Blood Typing and Crossmatching
Blood typing is a laboratory test done to determine a person's blood type. If the person needs a blood transfusion, another test called crossmatching is done after the blood is typed to find blood from a donor that the person's body will accept.
Blood typing and crossmatching are most commonly done to make certain that a person who needs a transfusion will receive blood that matches (is compatible with) his own. People must receive blood of the same blood type, otherwise, a serious, even fatal, transfusion reaction can occur.
Parents who are expecting a baby have their blood typed to diagnose and prevent hemolytic disease of the newborn (HDN), a type of anemia also known as erythroblastosis fetalis. Babies who have a blood type different from their mothers are at risk for developing this disease. The disease is serious with certain blood type differences, but is milder with others.
A child inherits factors or genes from each parent that determine his blood type. This fact makes blood typing useful in paternity testing. To determine whether or not the alleged father could be the true father, the blood types of the child, mother, and alleged father are compared.
Legal investigations may require typing of blood or other body fluids, such as semen or saliva, to identify persons involved in crimes or other legal matters.
Blood typing and crossmatching tests are performed in a blood bank laboratory by technologists trained in blood bank and transfusion services. The tests are done on blood, after it has separated into cells and serum (serum is the yellow liquid left after the blood clots.) Costs for both tests are covered by insurance when the tests are determined to be medically necessary.
Blood bank laboratories are usually located in facilities, such as those operated by the American Red Cross, that collect, process, and supply blood that is donated, as well as in facilities, such as most hospitals, that prepare blood for transfusion. These laboratories are regulated by the United States Food and Drug Administration (FDA) and are often inspected and accredited by a professional association such as the American Association of Blood Banks (AABB).
Blood typing and crossmatching tests are based on the reaction between antigens and antibodies. An antigen can be anything that causes the body to launch an attack, known as an immune response, against it. The attack begins when the body builds a special protein, called an antibody, that is uniquely designed to attack and make ineffective (neutralize) the specific antigen that caused the attack. A person's body normally doesn't make anti-bodies against its own antigens, only against antigens that are foreign to it.
A person's body contains many antigens. The antigens found on the surface of red blood cells are important because they determine a person's blood type. When red blood cells having a certain blood type antigen are mixed with serum containing antibodies against that antigen, the antibodies attack and stick to the antigen. In a test tube, this reaction is observed as the formation of clumps of cells (clumping).
When blood is typed, a person's cells and serum are mixed in a test tube with commercially-prepared serum and cells. Clumping tells which antigens or antibodies are present and reveals the person's blood type. When blood is crossmatched, patient serum is mixed with cells from donated blood that might be used for transfusion. Clumping or lack of clumping in the test tube tells whether or not the blood is compatible.
Although there are over 600 known red blood cell antigens, organized into 22 blood group systems, routine blood typing and crossmatching is usually concerned with only two systems: the ABO and Rh blood group systems.
ABO BLOOD GROUP SYSTEM. In 1901, Karl Land-steiner, an Austrian pathologist, randomly combined the serum and red blood cells of his colleagues. From the reactions he observed in test tubes, he discovered the ABO blood group system. This discovery earned him the 1930 Nobel Prize in Medicine.
A person's ABO blood type—A, B, AB, or O—is based on the presence or absence of the A and B antigens on his red blood cells. The A blood type has only the A antigen and the B blood type has only the B antigen. The AB blood type has both A and B antigens, and the O blood type has neither A nor B antigen.
By the time a person is six months old, he naturally will have developed antibodies against the antigens his red blood cells lack. That is, a person with A blood type will have anti-B antibodies, and a person with B blood
type will have anti-A antibodies. A person with AB blood type will have neither antibody, but a person with O blood type will have both anti-A and anti-B antibodies. Although the distribution of each of the four ABO blood types varies between racial groups, O is the most common and AB is the least common.
ABO typing is the first test done on blood when it is tested for transfusion. A person must receive ABO-matched blood. ABO incompatibilities are the major cause of fatal transfusion reactions. ABO antigens are also found on most body organs, so ABO compatibility is also important for organ transplants.
An ABO incompatibility between a pregnant woman and her baby is a minor cause of HDN and usually causes no problem for the baby. The structure of ABO antibodies makes it unlikely they will cross the placenta to attack the baby's red blood cells.
