4-1-7. Blood Typing
Blood transfusions in humans were risky procedures until the discovery of the major human blood groups by Karl Landsteiner, an Austrian biologist and physician, in 1900. Until that point, physicians did not understand that death sometimes followed blood transfusions, when the type of donor blood infused into the patient was incompatible with the patient’s own blood. Blood groups are determined by the presence or absence of specific marker molecules on the plasma membranes of erythrocytes. With their discovery, it became possible for the first time to match patient-donor blood types and prevent transfusion reactions and deaths.
Antigens, Antibodies, and Transfusion Reactions
Antigens are substances that the body does not recognize as belonging to the “self” and that therefore trigger a defensive response from the leukocytes of the immune system. (Seek more content for additional information on immunity.) Here, we will focus on the role of immunity in blood transfusion reactions. With RBCs in particular, you may see the antigens referred to as isoantigens or agglutinogens (surface antigens) and the antibodies referred to as isoantibodies or agglutinins. In this chapter, we will use the more common terms antigens and antibodies.
Antigens are generally large proteins, but may include other classes of organic molecules, including carbohydrates, lipids, and nucleic acids. Following an infusion of incompatible blood, erythrocytes with foreign antigens appear in the bloodstream and trigger an immune response. Proteins called antibodies (immunoglobulins), which are produced by certain B lymphocytes called plasma cells, attach to the antigens on the plasma membranes of the infused erythrocytes and cause them to adhere to one another.
More than 50 antigens have been identified on erythrocyte membranes, but the most significant in terms of their potential harm to patients are classified in two groups: the ABO blood group and the Rh blood group.
The ABO Blood Group
Normally the body must be exposed to a foreign antigen before an antibody can be produced. This is not the case for the ABO blood group. Individuals with type A blood—without any prior exposure to incompatible blood—have preformed antibodies to the B antigen circulating in their blood plasma. These antibodies, referred to as anti-B antibodies, will cause agglutination and hemolysis if they ever encounter erythrocytes with B antigens. Similarly, an individual with type B blood has pre-formed anti-A antibodies. Individuals with type AB blood, which has both antigens, do not have preformed antibodies to either of these. People with type O blood lack antigens A and B on their erythrocytes, but both anti-A and anti-B antibodies circulate in their blood plasma.
Rh Blood Groups
Table 1 summarizes the distribution of the ABO and Rh blood types within the United States.
Table 1. Summary of ABO and Rh Blood Types within the United States
In contrast to the ABO group antibodies, which are preformed, antibodies to the Rh antigen are produced only in Rh− individuals after exposure to the antigen. This process, called sensitization, occurs following a transfusion with Rh-incompatible blood or, more commonly, with the birth of an Rh+ baby to an Rh− mother. Problems are rare in a first pregnancy, since the baby’s Rh+ cells rarely cross the placenta (the organ of gas and nutrient exchange between the baby and the mother). However, during or immediately after birth, the Rh− mother can be exposed to the baby’s Rh+ cells (Figure 1). Research has shown that this occurs in about 13−14 percent of such pregnancies. After exposure, the mother’s immune system begins to generate anti-Rh antibodies. If the mother should then conceive another Rh+ baby, the Rh antibodies she has produced can cross the placenta into the fetal bloodstream and destroy the fetal RBCs. This condition, known as
A drug known as RhoGAM, short for Rh immune globulin, can temporarily prevent the development of Rh antibodies in the Rh− mother, thereby averting this potentially serious disease for the fetus. RhoGAM antibodies destroy any fetal Rh+ erythrocytes that may cross the placental barrier. RhoGAM is normally administered to Rh− mothers during weeks 26−28 of pregnancy and within 72 hours following birth. It has proven remarkably effective in decreasing the incidence of HDN. Earlier we noted that the incidence of HDN in an Rh+ subsequent pregnancy to an Rh− mother is about 13–14 percent without preventive treatment. Since the introduction of RhoGAM in 1968, the incidence has dropped to about 0.1 percent in the United States.
