[ABO BLOOD GROUP INCOMPATIBILITY] August 12, 2013

OUR LADY OF FATIMA UNIVERSITY

2013
ABO BLOOD GROUP
INCOMPATIBILITY
LACDAO, May | LAGMAN, Dan Cedric| LABAN, Francis| KASHIM,
Adawiya| KNAIK, Billy| LADERA, Anna Rona| LAFORTEZA, Maria
Lyn
GRP. 8|SECTION C1
V A L E N Z U E L A C I T Y
[ABO BLOOD GROUP INCOMPATIBILITY] August 12, 2013

ABO BLOOD GROUP INCOMPATIBILITY
LACDAO, May | LAGMAN, Dan Cedric | LABAN, Francis Dominic | KASHIM, Adawiya | KNAIK, Billy |
LADERA, Anna Rona | LAFORTEZA, Maria Lyn
SECTION C1; GROUP 8
I. RED BLOOD CELL MEMBRANE
Overview
The red blood cell membrane is composed of lipids (40%), proteins (49%), and
carbohydrates (7%) (Erhabor & Adias, 2013) which interact in order to form a dynamic and fluid
structure (Hillyer, 2007). The RBC membrane plays a role in regulation of surface deformability,
flexibility, cell adhesion, and immune recognition (Erhabor & Adias, 2013).
Accordingly, the RBC membrane has three layers, namely, (1) glycocalyx which is rich in
carbohydrates; (2) lipid bilayer which contains several transmembrane proteins aside from its
phospholipid main constituents; and (3) membrane skeleton which is a structural protein network
located at the inner surface of the lipid bilayer (Erhabor & Adias, 2013). The exterior glycocalyx is
known to play a role in cell adhesion and cell recognition. It contains mainly oligosaccharides and
glycolipids. The RBC membrane has a typical lipid bilayer, which is similar to virtually that of all
human cells. There are also multiple connections between the lipid bilayer and the membrane
skeleton causing the bilayer to follow contours of the membrane skeleton (Hillyer, 2007).
Together, the membrane skeleton and the lipid bilayer give the erythrocyte shape and resilience
(Hillyer, 2007).

