THE EFFECTS OF THE TRANSFUSION OF GROUP O BLOOD OF HIGH
ISO-AGGLUTININ TITER INTO RECIPIENTS OF OTHER
BLOOD GROUPS
MAJOR LESLIE H. TISDALL, CAPTAIN DONALD M. GARLAND,
1ST LIEUTENANT PAUL B. SZANTO, 1ST LIEUTENANT
ALBERT M. HAND AND CAPTAIN JOHN C. BONNETT*
Medical Corps, Army of the United States
From the Army Whole Blood Procurement Service, New York, N. Y.
Group 0 blood has been used as "universal donor" blood for inter group transfusions for many years. The procedure has been attended with varying degrees
of satisfaction and, in general, has been restricted to emergencies. This has been
due to a posttransfusion reaction rate reported as higher than that following the
use of group compatible blood. The higher reaction rate has been explained on
the basis of the presence of a high titer of anti-A and/or anti-B iso-agglutinins
and isohemolysins which cause agglutination and hemolysis of the recipient's
cells, although the evidence for this hypothesis has been derived from scattered
single case reports only. Recently the use of group 0 blood as a universal donor
has increased considerably, especially for the treatment of combat casualties,
and unquestionably has been of tremendous value in such cases.
A careful perusal of many reports, both pro and con, such as those contained
in the excellent review of Rosenthal and Vogel,1 has led us to the belief that in
both instances there have been many inaccuracies and discrepancies. The great
majority of the reactions in the adverse reports were actually pyrogenic and not
hemolytic in nature, and most of the truly hemolytic reactions, as reported, were
caused by errors in blood grouping or were due to the presence of anti-Rh or
other irregular iso-agglutinins. As for the reports with low reaction rates, we
believe that insufficient observation and study of the recipient makes them unreliable. In addition, due to the relative infrequency of group 0 bloods with a
high titer of iso-agglutinins, the reported series of universal donor transfusions
have not included a sufficient number of those with a high antibody content to
be statistically significant. Thus, there seemed to be a need for an accurate
study of the effects of the deliberate transfusion of group 0 blood containing a
high titer of iso-agglutinins to recipients of other blood groups, in whom careful
pre-and post-transfusion studies could be made. With the ultimate objective of
determining the proper preparation and necessary safeguards needed to finally
establish the therapeutic soundness of the use of group 0 blood as universal donor
blood, the present study was undertaken to determine the frequency of so-called
dangerously high titered bloods and to evaluate the effects of the deliberate
transfusion of such bloods to incompatible recipients.
During any discussion of the effects of agglutinins, we are referring also to the
action of their associated hemolysins. Agglutinins are responsible for agglutina* With the technical Assistance of Evan L. Durham and Staff Sergeant John W. Glach.
- 193
194
TISDALL, GARLAND, SZANTO, HAND AND
BONNETT
tion alone, while hemolysins cause hemolytic destruction of red blood cells. The
results of the present study tend to show that the titer of hemolysins is approximately proportional to that of agglutinins. It is easier to determine the titer
of agglutinins. Therefore, throughout this paper, whenever the effects of agglutinins are being discussed, those of the associated hemolysins are implied also.
The serums of 1650 group 0 bloods were titrated for their anti-A and anti-B
agglutinin content. It was somewhat surprising that the results disclosed titers
much higher than those reported by some other investigators. 1 ' 2 This is the
result, we believe, of a difference in technic, particularly the use of centrifugation.
Because we were interested primarily in the high titer serums and wished to
simplify the figures, only titers of 1-320 and above were recorded.
TECHNIC OF AGGLUTININ
TITRATION
All group O bloods were identified by grouping the cells with grouping serum
and proved as such by testing their serums with both pooled known A and pooled
known B cells for the presence of both anti-A and anti-B agglutinins. By a
process of serial dilution with normal saline, a row of Kahn tubes was set up with
TABLE 1
IsO-AGGLUTININ TITRATIONS IN 1650 GROUP O SERUMS
TITRATION
1-320
1-640
1-1280
1-2560
1-5120
ANTI-A ONLY
ANTI-B ONLY
83—5.0%
123—7.5%
47—2.8%
2-0.1%
0-0.0%
37—2.3%,
77-4.6%
17—1.0%
0—0.0%
0-0.0%
BOTH ANTI-A AND
ANTI-B
111—6.7%
99—6.0%
11—0.7%
0-0.0%
0-0.0%
TOTAL NUMBER
WITH EITHER ANTI-A
OR ANTI-B OR BOTH
231—14.0%,
299—18.1%
75— 4 . 5 %
2 - 0.1%
0 - 0.0%
dilutions of serum to be tested ranging from 1-40 to 1-2560. Next, two rows
of six Kahn tubes were set up,—one numbered in blue to denote anti-A agglutinins, and the other numbered in red to denote anti-B agglutinins. Using a
standard medicine dropper (a separate one for each serum) two drops from each
tube in the original row of diluted serums were placed in each of the correspondingly numbered tubes marked in red and blue. To the tubes numbered in blue,
two drops of a 2 per cent suspension of known A cells in normal saline were added;
to the tubes numbered in red, two drops of a similar 2 per cent suspension of
known B cells were added. Both the A and B cell suspensions were made up
from five pooled fresh A and B bloods respectively. No differentiation was
made between Ai and A2 cells. The tubes were shaken thoroughly and let
stand at room temperature for fifteen minutes. They were next centrifuged
for two minutes at 1000 r.p.m. and immediately examined macroscopically
for agglutination. The maximal dilution at which agglutination occurred was
recorded as the titer.
376 sera, or 22.7 per cent, had a titer of anti-A and/or anti-B agglutinins of
1-640 or over. The finding of higher titers' of anti-A agglutinins as compared
TRANSFUSION OF O BLOOD
195
with those of the anti-B, is in agreement with previously recorded figures. However, the entire problem of the technic of determining agglutinin titers is somewhat unsettled. We are of the opinion that a standard technic must be agreed
upon before the question of what constitutes a dangerously high agglutinin titer
can be answered satisfactorily.
