MY

UNIVERSITY
STEP INTO TOMORROW

Ms. Tayyaba Zulfiqar

Physiology-B
Blood Groups and Blood types

• The surfaces of erythrocytes contain a

genetically determined assortment of antigens
composed of glycoproteins and glycolipids,
called agglutinogens.
• Based on the presence or absence of various
antigens, blood is categorized into different
blood groups. Within a given blood group,
there may be two or more different blood
types.
1. ABO Blood Group
System

DR.SAADIA SAJJAD
 THE CLASSICAL OR ABO BLOOD GROUP
SYSTEM
• History
Landsteiner discovered the ABO Blood Group System
in 1900
He and his co-workers began mixing red blood
cells of one person with plasma of other and
accidentally performed the first forward and reverse
ABO groupings.
 A-B-O Blood Types
A and B Antigens—Agglutinogens

• The ABO blood group is based on two glycolipid

antigens called A and B.
• These two agglutinogens—type A and type B— are
inherited, that cause most blood transfusion
reactions.
• The locus for ABO alleles (genes) responsible for
synthesis of these antigens are on chromosome 9.
There are 3 basic genes, A, B and H. Any two of
these alleles are present to determine a blood group.
(Genotype)
 ABO blood group system
• The various classical blood group system are due to
presence of A or B antigen on the surface of RBCs.
• If only A is present blood group type is A, If only B
is present blood group type is B, If both A & B are
present blood group type is AB and if both are
absent the blood type is O.
• Corresponding to A and B antigens, anti A and anti
B antibodies are present in the plasma (produced in
response to exposure to respective antigen).
Antigens and antibodies of the ABO
blood types.
 Landsteiner’s Law
Landsteiners Rule:
If an antigen (Ag) is present on a persons
red blood cells the corresponding
antibody (Ab) will NOT be present in the
plasma, under ‘normal conditions’.
• If an agglutinogen is present in the RBCs of a
person then the corresponding agglutinin must be
absent from his plasma.
• If an agglutinogen is not present in the RBCs of a
person then the corresponding agglutinin must be
present in his plasma.
 Blood Types with Their Genotypes and Their Constituent
Agglutinogens and Agglutinins

Genotypes Blood Types Agglutinogens Agglutinins

(Phenotype)

OO O - - - Anti-A and Anti-B

OA or AA A A Anti-B

OB or BB B B Anti-A

AB AB A and B —
 Relative Frequencies of the Different Blood
Types
• O 47%
• A 41%
• B 9%
• AB 3%
 Agglutinins
• Antibodies against red cell agglutinogens are
called agglutinins.
• Most of them are IgM and IgG immunoglobulin,
produced by the bone marrow and lymph gland
cells.
• Immediately after birth, the quantity of
agglutinins in the plasma is almost zero.
• Two to 8 months after birth, an infant begins to
produce agglutinins—anti-A agglutinins when
type A agglutinogens are not present in the cells.
• A maximum titer is usually reached at 8 to 10
years of age, and this gradually declines
 Agglutination Process In Transfusion
Reactions

• When bloods are mismatched so that anti-A or anti-

B plasma agglutinins are mixed with red blood cells
that contain A or B agglutinogens, respectively, the
red cells agglutinate as a result of the agglutinins’
attaching themselves to the red blood cells. Because
the agglutinins have two binding sites (IgG type) or
10 binding sites (IgM type), a single agglutinin can
attach to two or more red blood cells at the same
time, thereby causing the cells to be bound together
by the agglutinin. This causes the cells to clump,
which is the process of “agglutination.”
• Then these clumps plug small blood vessels
throughout the circulatory system.
• During hours to days, either physical distortion of
the cells or attack by phagocytic white blood cells
destroys the membranes of the agglutinated cells,
releasing hemoglobin into the plasma, which is
called hemolysis of the red blood cells.
 Acute Hemolysis Occurs in Some Transfusion
Reactions
1- Immediate intravascular hemolysis Sometimes,
when recipient and donor bloods are mismatched,
immediate hemolysis of red cells occurs in the
circulating blood. In this case, the antibodies (IgM-
hemolysins) cause lysis of the red blood cells by
activating the complement system, which releases
proteolytic enzymes (the lytic complex) that rupture
the cell membranes.
2- Agglutination and delayed hemolysis, due to high
titer of antibodies for lysis called hemolysins.
Normal blood smear under microscope
Agglutination under microscope
 Blood Typing