(Source: Hillyer. Blood Banking and Transfusion Medicine: Basic Principles & Practice, 2007)
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Lipids
Lipids in the cell membrane form a lipid bilayer with the hydrophobic tails on the inside and
the hydrophilic polar groups on either the outside (extracellular) or the inside (cytoplasmic)
surface (Murray, R., et. al., 2012). There are three types of lipids occurring in the RBC membrane,
namely, (1) phospholipid (50%), (2) cholesterol (40%), and (3) glycolipids (10%) (Hillyer, 2007).
Unlike cholesterol which is evenly distributed between the inner and outer leaflets, the five (5)
major phospholipids are asymmetrically arranged in the bilayer. The outer leaflet is predominantly
composed of phosphatidylcholine and sphingomyelin, while the inner leaflet would contain the
aminophospholipids i.e. phosphatidylethanolamine, phosphatidylserine, and phosphatidylinositol
(Koeppen & Stanton, 2010).
This asymmetric phospholipid distribution among the bilayer is the result of the function of
several energy-dependent and energy-independent phospholipid transport proteins. Proteins
called flippases move phospholipids from the outer to the inner monolayer, while others called
floppases do the opposite operation, against a concentration gradient in an energy dependent
manner. Additionally, there are also scramblase proteins that move phospholipids in both
directions simultaneously, down their concentration gradients in an energy-independent manner.
There is still considerable debate ongoing regarding the identity of these membrane maintenance
proteins in the red cell membrane.
The lipid bilayer, along with the membrane skeleton, allows the RBC membrane to behave
as a semisolid with elastic and viscous properties (i.e. membrane permeability and fluidity)
(Erhabor & Adias, 2013; Hillyer, 2007).
Proteins
Peripheral proteins form a meshwork under the lipid bilayer which is the membrane
skeleton. It is considerably fluid and flexible. Deformability, flexibility, and durability of the RBC are
attributed to the proteins of the membrane skeleton. These properties are important in ensuring
the survival of the RBCs for 120 days during numerous cycles, approximately 75,000 cycles, and
passages through narrow veins and sinusoids in the spleen (Hillyer, 2007). The RBC membrane is
associated with the lipid bilayer via specific interactions with transmembrane proteins.
Specific protein components of the RBC membrane skeleton, which is associated with the
inner leaflet of the lipid bilayer, interact with the cytoplasmic domains of some antigen-carrying
transmembrane proteins. Two major and well-defined interactions are ankyrin which binds to
spectrin in the membrane skeleton and the cytoplasmic domain of the multipass transmembrane
protein, band 3 (anion exchanger protein) and protein 4.1, which provides a link between spectrin,
actin, and p55 in the membrane skeleton to the single pass proteins GPC and GPD (Hillyer, 2007).
Presently, there are over 50 known membrane proteins, and about 25 of these are
responsible for carrying the various blood group antigens such as A, B, and Rh antigens (Erhabor &
Adias, 2013). Many blood group antigens are carried on transmembrane proteins or glycoproteins;
however, a few antigens are carried on glycosylphosphatidylinositol (GPI)-linked proteins. Antigens
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in two blood group systems (Lewis and Chido-Rogers) are carried on proteins that are absorbed
onto RBCs from the plasma (Hillyer, 2007).
Carbohydrates
Carbohydrates are essentially located on the extracellular surface of the cell membrane,
where they collectively form a negatively-charged environment in order to prevent RBCs from
adhering to one another and to the endothelium (Erhabor & Adias, 2013; Hillyer, 2007). Majority of
the carbohydrates are attached to lipids on ceramide and to proteins by attachment to asparagines
(N-linked) or to serine or threonine (O-linked) during passage through the lumen of the Golgi.
Certain blood groups are determined via the terminal carbohydrate residue i.e. A and B
whereas others require the presence of carbohydrate residues e.g. Le
b
and I (Erhabor & Adias,
2013; Hillyer, 2007).
Moreover, carbohydrates form the glycocalyx, a negatively-charged barrier approximately
10 thick around the outside of the RBC membrane (Hillyer, 2007). This barrier can keep
immunoglobulin G (IgG) antibodies, particularly those recognizing antigens that reside close to the
lipid bilayer, fro readily interacting with the corresponding antigen (Hillyer, 2007). Thus, the
glycocalyx affects the ability of an IgG antibody to cause direct agglutination.

