaded leading
to edema, dyspnoea & orthopnoea
g) Iron overload - caused by transfusion of 12 – 20 units of blood & can
damage the liver, kidneys & pancreas

h) Delayed hemolytic reaction - it occurs within 5 – 10 days & varies from sub
- clinical to life threatening reaction
characterized by fever, reduced Hb conc.,
jaundice
• Treatment of transfusion reactions
- Stop the transfusion immediately
- Provide supportive care to the patients
- Remaining blood & i.v. tubings are saved for testing
• Concept of universal recipient (AB
positive) & universal donor (O negative) –

• Practically it’s misleading & dangerous

• As blood contains Ags & Abs of blood

groups other than ABO system

• However an exception could be made in

most extreme emergency, where ‘O - ve’
blood can be given immediately