• Blood group typing and matching

• Cross matching
 Blood Group Typing
Before giving a transfusion to a person, it is necessary to determine
the blood type of the recipient's blood and the blood type of the
donor blood so that the bloods can be appropriately matched.
The red blood cells are first separated from the plasma and diluted
with saline.
 One portion is then mixed with anti-A agglutinin and another
portion with anti-B agglutinin.
 After several minutes, the mixtures are observed under a
microscope.
 If the red blood cells have become clumped-that is, "agglutinated"-
one knows that an antibody-antigen reaction has resulted.
 Blood Typing, Showing Agglutination of Cells of the
Different Blood Types with Anti-A or Anti-B Agglutinins in the sera

Red Blood Cell Types Sera

Anti-A Anti-B
• O - -
• A + -
• B - +
• AB + +
 Cross-matching
• Cross-matching blood in transfusion medicine, refers to
the test that is performed prior to a blood transfusion in
order to determine if the donor's blood is compatible
with the blood of an intended recipient.

• Compatibility is determined through matching of different

blood group systems, the most important of which are the
ABO and Rh system.

• And/or by directly testing for the presence of antibodies

against a sample of donor tissues or blood.
• A test for incompatibility between donor and
recipient blood, carried out prior to transfusion to
avoid potentially lethal haemolytic reactions between
the donor's red blood cells and antibodies in the
recipient's plasma, or the reverse.
• Performed by mixing;
– a sample of red blood cells of the donor with plasma of the
recipient (major crossmatch)
– the red blood cells of the recipient with the plasma of the
donor (minor crossmatch).
• Incompatibility is indicated by clumping of red blood
cells and contraindicates use of the donor's blood.
=-
 CLINICAL SIGNIFICANCE
• BLOOD TRANSFUSION
• CERTAIN BLOOD DISEASES
• PATERNITY TEST
• FORENSIC MEDICINE
2. Rh blood grouping
 HISTORY

• The second most important blood group in humans is the

Rhesus (Rh) system. Landsteiner and his coworkers
discovered the Rh blood group in 1940.
• They found that when they injected rabbits with Rhesus
monkey blood; the rabbits produced antibodies against the
Rhesus red cells and serum of rabbit agglutinated Rhesus
monkey blood.
• Conclusion: A same antigen is found on RBCs of Rh
monkey and Humans.
 Rh- Blood Grouping
• The blood groups formed in it are
Rh Positive and Rh negative
• The bases of blood grouping is the presence or
absence of D antigen on the surface of RBC.
• If D antigen is present on the surface of red blood cell
the blood group is positive.
• If D antigen is not present on the surface of RBC the
blood group is negative.
 D antigen
• The type D antigen is widely prevalent in the
population and considerably most antigenic than the
other Rh antigens.

• Anyone who has this type of antigen is said to be

Rh positive, whereas a person who does not have
type D antigen is said to be Rh negative.
D-Antigen.
It comprises an integral protein of RBC
membrane with a phospholipid molecules .
.
 Genetics
Genotype Phenotype
DD D Rh positive
Dd D Rh positive
dd d Rh negative
 Genetics
• Rh Genetics: The genes that control the Rh
system are autosomal dominant located on the
short arm of chromosome 1.
• ABO & RH genes are not linked
• ABO & Rh(D) type are inherited independently
For example:
An A Rh(D) positive mother
and a B Rh(D) positive father
could have an O Rh(D) negative child
O positive and negative RBC
 Rh Immune Response-Rh antibodies
Formation of Anti-Rh Agglutinins
• In the O-A-B system, the plasma agglutinins
responsible for causing transfusion reactions
develop spontaneously, whereas in the Rh system,
Rh-Antibodies do not occur naturally .