II. ABO BLOOD GROUP
Overview
In 1900, Karl Landsteiner discovered the ABO system via extraction of blood samples from
his colleagues which he mixed with sera and afterwards, observing agglutination (Yamamoto, F.,
2004). Based on the agglutination pattern, he named the first two blood group antigens A and B,
using the first two alphabets. RBCs which did not agglutinate were first called type C but became
known as ohne A and ohne B (ohne: German, without) and finally as O (Hillyer, 2007).
The major blood groups of this system are A, AB, B, and O, as defined by the absence or
presence of the antigen A and B on the RBCs and of the antibodies against these antigens. This
blood group has a crucial role in transfusion medicine because essentially all individuals produce
antibodies to the ABH antigen that they lack. Accordingly, the naturally-occurring anti-A and anti-B
antibodies are called isoagglutinins (Fauci, et al., 2008). Thus, blood type A contains antigen A on
the surface of its cell membrane and produce anti-B antibody in its plasma. Type B individuals have
B antigens on their RBCs and produce anti-A antibodies. Blood group AB individuals have both A
and B antigens on RBCs and produce neither anti-A nor anti-B antibodies. On the contrary, blood
group O individuals have neither A antigens nor B antigens, but possess both anti-A and anti-B
antibodies. The observed rule that individuals have the antibodies against A or B antigens if they do
not express A or B antigens on RBCs, respectively, has been named the Landsteiners Law
(Yamamoto, F., 2004; Yamamoto F., 2008).
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Since type O individuals do not have any A or B antigens, their erythrocytes will not be
attacked by either anti-A or anti-B antibodies, thus they are called universal donors (Sherwood,
2001). Their blood can be transfused into persons of any blood type. However, type O individuals
can only receive type O blood because the anti-A and anti-B antibodies present in their plasma will
attack either A or B antigens in the incoming blood. In contrast, type AB individuals are called
universal recipients because they lack both anti-A and anti-B antibodies. Thus, they are able to
accept donor blood of any type, although they can only donate to other AB persons. Since their
erythrocytes would contain both antigen A and B, their RBCs will be attacked if transfused into
individuals with antibodies against either of these antigens (Sherwood, 2001).
Antigens
ABO antigens have been characterized as carbohydrate structures on glycoproteins and
glycolipids. Antigens are synthesized in a stepwise fashion by glycosyltransferase enzymes that
sequentially add specific monosaccharide sugars in specific linkages to a growing oligosaccharide
precursor chain (Hillyer, 2007). The terminal sugar determines the antigen specificity: an N-
acetylgalactosamine residue results in the expression of the A antigen, and a terminal galactose
residue is responsible for the B antigen. These structures are similar, differing only in that A antigen
has a substituted amino group in carbon 2. The precursor substrate for A and B antigen is the H
antigen. The terminal fucose in (1,2) linkage to galactose is responsible for H antigen specificity,
and large amounts of H are present on group O RBCs, because H is not converted to A or B.
RBC membrane proteins carry well over 2x10
6
A, B, and H antigens (ABH) combined per
RBC, and most (80%) are located on the major integral membrane protein, band 3 (anion exchanger
1 or AE1), which is the RBC Cl
-
-HCO3
-
anion exchanger. In addition, the glucose transporter, Rh-
associated glycoprotein (RhAG), and aquaporin-1 also carry A, B, and H, but in smaller amounts.
ABH antigens are also found on many tissues. Endothelial and epithelial cells of the lungs
and gut and on the epithelial cells of the urinary tract expressed large amounts of ABH antigens,
thus, they are referred to as histo-blood group antigens. ABH are also found in secretion such as
saliva and fluids like milk and urine of 80% of the population who have the secretor (Se)
phenotype. They are also found on platelets.
Genetic and Biochemical Basis of the Formation of AB(H)O Antigens
H Antigen
The H antigen is synthesized in RBCs when the H (FUT1) gene-encoded fucosyltransferase
attaches a fucose via an (1,2) linkage to the terminal galactose of the type II precursor chain or
substance. On the other hand, H antigen in secretions is synthesized when the Se (Secretor, FUT2)
gene-encoded fucosyltransferase attaches a fucose via an (1,2) linkage to the terminal galactose
on type I precursor chains in secretory tissues. The A and B glycosyltransferases do not
discriminate type 1 or 2 chains and add N-acetylglucosamine (A) or galactose (B) sugars to H
antigens on both.
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The H (FUT1) encodes a 365-amino acid type II transmembrane protein, and Se (FUT2)
encodes either a 332- or a 343-amino acid type II transmembrane protein.
A and B Antigen
Watkins and Morgan, in 1959, correctly suggested that the genes for the carbohydrate ABO
determinants actually encoded enzymes responsible for the assembly of the subunits. The ABO
locus encodes the A and B gycosyltransferases, which were mapped by linkage analysis to
chromosome 9q34.
The ABO glycosyltransferase gene contains seven exons and spans approximately 18 to 20
kilobases. It encodes a 354-amino acid, 41-kD transferase that has a short N-terminal region, a
hydrophobic transmembrane segment for retention in the Golgi membrane, and a large C-terminal,
catalytically active domain. The glycosyltransferase enzymes are membrane-bound in the lumen of
the Golgi, and glycosylation of membrane proteins takes place during transit through the Golgi.
A and B Transferase
The A and B transferase enzymes differ by only 4 of 354 amino acids, Arg176Gly, Gly235Ser,
Leu266Met, and Gly268Ala. The latter two are primarily responsible for substrate specificity.
Mutations in A or B transferase genes can result in weak expression (subgroup phenotypes) or in
nonfunctional O alleles. A and B subgroups result from a large variety of mutations that cause
reduced activity of the glycosyltransferase. The group O phenotype results from any mutation in an
A or B transferase gene that causes loss of glycosyltransferase activity and a nonfunctional enzyme.
The most common results from a single nucleotide deletion early in the gene near the N terminus,
referred to as 261delG. The deletion causes a frameshift and a truncated product with no enzyme
activity that probably does not reach the Golgi membrane.
The A and B transferases are coded for by A and B transferase genes, respectively. Based on
cDNA cloning of A transferase gene, cloning of B and O allelic cDNAs, and elucidation of molecular
genetic basis of the ABO system, the difference and cause of the specificity of A and B
glycosyltransferases is due to amino acid substitutions (arginine, glycine, lysine, and glycine for A
transferase and glycine, serine, methionine, and alanine in B transferase at codons 176, 235, 266,
and 285).