On the basis of studies conducted by the Department of Surgical Physiology
of the Army Medical School,3 it was decided, more or less arbitrarily, that group
0 blood with an agglutinin titer of 1-600 or over should be administered only to
group 0 recipients. For the determination of a 1-600 titer on a mass production
basis, the following technic was devised.
Using a 0.1 cc. pipet, 0.02 cc. of the serum was added to 12 cc. of physiological
saline, giving a dilution of 1-600. Two drops of the diluted serum were placed
in each of two tubes, numbered in blue and red as above. Two drops of a 2 per
cent suspension of pooled A cells in normal saline were added to the blue numbered tubes, and two drops of a 2 per cent suspension of pooled B cells were added
to the red numbered tubes. The tubes were centrifuged for 2 minutes at 1000
r.p.m. and immediately read macroscopically for agglutination. The presence of
agglutination denotes a titer of 1-600 or over, while its absence denotes a titer of
less than 1-600.
More than 50,000 group O serums were so titrated. 19.2 per cent were found
to have a titer of anti-A and/or anti-B agglutinins of 1-600 or over. These
figures are in agreement with the finding of 22.7 per cent of titers of 1-640 as
determined by the more detailed technic.
It is an incontestable fact that a high titer of anti-A and/or anti-B agglutinins
in group O blood may cause hemolysis of the recipient's cells if given to a heterologous recipient. 4,5 ' 6 However, the prevailing opinion seems to be that a clinically significant hemolytic reaction due to incompatible agglutinins following the
transfusion of group O blood, occurs less frequently than would seem probable
from theoretical consideration. Several factors have been suggested to account
for the infrequency of such reactions. There is a marked dilution of the agglutinins as soon as they enter the recipient's blood stream. Due to the large number
of the recipient's cells, the transfused antibodies are diffused so widely that most
of the cells do not come in contact with them and thus remain unaffected. The
plasma of group A recipients usually contains A substance, and that of group
B recipients, B substance. These A and B substances tend to neutralize their
respective iso-agglutinins and thus protect the red cells. Finally, those recipients who are secretors are said to have more protection against incompatible
agglutinins.
Certain criteria must be established before a diagnosis of hemolytic reaction
following any blood transfusion can be substantiated. Regardless of the presence or absence of the clinical syndrome of chill, fever, pain in the lumbar region,
and signs of oliguria and anuria, certain laboratory findings indicative of red cell
destruction must be present. These include the occurrence of hemoglobin and
an increase of urobilinogen in the urine, an increased bilirubinemia and a decreased hemoglobin content, red cell count and hematocrit. A definite increase in
196
TISDALL, GARLAND, SZANTO, HAND AND BONNETT
the bilirubin content of the serum is almost certain evidence of cell hemolysis and
is not necessarily accompanied by the presence of hemoglobin and urobilinogen
in the urine. The demonstration of intravascular agglutination is prima facie
evidence. Many reactions classified as hemolytic are actually pyrogenic or
nonspecific.
Even though the diagnosis of a hemolytic reaction following the transfusion
of group 0 blood has been substantiated by the above criteria, one must be wary
of ascribing the cause to the presence of a high titer of A and/or B antibodies.
First, it must be definitely proven that the donor blood was actually group 0 .
This can be done only if the presence of anti-A and anti-B agglutinins are demonstrated in the serum with known A and B cells. Unquestionably many hemolytic reactions following the use of alleged group 0 blood as universal donor
blood were really caused by errors in grouping. The use of the ordinary grouping technic is subject to many inherent faults. Nonpotent grouping serums,
and donor red cells with poor sensitivity for agglutinins, especially the subgroups
of A, are the main pitfalls. Group 0 blood should be used as universal donor
blood only when its group has been proved by grouping its cells and by demonstrating the presence of both anti-A and anti-B agglutinins in its serum.
Hemolytic reactions following the use of group 0 blood may also be due to Rh
incompatibility. This is particularly true of transfusions given to some pregnant or postpartum women and to individuals who have been the recipients of
multiple transfusions. In both instances Rh antibodies may be present in the
recipient's serum and may give rise to severe hemolytic reactions. These two
types of recipients should always be given Rh compatible blood. In those cases
in which the Rh factor of the recipient has not been determined, it is wise to use
group 0 Rh-negative blood. Rarely, hemolytic reactions may result from the
presence of antibodies associated with iso-agglutinins such as anti Hr, 7 anti-Ai,
anti-O, anti-M, anti-P, and certain other iso-agglutinins.8
In the final analysis, therefore, the diagnosis of a hemolytic reaction, following
the transfusion of group 0 blood, caused only by the presence of a high titer of
anti-A and/or anti-B iso-agglutinins and isohemolysins rests upon the demonstration that there has been hemolysis of the recipient's red cells, while the donor's
cells remain intact.
Until the advent of the Army Whole Blood Procurement Service, which processed an average of 1500 pints of group 0 blood daily, the difficulty in obtaining
a sufficient number containing a high iso-agglutinin titer made a study of their
effect impracticable. Because of the large volume of material examined, it was
an easy matter to screen out all group 0 bloods with a high iso-agglutinin content
according to the technic described above, and to select from them a sufficient
number for the purposes of this investigation.
Through the courtesy of the inmates of the Colorado State Penitentiary,* 39
volunteers, in good health, belonging to the blood groups A, B, and AB were
* We desire to express our sincere gratitude for the co-operation of Warden Roy Best and
the volunteers of the Colorado State Penitentiary, Canon City, Colorado.