• The person must first be massively exposed to an

Rh antigen, such as by transfusion of blood
containing the Rh antigen before enough
agglutinins to cause a significant transfusion
reaction.
– Rh-immune response.
– If an Rh-negative person is given for the first time a
transfusion of Rh+ve blood-------------- Anti-Rh
agglutinins develop slowly and maximum development
occur within 2-4 months.
– No immediate reaction occur. Delayed transfusion
reaction occur first mild after 2-4 weeks.
– With multiple exposure to Rh-factor, Rh-ve person
becomes sensitized to Rh-factor. The second exposure
produces an enhanced immunogenic response and
severe agglutination reaction like ABO mismatched
transfusion reaction.
– may cause death.
– Rh D-positive patients do not react to D
negative blood
 Erythroblastosis Fetalis (“Hemolytic Disease
of the Newborn”)

• Erythroblastosis fetalis is a disease of the fetus and newborn

child characterized by agglutination and phagocytosis of the
fetus’s red blood cells.
• IgG will cross the placenta enters baby’s circulation and
causes destruction of the fetal red blood cells.
• The mother is Rh negative and the father Rh positive.
The baby has inherited the Rh-positive antigen from
the father, and the mother develops anti-Rh
agglutinins IgG from exposure to the fetus’s Rh
antigen.

• In turn, the mother’s agglutinins diffuse through the

placenta into the fetus and cause red blood cell
agglutination.
 Incidence of the Disease
• An Rh-negative mother having her first Rh-
positive child usually does not develop sufficient
anti-Rh agglutinins to cause any harm.
• However, about 3 per cent of second Rh-positive
babies exhibit some signs of erythroblastosis
fetalis.
• About 10 per cent of third babies exhibit the
disease; and the incidence rises progressively
with subsequent pregnancies.
 Rh Factor
and
Pregnancy

mother w/Rh- baby– no problem

mother w/Rh+ baby– problem
mother w/Rh- father– no problem
mother w/Rh- baby-- no problem
Effect of the Mother’s Antibodies on the Fetus-signs and symptoms of
erythroblastosis fetalis

1- Jaundice
• Maternal antibodies cause agglutination of the
fetus’s blood. The agglutinated red blood cells
subsequently hemolyze, releasing hemoglobin into the
blood.
• The fetus’s macrophages then convert the hemoglobin
into bilirubin, which causes the baby’s skin to become
yellow (jaundiced).
• The antibodies can also attack and damage other cells of
the body.
Jaundice
Treatment of jaundice
2- Anemia
• The erythroblastotic newborn baby is anemic at
birth, and the anti-Rh agglutinins from the mother
usually circulate in the infant’s blood for another 1
to 2 months after birth, destroying more and more
red blood cells.
• Severe anemia of erythroblastosis fetalis is usually
the cause of death
3- Hepatosplenomegaly
The hematopoietic tissues of the infant attempt to
replace the hemolyzed red blood cells. The liver
and spleen become greatly enlarged and produce
red blood cells in the same manner that they
normally do during the middle of gestation.

• Because of the rapid production of red cells,

many early forms of red blood cells, including
many nucleated blastic forms, passed from the
baby’s bone marrow into the circulatory system.
Hepatosplenomegaly
4- Kernicterus
• Many children who barely survive the anemia
exhibit permanent mental impairment or
damage to motor areas of the brain because of
precipitation of bilirubin in the neuronal cells,
causing destruction of many, a condition called
kernicterus.
Clinical Picture of Erythroblastosis
 Treatment of the Erythroblastotic Neonate
1- Replace the neonate’s blood with Rh-negative blood
(EXCHANGE TRANSFUSION)
• About 400 milliliters of Rh-negative blood is infused over a
period of 1.5 or more hours while the neonate’s own Rh-positive
blood is being removed. This procedure may be repeated several
times during the first few weeks of life, mainly to keep the
bilirubin level low and thereby prevent kernicterus.
• By the time these transfused Rh-negative cells are replaced with
the infant’s own Rh-positive cells, a process that requires 6 or
more weeks, the anti- Rh agglutinins that had come from the
mother will have been destroyed.
2- Phototherapy-blue light
3- Drugs activate liver enzyme glucuronyle transferase bilirubin-
soluble bilirubin--urine
 Benefits of Exchange Transfusion

