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02 Transfusion Medicine II
Dr. Carina P. Villamayor | February 27, 2019

o Promoters of agglutination and are referred to as agglutinogens

o Recognized as “foreign”/ non-self if transfused into another
I. Blood Transfusion
A. History individual.
B. Blood Group Systems ● Presence or absence of these antigens is used to classify blood
C. Human Blood Groups groups
II. ABO Blood Group
A. ABO Blood Group II. ABO BLOOD GROUP
B. Landsteiner’s Law A. ABO Blood Group
C. Antigens
D. ABO Inheritance and Genetics ● Discovered in 1901 by Dr. Karl Landsteiner ( Austrian scientist)
E. Antibodies ● 4 main phenotypes (A, B, AB, O)
F. Blood Group Antibodies - Classification Genotype is the set of genes that you inherit. Phenotype is what
G. Antibody Screening you express, the observable trait.
H. ABO Blood Grouping System ● Antigens/ agglutinogens Type A and Type B on the surface of the
III. The Rhesus(RH) System RBCs are the cause of blood transfusion reactions.
A. Rh System
● Thus, the presence or absence of these Ags is the essential basis
B. Rh Antibodies
IV. Laboratory Determination of the ABO System that blood is grouped for the purpose of transfusion.
A. Blood Typing
V. Other Blood Group Systems B. Landsteiner’s Law
VI. Blood Transfusions ● If an antigen is present in the RBCs of an individual, the
VII. References corresponding antibody must be absent from the plasma.
● if an antigen is absent in the RBCs of an individual, the
At the end of the lecture, the student should be able to: corresponding antibody must be present from the plasma.
1. Review the basic concepts of immunohematology. Type A has anti-B antibodies but no anti-A antibodies. Type B
2. Apply the basic concepts and principles of the ABO and RH antigen has anti-A antibodies but no anti-B antibodies. Type AB has
typing. no anti-A and anti-B antibodies. Type O has both anti-A and anti-B
3. Discuss the important blood group system and its clinical
antibodies.
significance.
4. Discuss the investigation of transfusion reactions.

Legend:
Supplementary
Audio Recording Emphasized Notes
Book Information
• ☝

I. BLOOD TRANSFUSION
A. History
● 1665, England
o Physician Richard Lower
o First recorded successful blood transfusion in England
● 1818
o James Blundell
o British obstetrician
o First successful transfusion of human blood to a patient for the
treatment of postpartum hemorrhage.
Figure 1. ABO blood group.
B. Blood Group Systems
● 36 human blood group systems recognized by the International C. Antigens
Society of Blood Transfusion (ISBT) ● Blood group antigens vary in their ability to elicit an immune
● The most important: response.
o ABO blood group ● A, B, and D (Rh) antigens are the most immunogenic.
o Rh blood group ● ABO group inheritance is controlled by the A, B, and H genes.
These are the most immunogenic. Immunogenic is the capacity of
these blood groups to elicit an immune response. D. ABO Inheritance and Genetics
● The ABO gene is autosomal (chromosome 9).
C. Human Blood Groups ● This system consists of 3 antigens: A, B, and H and 4
● RBC membranes have glycoprotein antigens on their external phenotypes: Groups A, B, AB, and O.
surfaces. ● A and B blood antigens are CODOMINANT and are expressed on
● Human erythrocytes have >300 antigenic determinants. Group A, B, and AB red cells.
● These antigens are: ● Group O phenotype is autosomal recessive, expressing the H
o Unique to the individual antigen.

TRANSCRIBERS Chua P, Chua S, Cid, Claro EDITOR Estrada PAGE 1 of 7

● Each person has two copies of genes coding for their ABO blood
group (one maternal and one paternal in origin)

E. Antibodies
● Antibodies are found in the plasma and they are produced in
response to a foreign antigen.
● Complementary relationship between Ag-Ab.

Figure 4. Phenotypes. Type A has A antigen, type B has B antigen,

type AB has both A and B antigens, type O has no A and B antigens.