TRANSFUSION OF O BLOOD
197
given transfusions of 0 plasma containing a high titer of iso-agglutinins to which
they were incompatible. The plasma was prepared from individual donors by
means of the vacuum technic. 9 Plasma was used in place of whole blood in order
to be certain that any subsequent hemolytic reactions which might occur would
be due to hemolysis of the recipient's cells and not the donor's.
Each volunteer recipient was given a thorough physical examination and found
to be normal and healthy. His blood group was determined and he was tested
for the Rh factor. The recipient's saliva was examined for the presence of
soluble substance by the technic of Wiener.10 The plasma to be administered
was titrated for its iso-agglutinin content using the cells of the recipient. As was
expected, there was some degree of variation between these titrations and the
one previously performed in the laboratory against pooled cells. A skin test of
the plasma was made on each recipient by intradermal injection. Twenty-four
hours prior to the transfusion determinations were made of the hemoglobin by
means of the Fisher Haemometer, red blood cell count, hematocrit, serum
bilirubin, and urine urobilinogen of each recipient.* These tests were again performed one hour after the end of the transfusion, and each twenty-four hours
thereafter for seven days. In addition, immediately following the transfusion a
drop of the recipient's blood taken both from a vein and a finger was examined
for intravascular agglutination. This was repeated one hour later.
All recipients were alkalinized with sodium bicarbonate. With a few exceptions, the recipients were given 250 cc. of plasma. This is the equivalent of
the amount of plasma in a pint of blood. Each transfusion was given by one of
us and the recipient was observed closely for eight hours after. The temperature,
pulse and respirations were recorded every thirty minutes and at the sign of any
reaction. The duration of the transfusion ranged from ten to thirty minutes.
All complaints and reactions of the recipient were noted carefully.
The thirty-nine incompatible plasma transfusions varied in their iso-agglutinin
titer from 1-400 to 1-4000. Although plasma with higher titer was available,
it was not transfused, as it was felt that the results obtained from those, used were
sufficiently significant. In table 2 the results are shown until the fourth post
transfusion day only. Tests were carried out until the seventh day but were not
recorded on the chart, as after the fourth day the findings returned almost invariably to the pretransfusion normal levels.
Of the thirty-nine heterologous transfusions, two cases, # 2 and jji 6, had no
detectable reaction whatever. The titer of the plasma adminsitered to both
these cases was 1-500. In three cases, # 9 , #28, and #35, with titers of 1-1000,
1-2000 and 1-3000 respectively, chill and fever were present with no evidence of
hemolysis. These were considered as pyrogenic or nonspecific reactions, although throughout the preparation and administration of the plasma a scrupulous pyrogen-free technic was followed.
Thirty-four of these transfusions gave convincing evidence of hemolysis of the
* We gratefully acknowledge the assistance of Colonel Hugh Mahon, M.C., Chief of Laboratory Service, Fitzsimmons General Hospital.
TABLE 2
o
w
8
W
SKIN TEST
Rh TESTING
GROUP
RECIPIENT'S BLOOD
DATA
z
3
1"
A
neg
pos
neg
250
A
pos
pos
neg
250
A
neg
neg
neg
250
B
pos
pos
neg
250
B
pos
neg
neg
250
A
pos
pos
neg
250
A
pos
pos
neg
250
A
pos
pos
neg
250
B
pos
pos
neg
250
A
pos
pos
neg
250
A
pos
pos
neg
250
A
pos
pos
neg
250
A
pos
pos
neg
250
A
pos
neg
pos
250
A
pos
pos
neg
240
AB
pos
neg
250
A
neg
neg
A
pos B
pos
neg
250
A
pos
pos
neg
250
A
neg
pos
neg
250
A
neg
pos
neg
250
A
pos
pos
neg
250
1-500
anti-B
1-500
anti-A
1-500
anti-A
1-600
anti-A
1-750
anti-B
1-750
anti-A
1-750
anti-A
1-750
anti-A
1-750
anti-A
1-750
anti-A
1-800
anti-A
1-1000
TRANSFUSIONS
24 HRS. AFTER
PRIOR TO TRANSFUSION
AGGLUTININ
TITER OF
PLASMA
AGAINST
RECIPIENT'S
CELLS
1-400
anti-A
1-500
anti-A
1-500
anti-A
1-500
anti-B
O N iNcoMPAtriBLE
2ND DAY
CLINICAL REACTION
V
m
<X
gm.
millions
15
gm
100 cc.
millions
mg.l
100 cc.
gm
millions
mg./
100 cc.
gm.
millions
mg.l
100 cc.
gm.
S
tl
K
millions
mg.l
100 cc.
gm.
millions
mg.l
100 cc.