ABO Cross Matching
Clinicians are able to determine a patient’s blood type quickly and easily using commercially prepared antibodies. In this laboratory test, called
Cross Matching Blood Types
ABO Transfusion Protocols
To avoid transfusion reactions, it is best to transfuse only matching blood types; that is, a type B+ recipient should ideally receive blood only from a type B+ donor and so on. That said, in emergency situations, when acute hemorrhage threatens the patient’s life, there may not be time for cross matching to identify blood type. In these cases, blood from a
A patient with blood type AB+ is known as the
At the scene of multiple-vehicle accidents, military engagements, and natural or human-caused disasters, many victims may suffer simultaneously from acute hemorrhage, yet type O blood may not be immediately available. In these circumstances, medics may at least try to replace some of the volume of blood that has been lost. This is done by intravenous administration of a saline solution that provides fluids and electrolytes in proportions equivalent to those of normal blood plasma. Research is ongoing to develop a safe and effective artificial blood that would carry out the oxygen-carrying function of blood without the RBCs, enabling transfusions in the field without concern for incompatibility. These blood substitutes normally contain hemoglobin- as well as perfluorocarbon-based oxygen carriers.
ABO Blood Group
Antigens are nonself molecules, usually large proteins, which provoke an immune response. In transfusion reactions, antibodies attach to antigens on the surfaces of erythrocytes and cause agglutination and hemolysis. ABO blood group antigens are designated A and B. People with type A blood have A antigens on their erythrocytes, whereas those with type B blood have B antigens. Those with AB blood have both A and B antigens, and those with type O blood have neither A nor B antigens. The blood plasma contains preformed antibodies against the antigens not present on a person’s erythrocytes.
A second group of blood antigens is the Rh group, the most important of which is Rh D. People with Rh− blood do not have this antigen on their erythrocytes, whereas those who are Rh+ do. About 85 percent of Americans are Rh+. When a woman who is Rh− becomes pregnant with an Rh+ fetus, her body may begin to produce anti-Rh antibodies. If she subsequently becomes pregnant with a second Rh+ fetus and is not treated preventively with RhoGAM, the fetus will be at risk for an antigen-antibody reaction, including agglutination and hemolysis. This is known as hemolytic disease of the newborn.
Cross matching to determine blood type is necessary before transfusing blood, unless the patient is experiencing hemorrhage that is an immediate threat to life, in which case type O− blood may be transfused.
The process in which antibodies attach to antigens, causing the formation of masses of linked cells, is called ________.
People with ABO blood type O ________.
Hemolytic disease of the newborn is a risk during a subsequent pregnancy in which ________.
Critical Thinking Questions
Following a motor vehicle accident, a patient is rushed to the emergency department with multiple traumatic injuries, causing severe bleeding. The patient’s condition is critical, and there is no time for determining his blood type. What type of blood is transfused, and why?
In emergency situations, blood type O− will be infused until cross matching can be done. Blood type O− is called the universal donor blood because the erythrocytes have neither A nor B antigens on their surface, and the Rh factor is negative.
In preparation for a scheduled surgery, a patient visits the hospital lab for a blood draw. The technician collects a blood sample and performs a test to determine its type. She places a sample of the patient’s blood in two wells. To the first well she adds anti-A antibody. To the second she adds anti-B antibody. Both samples visibly agglutinate. Has the technician made an error, or is this a normal response? If normal, what blood type does this indicate?
The lab technician has not made an error. Blood type AB has both A and B surface antigens, and neither anti-A nor anti-B antibodies circulating in the plasma. When anti-A antibodies (added to the first well) contact A antigens on AB erythrocytes, they will cause agglutination. Similarly, when anti-B antibodies contact B antigens on AB erythrocytes, they will cause agglutination.
American Red Cross (US). Blood types [Internet]. c2013 [cited 2013 Apr 3]. Available from: http://www.redcrossblood.org/learn-about-blood/blood-types 2013
ABO blood group
hemolytic disease of the newborn (HDN)
Rh blood group