H. ABO Blood Grouping System

Figure 2. Antigen and Antibody
● Blood Group A - if you belong to the blood group A, you have A
antigens on the surface of your RBCs and B antibodies in your
F. Blood Group Antibodies - Classification
blood plasma
● Alloantibody – reacts to a foreign antigen not present on the
● Blood Group B - If you belong to the blood group B, you have B
patient’s own red blood cell.
antigens on the surface of your RBCs and A antibodies in your
o i.e. anti-A, anti-B in ABO system
blood plasma
● Autoantibody – reacts with an antigen on the patient’s own red
● Blood Group AB - If you belong to the blood group AB, you have
cells.
both A and B antigens on the surface of your RBCs and no A or B
● Based on type of antibody/ occurrence:
antibodies at all in your blood plasma
o Naturally-occurring (IgM) – present in individuals who have
● Blood Group O - If you belong to the blood group O (null), you
never been previously exposed to the RBC antigens by
have neither A or B antigens on the surface of your RBCs but you
transfusion, injection or pregnancy.
have both A and B antibodies in your plasma
▪ i.e. ABH, Hh, Ii, Lewis, Mn, and P.
o Immune (IgG) – present in serum of individuals who have been
transfused or pregnant. Capable of crossing the placenta.
▪ i.e. Rh, Kell, Duffy, Kidd, and Ss blood group systems.

G. Antibody Screening
● Detection of an “unexpected” antibody formed in response to the
introduction of a red cell antigen.
● Antibody screens are performed to detect antibodies in:
1. Patients requiring transfusions
2. Women who are pregnant
3. Suspected transfusion reaction
4. Blood and plasma donors

Figure 5. Possible Blood Groups

I. Special Phenotypes
● A phenotype
o The two main subgroups, A1 and A2, both react as an A but
can be differentiated by using the lectin anti-A1 reagent made
from Dolichos biflorus seeds (only agglutinates A1).
o Approximately 80% of group A individuals are A1;
approximately 20% are A2.
o Anti-A1 can be found in 1% to 8% of group A2 individuals
o Mixed field agglutination with anti A or anti B sera

Figure 3. Antibody screening

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 whatever red cells escape to the circulation can be attacked by
these RhoGAM.
● Rho(D) Globulin Treatment (RhoGAM)
o Administered to Rh- mothers who have had previous Rh+
pregnancies.
o This immune globulin will neutralize the antibodies to Rh that are
present in the mother's bloodstream.
o Usually administered at 28 weeks and again 72 hours before
delivery
o Also given before amniocentesis and/or after any injury to the
abdominal region and every 12 weeks thereafter.
● Racial variation in incidence of Rh negative individuals
Figure 6. Anti-A1 Typing. The problem with A1 is if you do o Caucasian - 15%
conventional typing, they will test forward typing as A, but reverse type o African-Americans and Hispanics - 8%
with test as type O. What happens here is that if you're A, you expect o Asians and Native Americans - 1%
your B cells to only be Positive. The A cells that are positive here is
caused by the interference due to the minor phenotype present

J. ABO Incompatibility in Newborns

● Type O mothers with Types A, B, or AB fetus
● Some mothers carry IgG anti-A and anti-B which crosses the
placenta
● Predisposing factors: trauma, difficult labor, unknown ⟹ escape
of fetal red cells ⟹ mother circulation
● Mild hemolytic disease in newborn (jaundice)

III. THE RHESUS (RH) SYSTEM

A. The Rhesus System
● The most complex of the red cell antigen system in humans
Figure 7. How Rh incompatibility occurs during pregnancy
● 5 different antigens (C, D, E, c and e)
● Rh antigen follows the rule of Mendelian inheritance IV. LABORATORY DETERMINATION OF THE ABO SYSTEM
● RBCs that are Rh positive express the antigen designated D A. Key Concepts
● 85% of the population is Rh D-positive, the other 15% of the ● Tests “knowns” with “unknowns”
population is running around with Rh D-negative blood ● When detecting or identifying RBC surface antigens, we test
● A person with Rh- blood can develop Rh antibodies in the blood patient’s RBCs (unknown) with reagent antisera (known).
plasma if he/she receives blood from a person with Rh+ blood ● When detecting or identifying antibodies, we test patient’s serum
whose Rh antigens can trigger the production of Rh antibodies (unknown) with reagent RBCs (known).
● A person with Rh+ blood can receive blood from a person with Rh-
blood without any problems. Table 1. Concepts in Blood Typing
● Rh+ can only donate to Rh+ but never to Rh-. If you are Rh-, you KNOWN! UNKNOWN REACTANT TEST
can donate to Rh+ because there are no antibodies in Rh- ? DETERMINED
Reagent antisera + Patient RBC Surface Forward
B. Rh Antibodies RBCs antigens Typing
● Antibodies against Rh antigens are the result of immune stimulation Reagent RBCs + Patient Serum Reverse
by either transfusion or pregnancy Serum antibodies Typing
● Antibodies against Rh antigens are of IgG (can cross the placental
barrier), reactive at 37°C and are usually detected in the AHG
B. Blood Typing
phase of testing (third stage of cross matching)
● Direct serologic detection of the ABO antigens.
● Rh antibodies are capable of producing hemolytic disease of the
● It is the main method in blood transfusion centers and hospital blood
fetus and the newborn(HDFN).
banks.
● Two Components of Blood Typing:
Erythroblastosis Fetalis (EF)
1. Antibodies (reagent antisera) that are specific at
● Rh incompatibility that leads to EF in 2nd pregnancy. In the first
detecting a particular ABO antigen on RBCs.
pregnancy, there will be no problem. Some red cells from Rh-
2. Cells of known ABO group (reagent RBCs) that are
positive fetus will escape and go inside the circulation of the
agglutinated by the naturally occurring antibodies in the
mother(woman becomes sensitized) hence causing an immune
individual’s serum.
response(antibodies form to fight Rh-positive blood cells). The next
● Antigen-antibody reaction results to agglutination (clumping of
time she becomes pregnant, the mother sufficiently developed Rh
RBCs).
antibody. Hence the red cells of the 2nd baby will now be attacked.
● Erythroblastosis fetalis can be prevented by treatment with
RhoGAM. This is given to the mother right after the delivery so