4,930 42
0.8
neg
15.5 5,210 15 '
1.25
neg
14.5 4,68( 44
0.85
neg
15
4.98C 45
0.85
neg
4.5 5,220 44
0.7
neg
15.5 4,450 48
0.3
neg
17
4,620 18
0.8
neg
16
4,570 5;
0.3
neg
16
4,850 49
0.2
neg
7
4,480 48
0.3
neg
17.1 4,910 45
0.3
neg
neg
16
4,980 45
1.15
neg
14.8 4,340 44
0.5
neg
12.8 4,790 48
0.7
neg
5
4,270 43
0.15
neg
16.8 5,170 45
15.5 5,510 45
0.4
neg
n e g . 13.2 4,880 42
1.05
neg
13.2 5,390 41
1.15
neg
13
5,050 40
1.26
neg
2
4,200 36
1.25
neg
12
14.5 5,220 44
0.7
Urticaria
Neg
0.8
neg
Urticaria
5,290 37
0.95
tr
Neg
Neg
4,960 43
0.4
neg
neg
14.2 5,020 42
1.55
neg
15.8 5,000 47
0.6
neg
18
5,140 46
0.6
tr
5,180 44
0.3
tr
16
4,780 44
0.5
neg
16.5 5,190 48
0.5
neg
neg
15.5 5,150 47
0.7
neg
15.5 5,270 50
0.6
neg
15.5 4,960 46
0.4
neg
5,160 46
0.8
neg
16
4,900 45
0.4
neg
Neg
5,690 46
0.6
neg
neg
14
4,510 43
1.45
neg
14.5 4,500 41.5
0.4
neg
15
4,970 42
0.6
neg
4,640 42
0.4
neg
15
4,620 42
0.45
neg
Urticaria
15.2 5,060 46
0.5
neg
neg
15.2 5,120 47
1.25
neg
15.5 5,180 50
0.15
tr
15
5,070 48
0.4
neg
5,250 49
0.3
neg
15
5,100 47
0.75
neg
Low back pain, h e moglobinuria, + 4 -
15.5 4,930 48
0.5
neg
neg
15.9 5,020 46
0.7
pos
15
5,260 49
0.7
tr
15.2 5,300 48
0.8
neg
5,210 46
0.7
tr
5,547 43
0.6
tr
neg
13
1.75
neg
12
4,500 43
1.25
neg
15.5 4,950 45
0.4
neg
4,220 41
0.3
neg
14.2 5,120 43
0.85
pos
13.5 5,370 38
1.25
neg
16
5,720 47
0.9
neg
16.5 5,020 44
0.3
neg
5,610 45
0.7
neg
16.2 5,180 45
0.8
neg
Neg
1.25
neg
14.9 4,360 40
0.5
neg
13.5 5,010 45
0.15
neg
5,150 42
0.5
neg
14
0.4
neg
Urticaria
16
14
16
5,680 42
16
5,720 45
0.4
neg
neg
15
4,500 47
0.05
neg
neg . 18
4,970 51
14.2 4,960 45
0.6
neg
neg
15
5,200 48
1.25
neg
15
48
0.3
tr
12.8 4,420 44
0.5
neg
neg
12.8 4,520 42
1.25
pos
13
43
0.4
si
16.2 5,340 46
0.4
neg
neg
14.5 5,320 41
1.35
neg
15
44
0.6
14
0.3
neg
pos
13
4,330 39
0.85
neg
13.2
0.6
4:
44
++
Chill , - T . = 100.6
4,630 40
Neg
0.5
neg
4,790 46
0.5
si t r
15.5 5,610 48.5
1.15
sltr
Neg
t r 14
5,090 43
0.4
si t r
4,910 43
0.4
neg
13
0.95
neg
Neg
neg,
15
5,150 44
0.6
neg
5,100 47
0.85
neg
15.5 5,370 47
0.95
neg
Neg
neg
13.5 4,610 44
0.15
neg
4,390 40
0.6
neg
14
0.7
neg
Hemoglobinuria,
15.5 5,170 46
4,950 41.5
4,930 41
-f-
+++
B
pos
nex
neg
250
A
pos
neg
neg
275
A
pos
pos
neg
250
A
pos
•
neg
neg
250
A
pos
pos
neg
250
A
pos
pos
neg
250
A
pos
pos
neg
250
A
pos
pos
neg
250
B
pos
pos
neg
250
A
pos
neg
ne^
200
A
pos
neg
pos
250
A
pos
pos
neg
250
A
pos
pos
neg
250
A
pos
pos
pos
120
B
pos
neg
neg
250
A
pos
pos
neg
250
A
pos
pos
pos
250
A
pos
pos
neg
250
1-1000
anti-A
1-1000
anti-A
1-1000
anti-A
1-1000
anti-A
1-1000
anti-A
1-1000
anti-B
1-1000
anti-A
1-1250
anti-A
1-1500
anti-A
1-1500
anti-A
1-2000
anti-A
1-2000
anti-A
1-2000
anti-A
18
5,190 47
0.85
neg
neg
14
5,140 43
1.9
neg
16
45
0.7
neg
15.9 5,130 44
0.3
neg
5,020 43
0.3
neg
15
44
0.5
neg
16
5,050 44
0.5
neg
neg
15
4,430 45
1.25
neg
16
49
0.2
neg
15.5 4,990 48
0.45
neg
5,250 48.5
0.4
neg
15.5
47
0.3
neg
16
5,340 46
1-2000
anti-B
1-2500
anti-A
1-2500
anti-A
1-3000
anti-A
1-3000
anti-A
1-3000
anti-A
Neg
Neg
0.85
neg
n e g . 14.5 4,860 44
0.95
neg
15.
46
2.0
neg
14.5 5,010 44
2.2
neg
4,
2.2
neg
14
39
1.6
neg
14.8 5,260 48
0.5
neg
neg
14.3 4,730 43
1.55
neg
15
46.5
0.85
neg
15
5,270 46.5
0.7
tr
5,020 43.5
0.8
neg
14.5
44
0.3
neg
15
5,510 46
0.7
sltr
neg
13.8 5,210 41
1.35
neg
15
45
0.95
tr
15
5,130 42.5
1.2
neg
5,510 46
0.95
neg
15
45
1.0
neg
Neg
14
42
Neg
Neg
5,450 45
0.7
neg
neg
12.5 4,860 43.5
1.45
neg
14.5
43
0.6
neg
14.5 5,160 43
0.6
neg
4.5 5,130 43.5
0.6
neg
14.5
42.5
0.66
neg
Neg
13.5 5,860 41
0.4
neg
pos
13
5,600 44
1.45
neg
16
47
0.45
neg
14.5 5,160 47.5
0.6
neg
5,120 45.5
0.6
neg
15
42.5
0.6
neg
Neg
16.8 5,350 46
0.6
tr
neg
13.2 5,010 40
1.05
neg
13.8
46
0.6
neg
14.2 5,030 45
0.2
neg
4,970 43
0.5
neg
14.2
44
0.5
neg
Neg
16
5,280 47
0.95
neg
neg
16
5,500 41
1.55
neg
16
46
0.8
neg
15.2 5,050 46
0.7
tr
5,080 48
0.85
tr
14
44
0.85
tr
Hemoglobinuria,
15
5,490 47
0.7
neg
neg
14.5 4,850 42
1.05
sltr
15
45.5
0.7
neg
15
5,400 48
0.6
neg
4,230 43.5
1.2
neg
15
46
0.95
neg
Neg
14.5 5,060 43
1.45
neg
neg
15
5.130 44
2.8
neg
16
45
1.65
neg
15.5 5,380 45
1.25
neg
5,100 45
1.9
neg
14
44
1.15
neg
Neg
15
4,
46
0.6
neg
neg
16
5,290 45
0.8
neg
15.5
47
0.5
neg
15.5 4,960 45
0.6
neg
5,010 45
0.6
neg
15.5
45
0.5
neg
Chill; T .