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(Source: Yamamoto D. F., Review: ABO blood group systemABH oligosaccharide antigens, anti-A and anti-B, A and B
glycosyltransferases,and ABO genes, 2004)
Genetics of Blood Typing
The ABO polymorphism was one of the first genetic traits in humans that were shown to be
inherited. To explain the mode of inheritance, Bernstein proposed the one gene locusthree allelic
model. The assumptions were: (1) A, B, and O genes are alleles at the same ABO genetic locus and
(2) the A and B alleles are co-dominant against the recessive O allele.

(Source: Yamamoto D. F., Review: ABO blood group systemABH oligosaccharide antigens, anti-A and anti-B, A and B
glycosyltransferases,and ABO genes, 2004)
Although different designations can be used, the symbols I
A
, I
B
, and i will be used to
distinguish these three alleles. The I designation stands for isoagglutinogen, another term for
antigen. If we assume that the I
A
and I
B
alleles are responsible for the productionof their respective
A and B antigens and that ii s an allele that does not produce any detectable A or B antigens, we can
list the various genotypic possibilities and assign the appropriate phenotype to each:

(Source: Klug, Cummings, Spencer, & Palladino, 2012)
The Bombay Effect
This is in people who are homozygous for a rare recessive mutation in a gene designated
FUT1 (encoding an enzyme, fucosyl transferase), which prevents them from synthesizing the
complete H substance. In this mutation, the terminal portion of the carbohydrate chain protruding
from the red cell membrane lacks fucose, normally added by the enzyme. In the absence of fucose,
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the enzymes specified by the I
A
and I
B
alleles apparently are unable to recognize the incomplete H
substance as a proper substrate. Thus, neither the terminal galactose nor N-acetylgalactosamine
can be added, even though the appropriate enzymes capable of doing so are present and functional.
As a result, the ABO system genotype cannot be expressed in individuals homozygous for the
mutant form of the FUT1 gene; even though they may have the I
A
and/or the I
B
alleles, neither
antigen is added to the cell surface, and they are functionally type O. To distinguish them from the
rest of the population, they are said to demonstrate the Bombay phenotype. The frequency of the
mutant FUT1allele is exceedingly low. Hence, the vast majority of the human population can
synthesize the H substance.
III. RH BLOOD GROUP
The Rh blood group involves the D antigen. This was first studied in the Rhesus monkey and
results showed that there were six (6) common types of Rh antigens: C, D, E, c, d, and e. Of the six,
only D is clinically significant because of its prevalence and antigenicity. An individual is considered
Rh-positve if he/she possesses the D antigen, Rh negative is otherwise.
Frequency studies showed that 85% of Caucasians are Rh positive, while only 15% were Rh
negative. In contrast with Asians, who are 99% Rh positive.
The anti-D antibodies do not develop spontaneously in the plasma. There is a need for
exposure in order to form such antibodies. Consider an Rh negative individual. In order for this
person to develop anti-D antibodies, he/she must be exposed to Rh positive blood in order to have
appreciable titers of the anti-D antibodies.
IV. ABO INCOMPATIBILITY
Overview
ABO incompatibility is an immune system reaction that occurs when blood from two
different and incompatible blood types are mixed together, such as in the following cases: (1)
patient with type A blood will react against type B or type AB blood; (2) patient with type B blood
will react against type A or type AB blood; (3) patient with type O blood will react against type A,
type B, or type AB blood; and (4) patient with type AB blood will NOT react against type A, type B,
or type AB blood.