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 RBCs. Type AB serum containing no anti-A and anti-B would show no
agglutination with A and B RBCs.
C. Blood Transfusions (Who can receive blood from whom?)
● Type O – “universal DONORS”
● Type AB – “universal RECEIVERS”

Figure 8. Agglutination Reaction. Human RBC before (left) and after

(right) adding serum containing Anti-A antibodies. The agglutination
reaction reveals the presence of the A antigen on the surface of the
cells.
Figure 10. Universal DONOR and RECEIVER. Type O can donate to
Table 2. ABO Forward Grouping A,B, and AB. While AB can receive from A, B, O, and AB.
PX RBCS WITH PX RBCS WITH INTERPRETATION
ANTI - A ANTI - B OF BLOOD
GROUP
0 0 O
4+ 0 A
0 4+ B
4+ 4+ AB
Principle: Detection of antigens on patient’s RBCs with known
commercial antisera. Type O having no A and B surface antigens
would show no agglutination. Type A blood containing RBCs with A
surface antigens would agglutinate with anti-A sera. Type B blood
containing RBCs with B surface antigens would agglutinate with anti-B
sera. Type AB containing both A and B surface antigens would
agglutinate with anti-A and anti-B.

Figure 11. Comprehensive Guide to Blood Donation (Donor-

Recipient). If you are Rh (-) you can only receive blood from Rh (-). O
(-) is the most restrictive among the group.

V. OTHER BLOOD GROUP SYSTEMS

A. Importance of Other Blood Groups
● May cause transfusion reactions or Hemolytic Disease of the
Newborn (HDN)
● May interfere with cross-matching
● For medico-legal parenthood problems

Figure 9. Reactions in Forward Typing. Monoclonal reagents

B. Blood Groups Classification
containing antibodies Anti-A (Blue/Azure) and Anti-B (Yellow/Banana).
● There are 36 known blood group systems (9 are major blood
groups).
Table 3. ABO Reverse Grouping
● Other Blood Group Systems:
PX SERUM WITH PX SERUM WITH INTERPRETATION
o Kell
REAGENT A1 CELLS REAGENT B OF BLOOD
o Duffy
CELLS GROUP
o Kidd
4+ 4+ O o MNS
0 3+ A o P
3+ 0 B o Lewis
0 0 AB o Lutheran
Principle: Detection of ABO antibodies (isoagglutinins) in serum of ● Classification:
patient with known commercial RBCs. Type O having both A and B o Carbohydrate-based Systems
antibodies in the serum would agglutinate when mixed to A and B ▪ Lewis
RBCs. Type A serum containing anti-B would agglutinate with B ▪ P
RBCs. Type B serum containing anti-A would agglutinate with A ▪ Ii
▪ ABO