16 .
5,620 49
0.7
neg
15.5 5,210 45
3.1
neg
15.5
46
1.55
tr.
16
5,180 49
0.7
neg
5,360 48
0.6
neg
18
51
1.35
neg
Nausea,
vomiting
sweating,
hemo
H—h
globinuria,
17
5,640 46
1.2
16
5,240 43
2.6
neg
17
5,430 47.5
1.0
neg
16
5,120 44
1.3
neg
5,610 47
0.95
neg
5,640 45.5
0.85
neg
Nausea, headache
15
5,430 42
0.35
15
5,250 42
4.0
neg
17
5,390 44
1.4
tr
16
6,
1.0
neg
5,410 41
0.35
neg
5,270 43
0.7
neg
4.8 5,520 40
0.95
neg
Hemoglobinuria,
++++N.andV.,
p a i n i n b a c k ; chill,
T . = 101.2
Chill; pain in back
0.7
48
++++
: 100.2
++
15
5,440 44.5 0.35
neg
pos
11.
5,500
0.35
neg
13
5,720 40.5
0.05
15
5,840 43
1.05
neg
0.95
neg
15
15
4,830 47
0.4
tr
neg
15
4,670
1.8
neg
15
4,600 41
0.5
neg
15
5,340 44.5
0.25
neg
5,040 44.5
0.45
neg
15.5 5,010 43.5
neg
Neg
5,560 48.5
1.0
neg
neg
15
5,130
1.95
pos
15
5,400 46
0.8
pos
15
5,240 46
0.95
neg
5,650 47
1.2
neg
16
5,240 47
0.45
neg
Headache
5,560 45
0.25
neg
neg
16
5,320
0.66
neg
14.2 5,040 41
0.45
neg
14.2 5,210 44
0.6
neg
5,240 43
0.6
neg
15
5,310 40
0.6
neg
5,013
1.95
pos
13
5,420
0.8
13
5,400 40
0.8
neg
5,370 41
0.95
tr
15
5,250 40
0.8
neg
Back pain, nausea,
headache, T . =
100.6
C h i l l ; T . = 101.8
0.8
neg
13
5,470 39
0.35
13.5 5,490 40.5
0.85
neg
5,420 42
0.95
neg
14
5,150 39
0.95
neg
2.05
tr
4,800 35
1.26
12
4,390 38
1.55
neg
1.65
neg
4,780
1.0
12.5 5,030 37
1.35
neg
1-3000
anti-B
1-3000
anti-A
15
5,110 42.5
0.8
neg
13
14
5,650 40
0.2
neg
12.5 5,170
1-3000
anti-A
1-4000
anti-A
13.5 5,680 40
0.45
neg
13
0.35
neg
5,100 40
pos
13
5,220
0.66
neg
13
5,170 37.5
0.7
neg
12.5 4,950 37
pos
13
5,550
1.2
neg
14
4,900 38
0.8
neg
13
4
40
5,320
.5
Hemoglobinuria,
+ + + + , chills, T .
- 100.4
Chills,
hemoglobinuria, + + + +
Headache,
hemo+ +
globinuria,
++
198
199
200
TISDALL, GARLAND, SZANTO, HAND AND BONNETT
recipient's cells, on the basis of a marked increase in serum bilirubin (the average
increase was over 200 per cent), and a decrease in hemoglobin, red cell count and
hematocrit. The titer of the iso-agglutinins in the plasma responsible for these
findings ranged from 1-400 upwards. Eight of these thirty-four cases had a
marked hemoglobinuria, and in seven cases evidence of intravascular agglutination was demonstrated; in four cases both of these phenomena were noted.
The eight cases in which hemoglobinuria occurred were classified as clinically
severe hemolytic reactions. These cases occurred in the higher titer group,
although in one instance the titer was only 1-600. Hemoglobinuria, when
present, was noted in the first posttransfusion urine specimen. In four cases,
the next specimen was clear. The longest duration of its persistence was four
hours.
Immediately at the end of the transfusion blood was taken from a vein and a
finger of the opposite arm and examined microscopically for evidence of intravascular agglutination after diluting with saline. . When noted, the reaction
was distinct. In a few instances it even could be detected macroscopically.
This phenomenon, when present, was so marked and so widespread, as shown by
its demonstration in blood from an arm and a finger opposite that used for the
transfusion, that the possibility of the occurrence of embolic phenomena was
considered. No evidence of this was noted. Within an hour after the transfusion this reaction could not be demonstrated in any of the cases. The occurrence of intravascular agglutination was noted only in the higher titer group, the
lowest titer being 1-1000.
The term "intravascular agglutination", as used in this paper, is actually a
misnomer. True intravascular agglutination can be detected only by direct
observation of the recipient's capillaries. The words are used to denote that
spontaneous agglutination occurred in vitro, immediately at the end of the transfusion. This spontaneous agglutination outside the body may mean that true
intravascular agglutination actually had occurred, or that the cells were so conditioned by the transfused antibodies that merely a change in their environment
caused agglutination. The explanation of the absence of emboli may lie in the
fact that the observed agglutination did not occur intravascularly or that the
agglutinates were so loosely adherent that the reaction was fleeting.
