Olle Berséus
MD, PhD, Ass.professor
Department for Transfusion Medicine
Örebro University Hospital
Sweden
Medical advisor in transfusion medicine
to the Swedish Armed Forces.
Safety of
low titer group O
Whole blood
Olle Berséus
2016 RDCR Symposium
June 20-22
Bergen
References of importance to the presentation can be found in
Transfusion 2013; 53: 114S-123S
Why group O whole blood ?
The transfusion of ABO-incompatible
red cells constitutes a
MAJOR INCOMPATIBILITY
The transfused cells may undergo a rapid
haemolysis and cause a severe (even fatal)
transfusion reaction.
This hazard is avoided by the use of
group O red cells
Berséus 2016
Blood group O plasma contains free
antibodies against A and B red cells
As the amount of plasma is limited in
the transfusion unit the severity of an
eventual transfusion reaction is more
moderate and very seldom fatal.
The transfusion of incompatible
plasma constitutes a
MINOR INCOMPATIBILITY
Berséus 2016
Adverse patient effects from transfusion
of ABO-incompatible plasma (1)
Immediate
effects
• 
• 
• 
• 
• 
• 
Formation of A-/B-immuncomplexes
Agglutination and hemolysis of the red cells
Activating mononuclear cytotoxic cells
Formation and release of acute phase
reactants (complement factors, cytokines)
Activation and aggregation of platelets
Activation of the coagulation system (DIC?)
Delayed effects
Late effects
Berséus 2016
Adverse patient effects from transfusion
of ABO-incompatible plasma (2)
Delayed
effects
within 2h
(up to 4 days)
• 
• 
• 
Febrile reactions
• 
• 
• 
Persistent thrombocytopenia
• 
Immunomodulation in the recipient
Increased osmotic fragility of the red cells
Persistent heme induced activation of
the inflammatory respone
Coagulopathies and increased fibrinolysis
Part in the pathogenesis of transfusion
related acute lung injury (TRALI)
Berséus 2016
Adverse patient effects from transfusion
of ABO-incompatible plasma (3)
Late
effects
(>50 years)
• 
Possibility of an increased incidence of
persistent microchimerism
Donor white cells can be found in the
circulation of the recipient in about
50% of transfused patients with a
major trauma and massive bleeding
No effect of leucocyte reduction
of the transfused blood unit
Utter GH. Transfusion 2012; 52: 926-8
Berséus 2016
Reports of hemolytic reactions by transfusion
of group O blood to non-group O recipients
1911 Ottenberg proposes group O blood donors as
”universal donors”
1945-1986 15 non military publications with case reports
of severe hemolytic reactions after a transfusion of group
O blood or plasma to non-group O recipients has been
found and reviewed.
Antibody titres varied from 16 to >8000 (IgM / IgG)
Volume of infused plasma varied from 25 mL to 800 mL
All patients recovered except for 2 fatalities
Berséus 2016
Military experiences of the transfusion of
group O blood to non-group O recipients
World War II
•  Group O blood used universally in US armed forces
•  In 1944 reports of haemolytic reactions in blood
units with high titres anti-A/B.
There after only ”low titre”* group O blood units were
being sent to the military hospitals.
•  No further reports of haemolytic reactions reported
within spite of more than 500.000 transfusions
* Anti- A and or anti-B saline titre < 250
Berséus 2013
Military experiences of the transfusion of
group O blood to non-group O recipients
Korean War
Only ”low titre” group O blood used.
During 1952 >60000 transfusions.
No hemolytic reactions reported.
Severe IHTR after return to recipient´s blood group.
After massive transfusion continue group O blood.
Berséus 2013
Military experiences of the transfusion of
group O blood to non-group O recipients
Vietnam war
”Low titre” group O blood used universally.
From 1965 all blood groups used at major military
hospitals, group O blood in the periphery
1967-69 >230000 transfusions
Only 1 report of an IHTR from transfusion with
group O blood
(A high titre unit by mistake released from hospital
the patient had uneventful recovery)
Berséus 2013
Platelet transfusions containing
ABO-incompatible plasma
Summary of 25 case reports (30 pat.) 1975 – 2009:
21 patients with systemic malignacies
4 surgical patients
5 other
2 fatalities
0 fatalities
0 fatalities
In all patients but one the transfused plasma the anti-A /
anti-B titres were above 100 (saline) and 400 (antiglobulin).
All patients with less than 200 mL transfused plasma
had anti-A / anti-B titres above 1000 (antiglobulin).
Berséus et al, Transfusion 2013;53. 114S-23S
Berséus 2013
Summary of the literature review
Reviewing literature there is no ”safe” low titer level with the
titration techniques being used.
In most laboratories there is a large uncontrolled variation in
the anti-A/-B titers owing to the individual reactivity between
the antigen presented on the test cell and the
corresponding plasma antibody.
In a primary healthy patient the risk for a clinically
significant acute complication mediated by the transfusion
of incompatible plasma seems very low even when a
considerable amount of antibody is being transfused.
All reviewed cases with a fatal outcome have occurred in
patients with an severe ongoing systemic disease.
Berséus 2016
Nature of ABO blood group immunization
Age
0 – 3 months
No ABO blood group antibodies
present.
3 months –
Bacterial A and B blood group
substances from the normal
intestinal bacterial flora induces
the formation of A- and or Bantibodies of the IgM-class
(the ”natural antibodies”)
Berséus 2016
(1)
Nature of blood group immunization
After:
pregnancy,
(2)
Active immunization with the
production of specific blood group
antibodies of both IgM and IgG class
transfusion of
a blood product,
vaccination.