Type O blood does not cause an immune response when it is received by people with type A,
type B, or type AB blood. This is why type O blood cells can be given to patients of any blood type.
People with type O blood are called "universal donors." However, people with type O can only
receive type O blood.

Assessment of Compatibility
Blood typing

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Blood typing is a method used to determine the specific type of blood a certain person has.
Blood is often grouped according to the ABO blood typing system. This method breaks blood types
down into four categories: Type A, B, AB, and O. Blood types are inherited genetically and are also
determined by the presence or absence of antigen A and/or B on the cell surface.

The test is performed by drawing blood from a vein, usually from the inside of the elbow or
the back of the hand. The puncture site is cleaned with a germ-killing product. An elastic band is
placed around the upper arm to apply pressure, which causes the vein to swell with blood.
A needle is inserted into the vein, and the blood is collected into a tube. During the procedure, the
elastic band is removed to restore circulation. Once the blood has been collected, the needle is
removed, and a band-aid or gauze is applied.

In infants or young children, the area is cleansed with antiseptic and punctured with a sharp
needle or a lancet. The blood may be collected in a pipette (small glass tube), on a slide, onto a test
strip, or into a small container. A bandage may be applied if there is any bleeding.

The test to determine your blood group is called ABO typing. Your blood sample is mixed
with antibodies against type A and B blood, and the sample is checked to see whether or not the
blood cells stick together (agglutinate). If blood cells stick together, it means the blood reacted with
one of the antibodies.

The second step is called back typing. The liquid part of your blood without cells (serum) is
mixed with blood that is known to be type A and type B. Persons with type A blood have anti-B
antibodies, and those with type B blood have anti-A antibodies. Type O blood contains both types of
antibodies. These two steps can accurately determine your blood type.

Blood typing is also done to tell whether or not you have a substance called Rh factor on the
surface of your red blood cells. If you have this substance, you are considered Rh+ (positive). Those
without it are considered Rh- (negative). Rh typing uses a method similar to ABO typing.

Blood typing is especially important during pregnancy. If the mother is found to be Rh-, the
father should also be tested. If the father has Rh+ blood, the mother needs to receive a treatment to
help prevent the development of substances that may harm the unborn baby. If you are Rh+, you
can receive Rh+ or Rh- blood. If you are Rh-, you can only receive Rh- blood.

There are many antigens besides the major ones (A, B, and Rh). Many minor ones are not
routinely detected during blood typing. If they are not detected, you may still have a reaction when
receiving certain types of blood, even if the A, B, and Rh antigens are matched.
A process called cross-matching followed by a Coombs' test can help detect these minor antigens
and is routinely done prior to transfusions, except in emergency situations.

Coombs test

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The Coombs' test looks for antibodies that may stick to your red blood cells and cause red
blood cells to die too early.

Blood is drawn from a vein, usually from the inside of the elbow or the back of the hand. The
site is cleaned with germ-killing medicine (antiseptic). The health care provider wraps an elastic
band around the upper arm to apply pressure to the area and make the vein swell with blood.
Next, the health care provider gently inserts a needle into the vein. The blood collects into
an airtight vial or tube attached to the needle. The elastic band is removed from your arm.
Once the blood has been collected, the needle is removed, and the puncture site is covered to stop
any bleeding.
There are two types of the Coombs' test: direct and indirect. The direct Coombs' test is used to
detect antibodies that are stuck to the surface of red blood cells. Many diseases and drugs
(including quinidine, methyldopa, and procainamide) can cause this. These antibodies sometimes
destroy red blood cells and cause anemia. Your doctor may order this test if you have signs or
symptoms of anemia or jaundice. The indirect Coombs' test looks for free-flowing antibodies
against certain red blood cells. It is is most often done to determine if you may have a reaction to a
blood transfusion.