In the group of thirty-four cases with evidence of hemolysis, clinical reactions,
other than hemoglobinuria, were manifested by chill, fever, headache, nausea, and
pain in the lumbar region, in eleven cases. Eight of these cases were accompanied by hemoglobinuria or intravascular agglutination or both. All but one of
these clinical reactions occurred in the titer group of 1-1000 or over. The fact
that only eleven clinical reactions occurred in thirty-four cases with evidence of
hemolysis, and that two cases of frank hemoglobinuria exhibited no clinical
symptoms, may be one reason why more hemolytic reactions have not been reported from the indiscriminate use of group O blood as universal donor blood.
This further emphasizes that the occurrence of clinical symptoms cannot be
relied upon as unfailing evidence of a hemolytic reaction even in severe cases.
It was clearly seen that there was a definite correlation between the height of
TRANSFUSION OF O BLOOD
201
the titer and the severity of the hemolytic reaction, as shown by the clinical
symptoms, the demonstration of hemoglobinuria and intravascular agglutination,
and the laboratory evidence of cell hemolysis. In other words, the higher the
incompatible iso-agglutinin titer becomes, the severer is the reaction.
In all of the thirty-four cases, the clinical symptoms subsided in several hours
and for the most part the laboratory findings returned to normal in one to two
days. No apparent lasting harm came to any recipient, and at no time was
there any evidence of oliguria, anuria or other indications of kidney damage.
Jaundice did not appear in any of the recipients. As previously noted all recipients were alkalinized prior to transfusion. This seemed to have no effect on
the occurrence of reactions, but we are unable to state whether or not it had an
effect on their severity. It is logical to assume, we believe, that if these same
plasma transfusions had been administered in greater quantities to incompatible
recipients in shock or with serious depletion of blood volume, instead of to healthy
males, much more serious results would have been encountered.
The saliva of each recipient was tested for the presence of group specific substance and the individual classified as a secretor or a nonsecretor. Thirty recipients of the thirty-nine receiving heterologous transfusions were secretors,
while nine were nonsecretors. Five nonsecretors experienced relatively severe
hemolytic reactions and all showed evidence of hemolysis of their cells. However, the severe reactions of the nonsecretor group occurred in titers of 1-1000 or
more, and recipients who were secretors also had reactions of the same degree
and severity. We are not able, therefore to state that there was any significant
difference between the reactions of the secretors and those of the nonsecretors.
Intradermal skin tests of the recipients with donor plasma resulted in four
positive and thirty-five negative readings. There was no apparent correlation
between skin testing and reaction rate. Although urticaria occurred in four
cases in this series, it was not present in those with positive skin tests.
As a control and to rule out nonspecific reactions, six group 0 recipients were
given group 0 plasma transfusions and were studied with the same technic as the
other group. The plasma administered had an anti-A agglutinin titer ranging
from 1-600 to 1-5000, while the anti-B titer was below 1-500 except in case # 4.
No significant clinical symptoms or laboratory findings indicative of hemolysis
of the recipient's cells were noted. There was no hemoglobinuria or intravascular agglutination observed. The findings are presented in table 3. The
figures are recorded only until the second day, as thereafter they remained
normal.
The results shown in table 2 give satisfactory evidence of hemolysis of the
recipient's cells in thirty-four cases out of thirty-nine who received group O
plasma transfusions with iso-agglutinin titers ranging from 1-400 to 1-4000. On
this basis, we are of the opinion that the use of group O individuals as universal
donors should be restricted to those with an iso-agglutinin titer of 1-200 or less,
and that transfusion of higher titers may well result in dangerous hemolytic
reactions. In this respect we take a much more serious view than Aubert and
her associates,4 who stated that they obtained no evidence that incompatible
202
TISDALL, GARLAND, SZANTO, HAND AND BONNETT
TRANSFUSION OF O BLOOD
203
TABLE 3
D A T A ON COMPATIJLE T R A N S F U S I O N S
RECIPIENT'S
BLOOD
GROUP
FUSION
NUMBER
Rh
TESTING
SECRETOR
SKIN
TEST
AMOUNT
TRANSFUSED
CC.
1
0
pos
neg
neg
250
2
0
pos
neg
neg
250
3
0
pos
neg
neg
20C
4
0
pos
neg
neg
250
5
0
neg
neg
pos
250
6
0
pos
neg
neg
260
1 HE. AFTER-
PRIOR TO TRANSFUSION
AGGLUTININ
TITER OF
PLASMA
IN VITRO
anti-A
1-3000
anti-A
1-5000
anti-A
1-4000
anti-A
1-3000
anti-B
1-1500
anti-A
1-600
anti-A
1-2500
Hb.
R.B.C.
gm.
million
Hematocrit
Urobilinogen
Bilirubin
mg.l
100 cc.
Hb.
R.B.C.
gm.
million
Hematocrit
24 H R S . AFTER
Urobilinogen
Bilirubin
mg.l
100 cc.
Hb
R.B.C.
gm.
million
Hematocrit
2ND DAY
Bilirubin
Urobilinogen
gm./
100 cc.
Hb.
R.B.C.
gm.
million
Hematocrit
Bilirubin
CLINICAL REACTION
Urobilinogen
mg./
100 cc.