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 ● Antibodies (Lewis, P, and I Systems)
o Protein-based Systems o IgM Class
▪ Kidd o Cold-reactive antibodies (react best at temperatures below
▪ Kell 37o C)
▪ Duffy o Do not cause HDN
▪ Lutheran
▪ MNS D. Protein-Based Antigens
▪ Rh ● MNS System
● Lutheran System
Table 4. 9 Major Blood Group Systems ● Kell System
ISBT No Blood group Major antigens Chromosome ● Duffy System
system location no. ● Kidd System
name
001 ABO A, B, A1 B, A1 9 Kell System
002 MNS M, N, S, s, U 4 ● K antigen is the most immunogenic antigen after the antigens of the
003 P P1 22 ABO and Rh system
004 Rh D, C, E, c, e 1 ● Anti-Kell is of class IgG
005 Lutheran Lua, Lub 19 ● Anti-Kell is an important cause of Hemolytic disease of the
006 Kell K, k, Kpa, Kpb, Jsa, Jsb 7 newborn
007 Lewis Lea, Leb 19
Duffy System
008 Duffy Fy , Fyb, Fy3
a
1
● Contains six antigens, the most important are Fya and Fyb
009 Kidd Jka, Jkb, Jk3 18
● Duffy antigens are the sites of attachment to the red cell for the
malarial parasites Plasmodium vivax and P. knowlesi
C. Carbohydrate-Based Antigens
absence of antigens makes one immune to these malarial
● Lewis System
parasites
o Two major antigens: Lea and Leb
● Those who are Fy(a-b-) have an advantage over those who have the
Synthesized from the GI tract which are present in the
antigen because they are resistant to invasion by these two
plasma and adhere to RBCs.
parasites.
o Antigens may be lost from the red cell surface of stored red
● Anti-Fya and Anti-Fyb are of IgG type (stimulated by transfusion or
cells
pregnancy)
o Need to use fresh red cells when you want to detect Lewis
● These antibodies are capable of causing severe transfusion
antigens or anti-Lewis antibodies
reactions and HDFN.
o They are more susceptible to gastritis and ulcers because
these bacteria may bind to the H, Lea and, Leb antigen
Kidd System
receptors (2019A).
● Two important antigens: Jka and Jkb are well developed on the
H. pylori infections have been associated to people having
RBC membrane of neonates; however their antigens are not very
these antigens (Lea, 2019A).
immunogenic
● P System
● The frequency of the Kidd blood groups system antigens varies
o Most important antigen in this system is P1
between different populations
o This antigen is not fully expressed on fetal and new natal red
● Antibodies are of IgG type that can activate complement (stimulated
cells.
by transfusion or pregnancy)
o Found in the urinary tract epithelium where it acts as a
o They are transient, meaning they can be lost after sensitization
receptor for microorganisms (E. coli causing UTI).
o Considered weak antibodies
o It doesn’t cross the placenta, so it doesn’t cause HDN (2019A).
o Found in combination with other antibodies making them
difficult to detect
● I System
o Common cause of delayed hemolytic transfusion reaction
o Two antigens: I and i
o Rarely cause HDFN
o Both are high frequency antigens (i.e. most people express
them)
VI. BLOOD TRANSFUSION
o Expression is inversely proportional
A. Compatibility Testing for Blood Transfusion
o Increase in age = increase in I antigen and decrease in i
1. ABO and Rh on donor units
antigen
2. ABO and Rh on recipient
o Fetal and neonatal red cells express the i antigen with little I
3. Antibody screening of recipient
o Normal adult red cells express more of the I antigen and less
4. Antibody identification
of the i
5. Autocontrol to detect the presence of autoantibodies
o Seen in conditions with autoimmune hemolytic anemia and
6. Crossmatch
acquired hemolytic anemia of cold-agglutinin type like
Mycoplasma infection (2019A).

