15 Blood groups and blood transfusion Learning objectives #“ To understand the inheritance and significance of the ABO system # To understand the nature and significance of the Rh blood group system including RhD « To know the principles involved in the selection of donor blood of suitable ABO and Rh groups for a recipient, and the principles of the cross-match, including the antiglobulin test # To understand the hazards of blood transfusion (incompatible blood, allergic reactions, bacterial infection, citrate toxicity and transmission of disease) and of massive blood transfusion # To know how to investigate a patient suspected of receiving an incompatible transfusion # To know the basis of blood fractionation and the rationale for the use of specific blood products, including red cells, platelet concentrates, fresh-frozen plasma (FFP) and cryoprecipitate # To know the pathogenesis, clinical features and the principles underlying the treatment and prevention of haemolytic disease of the newborn (HDN) due to anti-D “ To know the principles of antenatal care concerned withpredicting both the presence and severity of HDN due to anti-D To know the differences between HDN due to anti-D and that due to anti-A and anti-B Blood groups One of the main problems in the transfusion of blood is the avoidance of immunological reactions resulting from the differences between donor and recipient red cells. Blood groups have arisen because mutations have occurred in the genes controlling the surface constituents of the red cells. These alterations in the surface structures have not usually affected the function of the red cell, but when the red cells of a donor are transfused into a recipient who lacks these antigens, they may induce an immunological response. There are 30 major blood group systems (e.g. the ABO group, Rh group), together giving hundreds of possible red cell phenotypes. Although all the systems have given rise to transfusion difficulties (and in fact this is how they have been recognized), this chapter focuses on the two of greatest importance, the ABO and Rh systems. ABO system Practically all red cells have the H antigen, a carbohydrate group attached mainly to proteins on the cell membrane. This antigen is the basis for the ABO blood groups. The ABO locus is encoded on chromosome 9q, where one of three possible alleles may be found. The A allele encodes for a glycosyltransferase, whichmodifies the H antigen by adding N-acetylgalactosamine to it (thus forming the A antigen). The B allele of the ABO locus encodes an alternative glycosyltransferase that links galactose to the H antigen (thus converting it to the B antigen). The O allele, by contrast, encodes no functional enzyme at all, such that the H antigen remains unmodified. Since each patient inherits an allele of the ABO locus on each chromosome 9Q, there are six possible genotypes, namely AA, AO, BB, BO, AB and OO, and four possible phenotypes: A, AB, B and O. The frequency of these ABO group phenotypes differs in different populations; in the UK it is approximately group O, 46%; A, 42%; B, 9%; and AB, 3%. Patients with group O blood (genotype O/O) will have only unmodified H antigen on their red cells, but will have circulating IgM antibodies to the A and B antigens. These antibodies exist even if the patient has never been exposed to blood of another group; they are thought to arise due to cross-reactivity between the ABO antigens and commonly seen epitopes in bacteria and/or food products, since they are produced universally in the first year of life. Transfusion of blood of group A or B to patients who have group O blood would therefore result in intravascular haemolysis of the transfused cells. Transfusion of group B blood to a patient of group A would have a similar effect; but group O blood, featuring only the universal H- antigen, should not produce a haemolytic response in patients of any ABO group. As such, it has been termed the ‘universal donor’ group. While the ‘universal donor’ label is true to some extent, it is also subject to caveats: group O blood may not contain an ABO antigen that will cause haemolysis, but in rare group O donors there may be the presence of high-titre antibodies against groups A and B, which themselves mightinduce passive haemolysis of the recipient's own red cells. This must be borne in mind when determining safe donor blood groups for specific recipients (see Table 15.1). Table 15.1 Appropriate blood groups for transfusion. Recipient blood group Donor red cells Donor plasma A AorO Aor AB AB ABorO AB only B BorO BorAB Oo Oonly ABorO Note: This table does not take account of other blood group antigens, and assumes that high-titre/atypical antibodies have been excluded from the donor unit. It is the naturally occurring presence of anti-A and/or anti-B antibodies that makes ABO typing so critical to blood transfusion practice. Haemolytic reactions will occur immediately in the event of incompatible transfusion, and may be fatal (see complications of transfusion, below). Rh system The Rh system is also of great importance in transfusion medicine. It is frequently responsible for immunizing patients without the relevant antigen, and can cause problems with both transfusion and pregnancy. The inheritance of the Rh blood group system is slightly more complex than that of the ABO system. Two separate genetic loci on chromosome 1 encode for a total of five antigens. The first locus, RHD, has alleles D or d; D encodes a transmembraneprotein featuring the D antigen, while the allele d encodes a variant that does not bear this antigen. RHCE is an adjacent locus that encodes a transmembrane ion channel bearing the antigens C (or its variant, c) and E (or its variant, e). Alleles at this locus may be described as CE, Ce, cE and ce, denoting the set of antigens they encode. A complete description of the Rh haplotype for a patient will include alleles at both RHD and RHCE loci — for example, if a patient's full Rh genotype is DCe/DCE, they will have the RhD allele on both copies of chromosome 1, but Ce and CE alleles at the adjacent RHCE locus. They will therefore have the antigens D, C, E and e on their red cells. The commonest haplotypes are DCe, dce and DcE. The proximity of the two loci to each other means that meiotic crossing over is not seen, and the two loci are always inherited as a unit. The D antigen is the most clinically important of the Rh group antigens, due to its high immunogenicity. An RhD-negative person (e.g. dce/dce) has over a 50% chance of developing anti-D antibodies after the transfusion of one unit of RnD-positive blood: it is therefore important that RhD-negative patients receive RhD- negative blood. Exposure to the ‘c' antigen will provoke anti-c production in only 2% of people lacking this antigen, such that the risk of immunization after giving blood of type dce/dce to an individual who lacks the ‘c' antigen (for instance genotype DCe/DCe) is very small. Note that unlike the ABO system, Rh antibodies are not naturally occurring; they must be raised by exposure of an antigen-negative individual to the appropriate antigen, either through transfusion of incompatible blood or through pregnancy. After the exposure, IgG antibodies come to predominate, and haemolysis is generallyextravascular. Other blood group systems Other blood group antibodies, which are sometimes a problem during blood transfusion, include the following: anti-K (Kell system), anti-Fy* (Duffy system), anti-Jk® (Kidd system) and anti-S (part of the MNSs blood group system). These antigens are relatively poorly immunogenic. Their potency in stimulating antibody production is 10-1000 times less than that of RhD. Consequently, these antigens need not be routinely assessed prior to transfusion, although more care is required in patients who are on a chronic transfusion programme (e.g. in thalassaemia major), as the lifetime likelihood of immunization by these antigens is higher in heavily transfused patients. Compatibility The purpose of cross-matching blood before transfusion is to ensure that there is no antibody present in the recipient's plasma that will react with any antigen on the donor's cells. The basic technique for detecting such antibodies relies on their ability to agglutinate red cells that bear the appropriate antigen. Unfortunately, many red cell antibodies are unable to bring about agglutination on their own; many require additional proteolytic treatment of the red cells or the use of an antiglobulin reagent (see below). The ability of antibodies to agglutinate untreated red cells depends partly on the molecular structure of the antibody. Pentameric IgM antibodies, which readily span adjacent red cells, can bring about agglutination without the addition of any