Paternity testing compares the ABO blood types of the child, mother, and alleged father. The alleged father can't be the true father if the child's blood type requires a gene that neither he nor the mother have. For example, a child with blood type B whose mother has blood type O, requires a father with either AB or B blood type; a man with blood type O cannot be the true father.
In some people, ABO antigens can be found in body fluids other than blood, such as saliva and semen. ABO typing of these fluids provides clues in legal investigations.
RH BLOOD GROUP SYSTEM. The Rh, or Rhesus, system was first detected in 1940 by Landsteiner and Wiener when they injected blood from rhesus monkeys into guinea pigs and rabbits. More than 50 antigens have since been discovered belonging to this system, making it the most complex red blood cell antigen system.
In routine blood typing and crossmatching tests, only one of these 50 antigens, the D antigen, also known as the Rh factor or Rho[D], is tested for. If the D antigen is present, that person is Rh-positive; if the D antigen is absent, that person is Rh-negative.
Other important antigens in the Rh system are C, c, E, and e. These antigens are not usually tested for in routine blood typing tests. However, testing for the presence of these antigens is useful in paternity testing, and when a technologist tries to identify unexpected Rh antibodies
Unlike the ABO system, antibodies to Rh antigens don't develop naturally. They develop only as an immune response after a transfusion or during pregnancy.
The incidence of the Rh blood types varies between racial groups, but not as widely as the ABO blood types: 85% of whites and 90% of blacks are Rh-positive; 15% of whites and 10% of blacks are Rh-negative.
In transfusions, the Rh system is next in importance after the ABO system. Most Rh-negative people who receive Rh-positive blood will develop anti-D antibodies. A later transfusion of Rh-positive blood could result in a severe or fatal transfusion reaction.
Rh incompatibility is the most common and severe cause of HDN. This incompatibility can happen when an Rh-negative woman and an Rh-positive man produce an Rh-positive baby. Cells from the baby can cross the placenta and enter the mother's bloodstream, causing the mother to make anti-D antibodies. Unlike ABO antibodies, the structure of anti-D antibodies makes it likely that they will cross the placenta and enter the baby's bloodstream. There, they can destroy the baby's red blood cells, causing severe or fatal anemia.
The first step in preventing HDN is to find out the Rh types of the expectant parents. If the mother is Rh-negative and the father is Rh-positive, the baby is at risk for developing HDN. The next step is to test the mother's serum to make sure she doesn't already have anti-D antibodies from a previous pregnancy or transfusion. This procedure is similar to blood typing. Finally, the Rh-negative mother is given an injection of Rh Immunoglobulin (RhIg) at 28 weeks of gestation and again after delivery, if the baby is Rh positive. The RhIg attaches to any Rh-positive cells from the baby in the mother's bloodstream, preventing them from triggering anti-D antibody production in the mother. An Rh-negative woman should also receive RhIg following a miscarriage, abortion, or ectopic pregnancy.
OTHER BLOOD GROUP SYSTEMS. Several other blood group systems may be involved in HDN and transfusion reactions, although they are much less frequent than ABO and Rh. They are the Duffy, Kell, Kidd, MNS, and P systems. Tests for antigens from these systems are not included in routine blood typing, but they are commonly used in paternity testing.
Like Rh antibodies, antibodies in these systems do not develop naturally, but as an immune response after transfusion or during pregnancy. An antibody screening test is done before a crossmatch to check for unexpected antibodies to antigens in these systems. A person's serum is mixed in a test tube with commercially-prepared cells containing antigens from these systems. If clumping occurs, the antibody is identified.
Crossmatching is the final step in pretransfusion testing. It is commonly referred to as compatibility testing, or "Type and Cross."
Before blood from a donor and the recipient are crossmatched, both are ABO and Rh typed. In addition, antibody screening is done to look for antibodies to certain Rh, Duffy, MNS, Kell, Kidd, and P system antigens. If an antibody to one of these antigens is found, only blood without that antigen will be compatible in a cross-match. This sequence must be repeated before each transfusion a person receives.
To begin the crossmatch, blood from a donor with the same ABO and Rh type as the rcipient is selected. In a test tube, serum from the patient is mixed with red blood cells from the donor. If clumping occurs, the blood is not compatible; if clumping does not occur, the blood is compatible. If an unexpected antibody is found in either the patient or the donor, the blood bank does further testing to make sure the blood is compatible.