Blood Transfusion Reactions
The immune system never restsits 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.

If incompatible blood is given in a transfusion, the donor cells are treated as if they were
foreign invaders, and the patient's immune system attacks them accordingly. Not only is the blood
transfusion rendered useless, but a potentially massive activation of the immune system and
clotting system can cause shock, kidney failure, circulatory collapse, and death.
This chapter discusses the causes of transfusion reactions and how the hazards of blood
transfusions are minimized.

Many of the adverse effects of blood transfusions are mediated by the recipient's immune
system. In general, the formation of this and other immune responses occur in three stages: (1) the
immune system detects foreign material (antigen); (2) the immune system processes the antigen;
and (3) the immune system mounts a response to remove the antigen from the body.

The immune response varies tremendously, depending on the individual (the health of his
or her immune system and genetic factors) and the antigen (how common it is and how
"provocative" it is to the immune system).

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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.

When the macrophage encounters an antigen, it engulfs it, digests it, and then presents the
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.

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 pre-existing 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.

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Otherwise, the fate of the incompatible RBCs largely rests in the hands of macrophages in
the liver or the spleen. They remove the antibody-coated cells from the circulation and phagocytose
them. Phagocytosis is aided by the macrophages having a receptor that binds to the antibodies and
another receptor that binds to complement fragments. Therefore, incompatible RBCs are rapidly
destroyed after antibody binding. In addition, this antibody response may cause dangerous
hemolytic transfusion reactions as described below.

