History ABO System Phenotype ABO System Genotype Rh system Other Blood Groups Blood Group detection and incompatibility

1. History ABO System Phenotype ABO System Genotype Rh system Other Blood Groups Blood Group detection and incompatibility Hereditary Newborn Disease HDN Blood Transfusion

2. Karl Landsteiner (1868-1943) Discovered ABO blood groups, 1900 Nobel Prize, 1930

4. Red Blood Cell Membrane Components

5. Biological Functions of Blood group Systems Functional Diversity Transporters/Channels Transporting Water-Soluble molecules/compounds Rh, Colton, Diago, Kx, Kidd Receptors Biological Duffy, Knops, Indian Microbial MNS, P, Lewis, Duffy, Cromer Adhesion Molecules Leuthran, Xg, L-W, Indian Role in Complement Pathway Chido/Rodgers, Cromer, Knops Enzymes ABO, P, Lewis, H Structural Proteins Maintain Shape MNS, Diago, Gerbich

6. Type .2 Type .1

7. Type 2 Precursor Chain

8. Formation of H Antigen

10. ABO Antigen Genetics LOCATION The presence or absence of the ABH antigens on the red blood cell membrane is controlled by the H gene The presence or absence of the ABH antigens in secretions is indirectly controlled by the Se genes.

14. ABO Subgroups ABO subgroups differ in the amount of antigen present on the red blood cell membrane, specifically, they have less - it is quantitative. Subgroups are the results of less effective enzymes! Not as efficient at converting H antigens to A or B antigens so fewer are present on the rbc. Subgroups of A are more common than Subgroups of B.

15. Subgroups of A The two principle subgroups of A are: A1 and A2 Both react strongly with reagent anti-A. To distinguish A1 from A2 red blood cells test with plant lectin: Dolichos biflorus Approximately 80% of Group A and Group AB persons red cells are agglutinated by Dolichos biflorus and can be designated A1 and A1B. The remaining 20% are A2 and A2B.

16. ABO Subgroups A2 Phenotype A2 persons produce anti-A1 allo-antibodies (%1-8) A2B persons produce anit-A1 allo antibodies (%22-35) Allo-Anti-A1 can cause ABO Discrepancies (How?) and incompatibility in crossmatching. It is not considered clinically significant if it does not react at 37oC.

17. Number of A antigen A1=800000 A2=250000 A3=35000 Ax=4800 Aend=3500 Am=700

19. Amount of H Antigen according to ABO Blood Group Blood Group O people have red blood cells rich in H antigen. Why?

20. Formation Of ABO Antigens In Secretions

21. Bombay (Oh) Phenotype Results from the inheritance of hh genotype Red blood cells lack H, A and B antigens First discovered in Bombay, India Red cells are NOT agglutinated with anti-A, Anti-B or Anti-H (Ulex europaeus - lectin) Serum has strong anti-A, Anti-B and anti-H so they agglutinate ALL ABO blood groups ParaBombay (Ah) Phenotype

24. ABO Blood Grouping Reagents Forward Grouping Reagent Anti-A and Anti-B IgM class Monoclonal antibody reagent Reverse Grouping Reagent A1 and B cells (3-5% suspension) Routine tests on donors and patients must include both the forward and reverse grouping

26. Frequency of ABO Blood Groups Group O 47% Group A 42% Group B 8% Group AB 3%

27. The Rh Blood Group System Described by Landsteiner in 1940 Antibodies produced as a result of pregnancy or transfusion Immune antibodies - IgG Can cause haemolytic disease of the newborn and transfusion reactions

29. Inheritance of Rh genes Fisher-Race theory of inheritance Rh antigens produced by three closely linked alleles C or c, D or d, E or e. (these alleles are located in 2 locus RHD & RHCE We inherit these genes in groups of three from each parent A common combination is CDe/cde Other individuals have combinations of cDE, cde, Cde, cdE