In an emergency, when there is not enough time for blood typing and crossmatching, O red blood cells may be given, preferably Rh-negative. O blood type is called the universal donor because it has no ABO antigens for a patient's antibodies to attack. In contrast, AB blood type is called the universal recipient because it has no ABO antibodies to attack the antigens on transfused red blood cells. If there is time for blood typing, red blood cells of the recipient type (type specific cells) are given. In either case, the crossmatch is continued, even though the transfusion has begun.
To collect the 10 mL blood needed for these tests, a healthcare worker ties a tourniquet above the patient's elbow, locates a vein in the inner elbow region, and inserts a needle into that vein. Vacuum action draws the blood through the needle into an attached tube. Collection of the sample takes only a few minutes.
Blood typing and crossmatching must be done three days or less before a transfusion. A person doesn't need to change diet, medications, or activities before these tests. He should tell his healthcare provider if, during the last three months, he has received a blood transfusion or a plasma substitute, or has had a radiology procedure using intravenous contrast media. These can give false clumping reactions in both typing and crossmatching tests.
The possible side effects of any blood collection are discomfort or bruising at the site where the needle punctured the skin, as well as dizziness or fainting. Bruising is reduced if pressure is applied with a finger to the puncture site until the bleeding stops. Discomfort is treated with warm packs to the puncture site.
There are no risks from the blood collection or test procedures. Blood transfusions always have the risk of an unexpected transfusion reaction. A nurse watches a patient for signs of a reaction during the entire transfusion.
There is no normal blood type. The desired result of a crossmatch is that compatible donor blood is found. Compatibility testing procedures are designed to provide the safest blood product possible for the recipient, but a compatible crossmatch is no guarantee that an unexpected adverse reaction will not appear during the transfusion.
Except in an emergency, a person cannot receive a transfusion without a compatible crossmatch result.
American Association of Blood Banks. Technical Manual. 12th ed. Bethesda: American Association of Blood Banks, 1996.
Boral, Leonard I., and John B. Henry. "Transfusion Medicine." In Clinical Diagnosis and Management by Laboratory Methods. 19th ed. Ed. John B. Henry. Philadelphia: W. B. Saunders Co., 1996.
Daniels, Geoff. Human Blood Groups. Oxford: Blackwell, 1995.
Harmening, Denise M. Modern Blood Banking and Transfusion Practices. 3rd ed. Philadelphia: F. A. Davis, 1994.
Henry, John B., and Wendy V. Beadling. "Immunohematology." In Clinical Diagnosis and Management by Laboratory Methods. 19th ed. Ed. John B. Henry. Philadelphia: W. B. Saunders Co., 1996.
Silberstein, Leslie E., ed. Molecular and Functional Aspects of Blood Group Antigens. Bethesda: American Association of Blood Banks, 1995.
Beck, Malcolm L., and Lowell L. Tilzer. "Red Cell Compatibility Testing: A Perspective for the Future." Transfusion Medical Reviews (Apr. 1996): 118-130.
Widman, Frances. "Early Observations about the ABO Blood Groups." Transfusion (June 1997): 665-667.
American Association of Blood Banks. 8101 Glenbrook Road, Bethesda, MD 20814. (301) 907-6977. <http://www.aabb.org>.
American College of Obstetricians and Gynecologists. 409 12th Street, S.W., P.O. Box 96920
American Red Cross Blood Services. 430 17th Street NW, Washington, DC 20006. (202) 737-8300. <http://www.redcross.org>.
Nancy J. Nordenson
ABO blood type—Blood type based on the presence or absence of the A and B antigens on the red blood cells.
Antibody—A special protein made by the body as a defense against foreign material that enters the body. It is uniquely designed to attack and neutralize the specific antigen that triggered the immune response.
Antigen—Anything that causes the body to launch an immune response against that antigen through the production of antibodies.
Blood type—Blood categories based on the presence or absence of certain antigens on the red blood cells.
Crossmatch—A laboratory test done to confirm that blood from a donor and blood from the recipient are compatible.
Gene—A piece of DNA, located on a chromosome, that determines how traits such as blood type are inherited and expressed.
Immune response—The body's attack against an antigen that it considers foreign to itself. The attack begins with the production of antibodies against the antigen.
Rh blood type—Blood type based on the presence or absence of the D antigen on the red blood cells.
Transfusion—The therapeutic introduction of blood or a blood component into a patient's bloodstream.