Hemolytic Disease of the Newborn
Hemolytic disease of the newborn (HDN) used to be a major cause of fetal loss and death
among newborn babies. The first description of HDN is thought to be in 1609 by a French midwife
who delivered twinsone baby was swollen and died soon after birth, the other baby developed
jaundice and died several days later. For the next 300 years, many similar cases were described in
which newborns failed to survive.
It was not until the 1950s that the underlying cause of HDN was clarified; namely, the
newborn's red blood cells (RBCs) are being attacked by antibodies from the mother. The attack
begins while the baby is still in the womb and is caused by an incompatibility between the mother's
and baby's blood.
By the 1960s, trials in the United States and the United Kingdom tested the use of
therapeutic antibodies that could remove the antibodies that cause HDN from the mother's
circulation. The trials showed that giving therapeutic antibodies to women during their pregnancy
largely prevented HDN from developing. By the 1970s, routine antenatal care included screening of
all expectant mothers to find those whose pregnancy may be at risk of HDN, and giving preventative
treatment accordingly. This has led to a dramatic decrease in the incidence of HDN, particularly
severe cases that were responsible for stillbirth and neonatal death.
Maternal antibodies cross the placenta and attack fetal red blood cells
During pregnancy, some of the mother's antibodies are transported across the placenta and
enter the fetal circulation. This is necessary because by the time of birth, newborns have only a
primitive immune system, and the continuing presence of maternal antibodies helps ensure that
they survive while their immune system matures. A downside to this protection is that by targeting
fetal RBCs, maternal antibodies can also cause HDN.
A major cause of HDN is an incompatibility of the Rh blood group between the mother and
fetus. Most commonly, hemolytic disease is triggered by the D antigen, although other Rh antigens,
such as c, C, E, and e, can also cause problems.
Pregnancies at risk of HND are those in which an Rh D-negative mother becomes pregnant
with an RhD-positive child (the child having inherited the D antigen from the father). The mother's
immune response to the fetal D antigen is to form antibodies against it (anti-D). These antibodies
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are usually of the IgG type, the type that is transported across the placenta and hence delivered to
the fetal circulation.
HDN can also be caused by an incompatibility of the ABO blood group. It arises when a
mother with blood type O becomes pregnant with a fetus with a different blood type (type A, B, or
AB). The mother's serum contains naturally occurring anti-A and anti-B, which tend to be of the IgG
class and can therefore cross the placenta and hemolysefetal RBCs.
HDN due to ABO incompatibility is usually less severe than Rh incompatibility. One reason
is that fetal RBCs express less of the ABO blood group antigens compared with adult levels. In
addition, in contrast to the Rh antigens, the ABO blood group antigens are expressed by a variety of
fetal (and adult) tissues, reducing the chances of anti-A and anti-B binding their target antigens on
the fetal RBCs.
Less common causes of HDN include antibodies directed against antigens of the Kell blood
group (e.g., anti-K and anti-k), Kidd blood group (e.g., anti-Jka and anti-Jkb), Duffy blood group (e.g.,
anti-Fya), and MNS and s blood group antibodies. To date, antibodies directed against the P and
Lewis blood groups have not been associated with HDN.
Sensitization occurs during the first pregnancy
Sensitization to an antigen occurs when the immune system encounters an antigen for the
first time and mounts an immune response. In the case of HDN caused by Rh incompatibility, an Rh
D-negative mother may first encounter the D antigen while being pregnant with an Rh D-positive
child, or by receiving a blood transfusion of Rh D-positive blood. Once a mother has been sensitized
to the D antigen, her serum will contain anti-D. The direct Coombs test (see below) confirms the
presence of anti-D and hence that the mother has been sensitized.
Only a small amount of fetal blood need enter the mother's circulation for sensitization to
occur. Typically, this occurs during the delivery of the first-born Rh D-positive child. Fetal-maternal
hemorrhage is common during labor and is increased during a prolonged or complicated labor,
which in turn increases the risk of sensitization. Sensitization can also occur earlier in the
pregnancy, for example during a prenatal bleed or a miscarriage. It may also occur during medical
procedures, such as a termination of pregnancy or chorionic villus sampling.
The risk of sensitization to the Rh D antigen is decreased if the fetus is ABO incompatible.
This is because any fetal cells that leak into the maternal circulation are rapidly destroyed by potent
maternal anti-A and/or anti-B, reducing the likelihood of maternal exposure to the D antigen.
HDN occurs in subsequent pregnancies
Initially, the maternal anti-D that is formed at the time of sensitization is of the IgM type,
which can not cross the placenta. In subsequent pregnancies, a repeat encounter with the Rh D
antigen stimulates the rapid production of type IgG anti-D, which can be transported across the
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placenta and enter the fetal circulation. Once in the fetal circulation, anti-D attaches to the Rh D
antigens found on the fetal RBCs, marking them to be destroyed.
The rate of hemolysis determines whether the nature of HDN is mild, moderate, or severe.
In mild cases, the small increase in the rate of hemolysis is tolerated by the fetus. At birth and
during the newborn period, symptoms include a mild anemia and jaundice, both of which may
resolve without treatment.
In cases where there is a greater increase in the rate of hemolysis, the level of bilirubin may
still remain low during the pregnancy because of the ability of the placenta to remove bilirubin
from the fetal circulation. However, after birth the neonate's immature liver is unable to metabolize
the increased amount of bilirubin that instead accumulates in his or her blood. Within 24 hours of
birth, the level of bilirubin may rise dramatically. If levels continue to rise, bilirubin may enter the
brain to cause kernicterus, a potentially fatal condition that leaves permanent neurological damage
in the babies that survive.
An even greater rapid and prolonged destruction of RBCs leads to severe anemia in the
fetus. The liver, spleen, and other organs increase their production of RBCs to compensate for their
loss. The drive to produce RBCs causes the liver and spleen to increase in size
(hepatosplenomegaly), and liver dysfunction can occur. Immature RBCs (erythroblasts) spill into
the circulation, giving rise to the alternative name of this disease, erythroblastosisfetalis. A
complication of severe HDN is hydropsfetalis, in which the fetal tissues become swollen
(edematous). This condition is usually fatal, either in utero or soon after birth.
V. SUMMARY
The ABO blood group plays an integral role in transfusion medicine due to antibody-antigen
interaction which can be fatal the first time if the blood donated does not match with that of the
recipient. However, in order to appreciate the mechanisms by which this phenomenon happens,
there is a need to understand the structure and components of the red blood cell membrane. The
RBC membrane is well-studied and it is known that it contains proteins, carbohydrates, and lipids.
Both lipids and proteins play a structural role by providing the cell with shape and tensile strength.
Its properties such as flexibility, deformability, and elasticity are also attributed to membrane
proteins. But more than that, transmembrane proteins also serve as carriers of blood group
antigens such as A, B, and H. Carbohydrate components of the RBC membrane which are confined
exteriorly are important in cell recognition. Moreover, the terminal sugars of antigens which are
sticking out on the cell surface are made up of carbohydrates, i.e. N-acetylglucosamine for antigen A
and galactose for antigen B.
Blood typing, in particular under the ABO blood group system, is based on both genetics and
biochemistry. Basically, an individuals blood type is determined by the presence or absence of a
certain antigen and antibodies. The rule is that: a certain individual will produce antibodies for the
antigen that he/she does not possess. Thus, if this person is type A, the antibodies that he/she will
[ABO BLOOD GROUP INCOMPATIBILITY] August 12, 2013