31. Rh System D Positive are either D/D or D/d D Negative are d/d 85% of the population are D Positive 15% of the population are D Negative Other Rh antigens discovered and named C,c,E and e Weak D phenotype Rhnull

32. Weak D Phenotype (Du) The weak D phenotype is thought to occur by one of three mechanisms: (a) inheritance of an RHD gene encoding for a weakened expression of D (DCe or DcE) (b) interaction of the D gene with other genes (Dce/Ce) (c) inheritance of an RHD gene missing some epitopes. (lack of part of D)

34. Hemolytic Disease of the Newborn (HDN) (Erythroblastosis fetalis)

35. Background A French midwife was the first to report hemolytic disease of the newborn (HDN) in 1609. In 1932, Diamond and colleagues described the relationship of fetal hydrops, jaundice, anemia, and erythroblasts in the circulation, a condition later called erythroblastosis fetalis. Levine later determined the cause after Landsteiner and Weiner discovered the Rh blood group system in 1940. In 1953, Chown subsequently confirmed the pathogenesis of Rh alloimmunization to be the result of passage of Rh-positive fetal red blood cells after transplacental hemorrhage into maternal circulation that lacked this antigen.

37. Rh Incompatibility Expression is limited to RBCs Rh positive: 45% are homozygous and 55% are heterozygous Rh incompatibility is a condition which develops when there is a difference in Rh blood type between that of the pregnant mother (Rh negative) and that of the fetus (Rh positive). After the initial exposure to a foreign antigen, the maternal immune system produces antibodies of the immunoglobulin M (IgM) isotype that do not cross the placenta, and later it produces antibodies of the IgG isotype that traverse the placental barrier.

38. ABO incompatibility ABO incompatibility is limited to type O mothers with fetuses who have type A or B blood in type O mothers, the antibodies are predominantly IgM in nature Because A and B antigens are widely expressed in a variety of tissues besides RBCs, only small portion of antibodies crossing the placenta is available to bind to fetal RBCs. In addition, fetal RBCs appear to have less surface expression of A or B antigen, resulting in few reactive sites�hence the low incidence of significant hemolysis in affected neonates.

39. Causes

40. BEFORE BIRTH Antibodies cause destruction of the red cells Anemia heart failure fetal death

42. AFTER BIRTH Antibodies cause destruction of the red cells Anemia Heart failure Erythroblastosis General edema Called hydrops fetalis and erythroblastosis fetalis Build up of billirubin Kernicterus Severe retardation

45. ???? ?????: (1) interruption of normal neurotransmission (inhibits phosphorylation of enzymes critical in release of neurotransmitters) (2) mitochondrial dysfunction (3) cellular and intracellular membrane impairment (billirubin acid affects membrane ion channels and precipitates on phospholipid membranes of mitochondria (4) interference with enzyme activity (binds to specific billirubin receptor sites on enzymes).

46. PREVENTION Before birth Work up mother for risk and evaluation of complications After birth Rh immune globulin - IgG anti-D given to prevent primary immunization

47. Before birth workup Identify women at risk ABO - Rh -(Du) - Antibody screen based on results continue testing (Handout) IgM antibodies are insignificant IgG antibodies - titer - freeze and store - retiter with a second sample - looking for a 1:32 rise or change in titer

48. Before birth workup titer identifies mothers who need amniocentesis titer every 4 week until 24th week - then every 2 weeks amniocentesis is performed after 21st week on high titer - high mortality

49. Amniocentesis Analyze pigment that indicates increased hemolysis Measure OD from 350 - 700 and plot as a function of wavelength Draw straight line and obtain difference in OD at 450

51. Intrauterine transfusions Bilirubin Hb is below 11 g/dL Usually O and compatible with mother�s antibody CMV, Hb S, and leukocyte negative immediate correction of anemia and resolution of fetal hydrops, reduced rate of hemolysis and subsequent hyperinsulinemia, and acceleration of fetal growth for nonhydropic fetuses who often are growth retarded