Berséus 2016
Vaccination mediated A and B immunization
Elevated levels of both IgM and IgG class anti-A and/
or anti-B have been reported after vaccinations with
bacteria or virus derived vaccines against:
tetanus, typhoid, diphteria, plague,
meningococcus, hemophilus influenza,
influenza virus A/B.
The stimulative activity varies with the different brands
of the same vaccine
Very high levels of IgM and IgG class anti-B has been
described in a group A donor after per oral intake of a
commercial probiotic containing lactobacillus
Berséus 2016
Booster effects on anti-A/B by vaccines
(1)
In order to evaluate the risk for a booster effect on the
synthesis of the anti ABO antibodies in blood donors from
the military vaccination program of today, all crew
members of the Swedish naval vessel HMS Carlskrona
were investigated before and after the seven months
deployment to the Indian Ocean during 2013.
Berséus 2016
Booster effects on anti-A/B by vaccines
(2)
98 males, 22 females, age 21-66 years, all healthy.
Plasma samples taken before the vessel was
leaving were frozen and later titrated in duplicated
pairs with samples taken 8-10 months after the
return to Sweden.
Titration for anti-A and -B (IgM and IgG) was
performed in gel columns on microcards.
The vaccination program included vaccines against:
Cholera, Hepatis A and B, Influensa A and B type,
Meningococcus, Measles, Mumps, Pertussis, Polio,
Rubella, TBE, Tetanus, Typhus, Yellow Fever.
Berséus 2016
Booster effects on anti-A/B by vaccines
No individual showed any significant change in
their A- or B- antibody titer for either IgM and
IgG type.
Maximal difference in the paired samples were
1 dilution step (6 individuals).
6 individuals were ”high titer” and showed
the same titer in both samples.
(3)
Quantification of anti-A and anti-B
Titration:
in a saline medium
with antiglobulin
(only IgM)
(IgG and/or IgM)
Technique:
agglutination, in test tubes
agglutination, separation in gel tubes
manual or automated
Flow
cytometry:
specific quantification of antibody
technically complicated, expensive
”Gold standard”
Berséus 2016
Quantification of anti-A and anti-B
Titration:
in a saline medium
(only IgM antibodies)
with antiglobulin method (IgG and/or IgM antibodies)
Technique: agglutination in test tubes
agglutination and separation in gel tubes
Flow cytometry:
specific quantification of the antibody
technically complicated and expensive
”Gold standard”
No functioning standardization or
reference value
No generally approved method for
laboratory routine titrations
Berséus 2016
Low titer group O blood in Sweden
Anti-A and anti- B
Titer IgM < 1:100 agglutination in saline
Titer IgG < 1:400 agglutination in AHG
after inactivation of IgM with dithiothreitol (DTT)
Titration is performed with a manual gel
technique on microcards using randomly
chosen A1 and B red cells as reagents.
Berséus 2016
Reproducibility of the gel technique
On six consecutive days a cold stored (+4OC)
group O plasma sample was titrated against
identical daily prepared A1 and B red cells in a
freshly prepared dilution serie.
All the corresponding gelcards showed the same picture.
The A1 IgM dilution serie day 1 and day 6 are shown.
Berséus 2016
Antigen reactivity of different red cells
A ”high titer (anti-A+B)” group O plasma sample
was titrated for anti-A and -B (IgM and IgG)
against 10 randomly chosen A1 and B red cells.
The titer for IgM differed 4 dilution steps with
the A1-cells and 5 steps with the B-cells.
The titer for IgG differed 5 dilution steps
with both the A1-cells and B-cells.
3 of the A1-cells classified the donor as ”low titer”
2 of the B-cells classified the donor as ”low titer”
Berséus 2016
Antibody reactivity of different donors
Titration of 40 group O plasmas against 2 ”high
reactive” cells group A1 (Ax,Ay) and group B (Bx,By).
IgM
The diagram shows
the difference in
dilution steps
between the two cells
Donors shifting
”low” / ”high” titer
IgM: A cells 5, B cells 3
IgG: A cells 5, B cells 2
Only 1 donor had a shift in
both A and B cells
Noof
plasmas
IgG
A-cells
B-cells
A-cells
B-cells
No=2x40
No=2x40
No=2x40
No=2x40
23
22
21
20
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
1 2 3 0 1 2
Differenceindilutionsteps
0
1 2 3 4 0 1 2
Differenceindilutionsteps
3
Berséus 2016
High titres of anti-A and anti-B in group
O donors at the Örebro Blood Center
Titration of aniti-A resp. anti-B with gel-technique
in saline medium (IgM) and with antiglobulin (IgG)
Cut off value for IgM <1/100 and for IgG <1/400
Regular plt-apheresis donors
Regular active military personnel
Swedish Special Forces
(11/248) 4,4 %
(1/33)
3 %
27 %
Berséus 2013
Final conclusion (1)
In emergency life saving support the risks for an
IHTR or other severe adversive effects from the
transfusion of group O blood or plasma to a nongroup O recipient constitutes a minor risk which
with good margins is outweighed by the benefit.
Whenever possible all “universal” donors should
be screened for low titres of anti-A and anti-B
(IgM and IgG) in order to eliminate the risk of
donors with very high titers.
Berséus 2016
Final conclusion (2)
For non emergency situation the above
mentioned screening for anti-A and anti-B
of both IgM and IgG classes should be
mandatory.
For prematures non compatible blood and
blood components should be tested against
the red cells of the recipient.
Berséus 2016