15.2
4,690
45
0.5
neg
15
4,420
43.5
0.8
neg
15
5,510
47
0.5
neg
15.5
5,190
41.5
0.95
neg
Neg
14.5
5,770
46.5
0.2
neg
14.5
5,150
42.5
0.7
neg
14
4,870
40.5
0.3
neg
14
5,070
40
0.5
neg
Low b a c k p a i n
16
5,540
48
0.7
neg
16
5,200
40.5
0.25
tr
16
5,155
42.5
0.8
neg
15
5,610
42.5
0.8
neg
Neg
16
5,560
43
0.95
tr
15
5,790
42.5
0.66
neg
15
5,200
43
0.35
neg
Urticaria
16
5,150
45
C.65
neg
16
5,450
47.5
0.45
neg
16
5,640
45.5
0.45
neg
16
5,100
47
0.2
neg
16
5,270
46
0.85
neg
Neg
14
5,520
42.6
0.8
neg
12.5
5,240
40.5
0.3
neg
13
5,380
42
0.4
neg
13
5,370
45
0.3
neg
Neg
TABLE 4
D A T A ON INCOMPATIBLE T R A N S F U S I O N S
neg
neg
3
8
neg
4
39
neg
anti-A
1-1000
anti-A
1-8000
anti-A
1-3
anti-A
1-150
anti-A
1-4000
anti-A
1-2000
anti-A
1-200
anti-A
1-2
mg.l
100 cc.
0.15 t r
gm. million
mg.l
gm. million
100 cc.
neg 13
0.5
4,650
4,670
39
neg
12
4,480 37
12.5 4,800
39
13.5 5,090
39
0.5
neg
neg
13
5,220 40.5
1.05
neg 14
5,490
42
2.0
neg 14.2 5,620
5,550
43
0.6
neg
neg
14
5,660 45
0.3
neg 14
5,270
43
1.65
neg 15.
12.5 5,030
37
1.37
neg
neg
11
4,830 35-
1.75
neg 13
5,140
36
0.95
neg 12
12
mg.l
gm. million
100 cc.
neg 14
40
0.4
5,060
mg.l
gm. million
100 cc.
41
0.5
neg 12.5 4,850 40
43
1.65
pos
14
5,550
40
2.2
pos 13
4,310 35.5
5,420
41
0.95
pos 13
4,960
37
1.45
tr
13
5,040 40
4,790
34
1.25
neg 11.2 5,100
35
1.15
tr
11.2 5,080 35.5
a
U
pa
Hematocrit
Urobilinogen
Bilirubin
a
Hematocrit
J2
R.B.C.
Urobilinogen
Bilirubin
Hematocrit
•J2
R.B.C.
Urobilinogen
Bilirubin
Hematocrit
i
R.B.C.
Urobilinogen
Bilirubin
Hematocrit
a
R.B.C.
A
gm. million
J3
mg.l
gm. million
100 cc.
neg 12.5 5,000 40
0.8
1.75
tr
11.2 4,740 35.5
Urobilinogen
16
25
5 T H DAY
Bilirubin
1
2
mg.l
100 cc.
neg
0.5
Urobilinogen
a
gm. million
Bilirubin
OS
p.
Hematocrit
>w
4 T H DAY
CLINICAL
REACTION
R.B.C.
c
INTRAVAS. AGGLUT.
O
3RD DAY
2ND DAY
24 H R S . AFTER
1 H R . AFTER
Urobilinogen
H
Bilirubin
<OS
Hematocrit
Z
PRIOR TO TRANSFUSION
R.B.C.
P
AGGLUTININ TITER OF PLASMA
AGAINST RECIPIENT CELLS
AFTER ADDITION OF
"A"
AND "B" SUBSTANCE
z
o
SKIN TEST
TRANSFUSION NUMBER
1
AGGLUTININ TITER OF PLASMA
AGAINST RECIPIENT CELLS
BEFORE ADDITION OF "A"
AND "B" SUBSTANCE
Modified by " A " and " B " Substance
mg.l
100 cc.
0.5
neg
Neg
1.45
neg
0.85
neg
D i z z y spell
w i t h weakness after
48 h r s .
Neg
0.5
neg
Neg
f
13
1.45
neg 13
0.6
pos 12.2 5,230 36
5,100 39.5
204
TISDALL, GARLAND, SZANTO, HAND AND BONNETT
iso-agglutinins are responsible for severe hemolytic reactions, and who recommended titers up to 1-512 as safe. Similarly, we must condemn the indiscriminate use of universal donor blood as recommended by others. While this work
did not include a study of the effects of titers below 1-400 on incompatible recipients, it is felt that titers of 1-200 or less would have a negligible hemolytic
effect, if any. According to table 1, 37 per cent of group O blood contains an
agglutinin titer of 1-320 or over. Limiting the use of universal donor blood to
those with titers not exceeding 1-200 means restricting approximately 50 per
cent of group O blood from use for intergroup transfusions. This may seem
ultra conservative but would not in any way affect an adequate supply of universal blood, as the need for such blood, while of primary importance, is limited.
The addition of A and B group specific substances to group O blood for use
as universal donor blood has been recommended to reduce the titer of iso-agglutinins.11 Some investigations of this subject were undertaken in the course of
the present study. Four recipients, # 8 #16 #25 and #39 who had previously suffered severe hemolytic reactions, were again transfused with incompatible plasma to which 10 cc. of A and B substances had been added.* The
time interval between the first and second transfusion varied from one to four
weeks. The results are presented in table 4.
The addition of the group specific substances caused the agglutinin titers to
drop to a fraction of their previous values. The titrations performed before
and after the addition were done with the recipient's cells. In case 1, the titer
was changed from 1-1000 to 1-3; in case 2, from 1-8000 to 1-150; in case 3, from
1-4000 to 1-200; and in case 4, from 1-2000 to 1-2. I t seems that the neutralization of the agglutinins by the A and B substances is somewhat proportional
to the height of the titer in the original unmodified plasma. In these four cases
there were no significant clinical reactions, nor any hemoglobinuria, nor evidence
of intravascular agglutination. However, in cases 2 and 3, evidence of delayed
and somewhat prolonged hemolysis was noted. This is predicated on an increased bilirubinemia and decreased red cell, hemoglobin and hematocrit values
which occurred later or persisted longer than was noted in the group to whom
unmodified incompatible plasma was given. Such a small series of cases is not
conclusive, but it is interesting to speculate on the reason for these findings.