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 ● Alloantibody identification
B. Cross Matching ● Antigen typing
● Major cross matching – Donor’s RBCs are mixed with recipient’s ● Free hemoglobin in first voided urine, post-BT
serum ● Unconjugated bilirubin 5-7 hours, post-BT
● Minor cross matching– Recipient’s RBCs are mixed with donor’s
serum (not done anymore) 3. Extended Procedures
● When no agglutination occurs, only then can donor’s blood be ● Gram stain and bacterial culture of unit
transfused ● Quantitative serum hemoglobin
● Investigations of transfusion reaction are necessary for: ● Serum haptoglobin, pre and post transfusion
o Diagnosis ● Peripheral blood film
o Selection of appropriate therapy ● Coagulation and renal output study
o Transfusion management ● Urine hemosiderin
o Prevention of future transfusion reaction
● Important Clinical Data QUIZ
o Diagnosis 1.The most important STEP in the safe administration of blood is to
o Medical history of pregnancies, transplant, and previous A. Accurately perform compatibility testing
transfusion B. Get a complete patient history
o Current medication C. Accurately identify donor unit and recipient
o Clinical signs and symptoms of the reaction D. Exclude disqualified donors
● Questions related to the transfusion 2. With regards to inheritance, most blood group systems are
o Amount of blood transfused to cause the reaction. A. Autosomal co-dominant
o How fast was the blood given? How long was the patient B. Autosomal recessive
hooked to the unit? C. Sex-linked recessive
o The use of blood warmer D. Sex-linked dominant
o Any filter used? Other solutions 3. A patient's serum was tested on known A and B cells. Under light
o Any drug/s given at the time of transfusion microscopy, the red cells are freely dispersed on both labeled tubes.
Based on these reactions, the blood type of this patient is:
“A Negative or Compatible crossmatch shows that antibodies A. Type O
corresponding to the antigens of donor’s red cells are absent in B. Type AB
patient’s serum/plasma. But a compatible crossmatch does not signify C. Type A
that there are no atypical antibodies present in patient’s
D. Type B
serum/plasma”
4. After receiving a unit of packed red cells, a patient immediately
Acute Delayed developed fever, chills, and hemoglobinuria. Laboratory investigation
● Acute Hemolytic Transfusion ● Delayed Hemolytic of this adverse reaction would most likely show:
(HTR) Transfusion (HTR) A. ABO mismatch
● Non-hemolytic febrile ● Transfusion-associated B. Rh incompatibility
transfusion reaction Graft vs Host disease C. Bacterial contamination of blood product
● Allergic reaction (GVHD) D. Presence of anti-Jk antibody in patient’s serum
● Acute non-immunologic ● Post-transfusion purpura
5. Which of the following blood group systems is commonly
reactions (Circulatory ● Non-immunologic reactions
overload, bacterial (Citrate toxicity, associated with delayed hemolytic transfusion reactions
contamination) hypothermia, hyperkalemia) A. Kidd
Table 5. Transfusion Reactions B. I system
C. Lewis
Most common – Non-hemolytic febrile transfusion reaction; 2nd most D. P system
common – allergic reaction 6. Which of the following blood group/s is/are associated with a certain
disease condition?
C. Laboratory investigation outline for transfusion reactions A. Lewis
1. Immediate Procedures B. Duffy
● Clerical checks C. P system
● Visual inspection of serum and plasma for free hemoglobin (pre and D. All of the above are correct
post transfusion) E. Only A and B are correct
● Direct anti-globulin test on the post-transfusion EDTA sample 7. A patient who received massive blood transfusion of 8 units of
whole blood developed signs and symptoms of hypocalcemia in less
Clerical error is the most common cause of error in transfusion. than 24 hours posttransfusion. The most likely reason for the patient’s
Always check recipient’s name, blood type, how fast will you give it condition:
and monitor transfusion reactions. A. Volume overload
B. Citrate toxicity
2. As Required Procedures C. Allergic reaction
● ABO grouping and RH typing, pre and post transfusion D. Unrelated to transfusion
● Major compatibility testing, pre and post transfusion
● Antibody screening test, pre and post transfusion

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8. Two individuals were similarly exposed when they travelled to an
endemic area for malaria. What blood group antigen should be tested
to determine susceptibility or resistance of this type of infection?
A. Duffy antigen
B. I antigen
C. P antigen
D. A or B antigen
9. An individual had the following results during blood typing:
Forward type Reverse type
Anti-A Anti-B A cells B cells
Positive Negative Positive Positive

Which of the following phrases is true of this reaction?

A. This may be a subgroup of type A
B. Majority of type A individuals carry the red cell antigen
C. This red cell antigen agglutinates with lectin reagent derived from
Dolichos biflorus
D. Only anti-B is seen in plasma
10. The common feature shared by the antibodies of Kell and Duffy
blood group system is:
A. Their corresponding antigens are carbohydrate-based
B. Both cause hemolytic disease of the newborn
C. Their immunoglobulin is IgM
D. Both react in the saline phase at room temperature
11. A newlywed couple wherein the male is blood type AB and the
female is type B may have offspring with possible blood type
EXCEPT:
A. Type B
B. Type A
C. Type AB
D. Type O
CABAADBAABD
REFERENCES
1. Dr. Villamayor’s Lecture
2. Recordings

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