1. Removes antibody coated Rh positive RBCs: Not all but

many.
2. Removal of maternal antibody. Remember this antibody
is passively transferred so the more we remove the
better.
3. Removal of bilirubin: reduce bilirubin in newborn.
4. Replacement of Rh negative RBCs: Are not attacked by
antibody IgG. Anemia is treated.
 Prevention of Erythroblastosis Fetalis in mother

1- Rh immunoglobulin, an anti-D antibody that is

administered to the
• expectant mother starting at 28 to 30 weeks of
gestation.
• Rh-negative women who delivers (within 72 hrs after
delivery) Rh-positive babies--- to prevent
sensitization of the mothers to the D antigen.
This greatly reduces the risk of developing large
amounts of D antibodies during the second pregnancy.
2- Plasmapheresis of mother: Rh antibodies from
maternal blood are removed
 Anti-D injection
The injected antibody causes
1- rapid destruction of Rh positive red cells of
fetal origin with D antigen in maternal
circulation.
2- inhibit antigen-induced B lymphocyte
antibody production in the expectant mother.
Must be given again after delivery of next
Blood transfusions
 Tests done for transfusion of blood

1- ABO blood typing and Rh factor

2- Cross matching
3- Tests for infective agents
A- Blood smear for malarial parasites
B- Serological tests:
• Hepatitis B surface antigen
• Hepatitis C antigen
• Human immune deficiency syndrome (AIDS)
 CHANGES IN STORED BLOOD
1-Fall in 2-3 biphosphoglyceric acid

2-Fall in ATP

3-Decreased activity of Na K Pump—hyperkalemia& increased

osmotic fragility of RBCs

4-Fall in pH due to glycolysis in RBCs.

5-Disappearence of platelets (in 24 hrs)and granulocytes

6-Destruction of clotting factors V and VIII

 TRANSFUSION REACTION
• Immune system can tell its own blood cells
from those of another person. If you receive
blood that is not compatible with your blood,
your body produces antibodies to destroy the
donor's blood cells. This process causes the
transfusion reaction
 What Causes the Transfusion Reaction?

 Antibodies in the recipient’s blood can attack the donor

blood if the two are not compatible.

 If recipient’s immune system attacks the red blood

cells of donor  HEMOLYTIC REACTION.

 If recipient’s immune system attacks the white blood

cells of the donor blood  FEBRILE REACTION
Transfusion Reactions Resulting
from Matched Blood Types
IMMEDIATE REACTIONS
• Circulatory overload: 2ml/kg/hour
• Air embolism
• Hypothermia
• Febrile reactions - Antibodies directed against donor
leucocytes and HLA antigen. Headache, nausea,
vomiting, chill and fever.
• Hyperkalemia
• Hypocalcemia
• Transmission of infection,
• Hemosidrosis (deferoxamin---thalassemia patients)
LONG TERM COMPLICATIONS
Infections -----------AIDS, Hepatitis etc
Transfusion Reactions Resulting
from Mismatched Blood Types
• If donor blood of one blood type  transfused into a
recipient of another blood type  transfusion reaction
occurs red blood cells of the donor blood are agglutinated.

• Chills
• Urticaria
• Pain in back
• Tightness in the chest
• Anxiety
• Restlessness
• Bloody urine
• Fainting or dizziness
• Fever
• Flank pain
• Flushing of the skin
All transfusion reactions eventually cause:

• Immediate hemolysis resulting from hemolysins (IgM)

later hemolysis resulting from phagocytosis of
agglutinated cells.