52. After birth Rh Immune Globulin Give antenatal 28 -32 weeks also after amniocentesis - IUT - abortion - ectopic pregnancy - miscarriage Each vial contains 300 ugm and will prevent sensitization by 15 ml RBC or 30 ml whole blood

53. Post Natal Laboratory Studies Mother ABO - Rh - Du (micro) - Antibody screen - Antibody identification if necessary Baby ABO - Rh - Du - DAT for IgG antibodies - elute DAT positive and identify antibody CBC Imaging studies

54. TREATMENT Exchange transfusion Phototherapy

56. The following are requirements for exchange transfusion : Severe anemia (Hb <10 g/dL) Rate of bilirubin rises more than 0.5 mg/dL/hr despite optimal phototherapy Hyperbilirubinemia DAT

57. Exchange Transfusions Objectives Decrease serum billirubin and prevent kernicterus Provide compatible red cells to provide oxygen carrying capacity Decrease amount of incompatible antibody Remove fetal antibody coated red cells

58. Potential complications of exchange transfusion include the following: Cardiac - Arrhythmia, volume overload, congestive failure, and arrest Hematologic - Overheparinization, neutropenia, thrombocytopenia, and graft versus host disease Infectious - Bacterial, viral (CMV, HIV, hepatitis), and malarial Metabolic - Acidosis, hypocalcemia, hypoglycemia, hyperkalemia, and hypernatremia Vascular - Embolization, thrombosis, necrotizing enterocolitis, and perforation of umbilical vessel Systemic - Hypothermia

59. Blood banking & transfusion

62. HISTORY

63. James Blundell

68. Donors must be:� 17 years of age in good health � weigh at least 40 kg pass a physical and health history examination prior to donation

69. Who should not donate blood? Anyone who has ever used illegal intravenous (IV) drugs� � Hemophiliacs� Anyone with a positive test for HIV� Anyone who has had hepatitis since his or her eleventh birthday�

71. Transfusion Autologus transfusion : it refers to those transfusions in which the blood donor & transfusion recipient are the same. Allogeneic transfusion: It refers to blood transfused to someone other than the donor.

72. Autologous transfusion Preoperative donation Blood dilution Intraoperative blood salvage Post operative blood collection

73. Experienced mild side effects by a donor Stinging during insertion the needle Upset stomach Dizziness A small amount of bruising

75. No Whole blood BUT blood components

79. Red blood cells For chronic anemia resulting from disorders For acute blood loss resulting from trauma or surgery Shelf life of RBC = 42 days Frozen for up to 10 years

80. Plasma Contain albumin � fibrinogen � globulins Usually separated into specific products. Fresh frozen plasma stored for 1 � 7 years. Cryoprecipated AHF, rich in certain clotting factors.( factor VIII , fibrinogen, von Willbrand factor, factor XIII AHF prevent or control bleeding in individuals with hemophilia and von Willbrand�s disease.

81. Platelets Prevent massive blood loss resulting from trauma. Maybe obtained from donor by a process known as APHERESIS. Stored at room temperature for up to 5 days. used to treat thrombocytopenia.

82. White blood cells Transfused within 24 h after collection. Used for infections that are unresponsive to antibiotic therapy. The effectiveness is still being investigated.

85. Compatibility testing ABO-Rh blood typing Antibody screening Cross-matching Cross-matching is performed to determine if the patient has antibodies that react with the donor�s cells

86. The risk of infection from transfusion About 1 in 600,000 units for hepatitis B About 1 in 2 million units for HIV and hepatitis C

87. The greater concern is an ABO incompatibility and transfusion reactions.ABO incompatibility occurs when blood samples from two people with different ABO blood types are mixed.

88. Several types of transfusion reactions like allergic and febrile(characterized by fever) Treatment will depend on type of reaction and patient�s symptoms.

89. Fully automated grouping and antibody screening