Possible explanations are: 1. An increased sensitivity of the recipient's cells
as a result of the previous incompatible transfusion. 2. A loose absorption
of the antibodies by their respective group specific substances resulting in their
gradual release with subsequent hemolysis. 3. Since the two cases which had
hemolysis after the administration of neutralized plasma, occurred following the
use of plasma with residual titers of 1-150 and 1-200, it is possible that these
titers, although relatively low, may have been responsible for the hemolysis.
4. It is conceivable that a larger amount of group specific substance than has
* The A and B substances were supplied through the courtesy of Dr. E. J. Teeter, Eli
Lilly & Co.
TRANSFUSION OF O BLOOD
205
been recommended is needed to absorb iso-agglutinins with titers greater than
1-2000.
Unquestionably there was a much less severe reaction following the use of the
A and B substances than would have occurred had the recipient received the
original unmodified plasma. It is felt, however, that further study on the use of
A and B substances must be done before its addition to group 0 blood, destined
as universal donor blood, is recommended as a routine procedure.
None of the findings of this study has shaken our conviction that the use of
group 0 blood as universal donor blood has a definite place in the treatment of
shock and hemorrhage. Certain safeguards, however, must be adopted to
promote its efficaciousness. It is an easy matter to screen out, routinely, all
group 0 bloods with a titer of 1-200 or more, utilizing the mass production
technic for screen titration, as detailed earlier in this report, by testing a final
dilution of the serum at 1-200. Because of the different technics used by various
laboratories, it must be remembered that while an agglutinin titer of 1-200 or
less as determined by the centrifuge method is considered safe, corrections must
be made for titers obtained by other methods such as the well-slide technic. The
titers obtained by the centrifuge method are four to twelve times greater than
those obtained by the well-slide technique.12
The use of group O blood as universal donor blood has been restricted largely
to military requirements under combat conditions. It is not our purpose to
propose that group O blood should be used exclusively in civilian hospitals.
However, when facilities for grouping and crossmatching are not readily available, or when the need for blood is so pressing that the time required to determine
the blood compatibility might be detrimental to the patient, proven group O
Rh-riegative blood with an iso-agglutinin titer of 1-200 or less can be administered
with safety. Even the largest and most efficient blood banks are occasionally
lacking in needed quantities of the rare groups. Such instances will not be infrequent in view of the more complete knowledge of the physiology of shock and the
effects of hemorrhage, and the recognition that the efficacious treatment of both
shock and hemorrhage depends on the earliest possible restoration of an adequate
circulating blood volume. The modern therapy of severe hemorrhage demands
immediate blood transfusion. It is appalling to note that, in many of the finest
hospitals, deaths from hemorrhage are still being reported where a transfusion
was not given until three or more hours after admission. Every hospital should
have on hand proved group O blood with an iso-agglutinin titer not exceeding
1-200, to meet such demands. As an added safety factor this blood should be
Rh-negative.
CONCLUSIONS
1. A standardized technic for agglutinin titer determination should be adopted.
2. Criteria are described for making a diagnosis of a hemolytic transfusion"
reaction due to the presence of a high titer of anti-A and/or anti-B agglutinins
and hemolysins in group O blood, administered to recipients of other blood
groups.
206
TISDALL, GARLAND, SZANTO, HAND AND BONNETT
3. Group 0 blood is safe for use as universal donor blood when its antibody
titer is not higher than 1-200 by the centrifuge method of titration described in
this paper.
4. The use of A and B substances to condition group 0 blood as universal
donor blood requires further study.
5. Properly selected Rh-negative low-titer group 0 blood should be available
for immediate transfusion in every hospital blood bank as safe universal donor
blood.
REFERENCES
1. ROSENTHAL, N . , AND VOGEL, P . : Observations on Blood Transfusions from Universal
Donors, in M U D D , S., AND THALHIMER, W.: Blood Substitutes and Blood Transfusions, Springfield, Charles C. Thomas, 1942, p p . 297-308.
2. DAVIDSOHN, I . : Irregular iso-agglutinins. J . A. M. A., 120: 1288, 1942.
3. ELLIOTT, J . : Personal communication.
4. ATJBERT, E . F . , BOOKMAN, K. E., D O D D , B . E., AND L O U T I T , J . F . : Universal donor with
high titer iso-agglutinins. Brit. M . J., 1: 659, 1942.
5. ALBERTON, E . C . : F a t a l i t y due t o transfusion of unpooled plasma. Am. J . Clin. P a t h . ,
15:128,1945.
6. M A L K I E L , M . D . , AND BOYD, W. C.: A transfusion reaction due t o a dangerous universal
donor. J . A. M . A., 129: 344, 1945.
7. W I E N E R , A. S., DAVIDSOHN, I., AND P O T T E R , E . L . : H e r e d i t y of t h e R h blood t y p e s .
Observation on t h e relation of factor H r t o t h e R h blood types. J . Exper. Med., 81:
63, 1945.
8. W I E N E R , A. S.: Blood Groups and Transfusions, Springfield, Charles C. Thomas, 1943,
p . 118.
9. TISDALL, L. H . : Plasma in obstetrics. Am. J . Obst. & G y n e c , 42: 889, 1941.
10. W I E N E R , A. S.: Blood Groups and Transfusions, Springfield, Charles C. Thomas, 1943,
p . 65.
11. KLENDSHOJ, N . C , AND WITEBSKY, E . : Transfusion of " O " blood conditioned by t h e
addition of blood group specific substances. J . A. M . A., 128: 1091, 1945.
12. THALHIMER, W . : Personal communication.
897 P a r k Place, Brooklyn, N . Y .