The hemoglobin released from the red cells 

converted by the phagocytes into bilirubin
excreted in the bile by the liver,

• The conc of bilirubin in the body fluids rises high

enough to cause jaundice—that is, the person’s
internal tissues and skin become colored with
yellow bile pigment
 Acute Kidney Shutdown After
Transfusion Reactions
• One of the most lethal effects of
transfusion reactions is kidney failure 
begin within a few minutes to few hours 
continue until the person dies of renal
failure.
• The kidney shutdown seems to result from three
causes:

1. Antigen-antibody reaction (mismatched transfusion) 

releases toxic substances from the hemolyzing blood

cause powerful renal vasoconstriction.

2. Loss of circulating red cells in the recipient-----
production of toxic substances from the hemolyzed cells
and from the immune reaction

circulatory shock.
• The arterial B.P falls very low---renal blood flow and
urine output decreases.
3. If the total amount of free hemoglobin
released into the circulating blood is greater than
“haptoglobin”(PROTEIN from Liver)

much of the excess leaks through the glomerular

membranes into the kidney tubules.
• If this amount is still slight  reabsorbed through the tubular
epithelium into the blood  cause no harm;
• If it is great, only a small % is reabsorbed.
• Water continues to be reabsorbed causing the tubular Hb
conc to rise so high Hb precipitates and blocks many of
the kidney tubules.

Renal vasoconstriction, circulatory shock, and renal tubular

blockage together cause acute renal shutdown.

• If the shutdown is complete  fails to resolve, the patient

dies within a week -- 12 days unless treated with an
artificial kidney or dialysis.
• Another transfusion reaction type is the transfusion
related acute lung injury (TRALI). This reaction
occurs when donor plasma contains antibodies that
cause damage to the cells of the lungs.

• This lung damage results in fluid accumulating in the

lungs and can severely limit the ability of the lungs to
supply oxygen to the body. This reaction usually
occurs within six hours of receiving blood.
 Tissue transplantation

• Different antigens of RBC are present on the

other cells of body and each tissue has its own
additional complement of antigen.

• Foreign body cells transplanted anywhere in

the body of a recipient can produce immune
reaction.
• Autograft
Transplant of a tissue or whole organ from one part of the
same animal to another part.
• Isograft
From one identical twin to another.
• Allograft
From one human being to another or from one animal to
another animal of the same species.

• Xenograft
From a lower animal to a human being and from an animal
of one species to one of another species.
• Transplantation of cellular tissues
 In case of Autograft and Isograft, cells in the
transplant contain virtually the same type of
antigens as in the tissue cells of recipient and
continue to live normally if adequate blood
supply is provided.
 In case of Xenograft, Immune reactions always
occur leading to the death of the cells within 1
day - 5 weeks after transplantation unless some
therapy is used to prevent immune reactions.
 Allograft may be experimental or therapeutic.
• Survival of graft depends upon;
With proper matching of tissues b/w persons,
many kidney allografts have been successful for
at least 5 to 15 years

• Allografts of liver & heart transplants for 1 to

15 years
Attempts to overcome immune
reactions in transplanted tissue
 Tissue typing-Human Leucocyte
Antigen

• Matching of HLA antigen between donor and

recipient.
• Development of significant immunity against any
one of these antigen can cause graft rejection.
• Trasplants between identical twins are almost
never rejected.
Methods to prevent immune reactions

• HLA antigen
• Antigen responsible for causing graft rejection. Present on
the white blood cells and other tissues cells.
• Six of these antigens are present on the tissue cell membranes.
• Previous blood transfusion of donor to
recipient.
• Immunosuppressant therapy
 Prevention of graft rejection by
immunosuppressive therapy
1.Glucocorticoid therapy
• Isolated from adrenal cortex
• Suppress the growth of all lymphoid tissue.
• Decreases the formation of antibodies and T-cells
2.Therapy by Azathioprene
These drugs can block the formation of T-lymphocytes and
antibodies.
3. Cyclosporine
• One of the most valuable drug.
• Which have specific inhibitory effect on the helper T-cells.
• Block the T-cell rejection reactions.