have would be anti-B antibodies. Moreover, it is also known that the antigen A will have GalNac as
its terminal carbohydrate, antigen B will have galactose, and fucose for antigen O/H.
The formation of these antigens will start from an H precursor substance which is
composed of a galactose and N-acetylglucosamine which are connected by a (1,4) linkage. Via the
action of the fucosyltransferase encoded for by the FUT1 allele, fucose is added to the H precursor
chain via (1,2) linkage. This would now produce the H substance or antigen which serves as the
antigen present in type O RBCs and the precursor substance of antigen A and B. The H substance
gets modified via addition of either GalNac or Gal through the action of the GalNac or A
glycosyltransferase and/or Gal or B glycosyltransferase. These two enzymes are coded for by two
genes in the ABO locus, namely, A and B genes. Molecular studies have shown that the specificity of
the transferases as to which sugar to act upon is based on four amino substitutions (for A
transferase: arginine, glycine, lysine, and glycine and for B transferase: glycine, serine, methionine,
and alanine at codons 176, 235, 266, and 285). In case that a mutation in the gene coding for A and
B transferases occurs, the product will either be a weak enzyme or inactive (O allele). When the A
and B transferases are produced, they will be brought to the Golgi, all the while being glycosylated
during transit then eventually become membrane-bound in the organelles lumen. After synthesis
and glycosylation, the glycosyltransferase can now catalyze the final step of the biosynthesis of A
and B oligosaccharide antigens. A nd B glycosyltransferase will catalyze the addition of an N-
acetyl-D-galactosamine and D-galactose by an (1,3) glycosidic linkage to synthesize the A and B
structures, respectively.
ABO incompatibility involves the interaction between the antibody and the RBC-bound
antigen. This interaction can lead to agglutination (clumping) or hemolysis (rupture) of the
attacked red blood cells. Agglutination and hemolysis of the attacked red blood cells by antibodies
in the recipients plasma can lead to a sometimes fatal transfusion reaction. Agglutinated clumps of
incoming donor cells can plug small blood vessels. In addition, one of the most lethal consequences
of mismatched transfusions is acute kidney failure caused by the release of large amounts of
hemoglobin from damaged donor RBCs. If the free hemoglobin in the plasma rises above a critical
level, it will precipitate in the kidneys and block the urine-forming structures, leading to acute
kidney shutdown.
Another blood group which is commonly discussed under blood incompatibility is the Rh.
The Rh factor is of particular medical importance when an Rh negative mother develops antibodies
against the erythrocytes of an Rh positive fetus she is carrying. This condition is known as
erthroblastosis fetalis or hemolytic disease of the newborn.
[ABO BLOOD GROUP INCOMPATIBILITY] August 12, 2013

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