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Year : 2020  |  Volume : 14  |  Issue : 4  |  Page : 355-357

Are weak blood groups important to look for in kidney transplantation? A case report on interchanging blood groups

1 Department of Nephrology, Bombay Hospital, Mumbai, Maharashtra, India
2 Department of Nephrology, Apex Kidney Care, Mumbai, Maharashtra, India
3 Department of Immunohematology, Indian Council of Medical Research, Mumbai, Maharashtra, India
4 Department of Nephrology, Bombay Hospital; Department of Nephrology, Apex Kidney Care, Mumbai, Maharashtra, India

Date of Submission04-Aug-2020
Date of Acceptance05-Sep-2020
Date of Web Publication30-Dec-2020

Correspondence Address:
Dr. Viswanath Billa
Bombay Hospital, Mumbai, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijot.ijot_92_20

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The principles of ABO compatibility are fundamental to clinical solid organ transplantation, and conventional blood grouping techniques may mislabel patients with rare blood groups. We present a case of a kidney donor and her recipient who were mislabeled by conventional blood grouping methodology due to the presence of weak blood groups in both individuals, which were identified on detailed analysis, thus avoiding the need to undergo unnecessary desensitization protocols. The recipient underwent a successful transplant with the same donor and continues to do well 6 months after the transplant.

Keywords: ABO blood grouping, transplantation, weak blood groups

How to cite this article:
Ukirde V, Usulumarty D, Maru H, Billa V. Are weak blood groups important to look for in kidney transplantation? A case report on interchanging blood groups. Indian J Transplant 2020;14:355-7

How to cite this URL:
Ukirde V, Usulumarty D, Maru H, Billa V. Are weak blood groups important to look for in kidney transplantation? A case report on interchanging blood groups. Indian J Transplant [serial online] 2020 [cited 2021 May 14];14:355-7. Available from: https://www.ijtonline.in/text.asp?2020/14/4/355/305441

  Introduction Top

Accurate ABO grouping and crossmatching is the cornerstone of all ABO compatible organ transplants. While conventional methods identify blood groups accurately in most cases, rare and weak blood groups could occasionally be misread by these methods and need more specialized techniques for accuracy to avoid disasters arising from a mismatch.[1]

  Case Report Top

A living donor kidney transplant was planned for a 38-year-old woman with end-stage renal disease secondary to crescentic immunoglobulin A (IgA) nephropathy. The donor was her 59-year-old mother. Both of them underwent a pretransplant workup at a community pathology laboratory. Blood grouping was done by the conventional tube technique (CTT) and reported the donor and recipient's groups as “O” Rh positive and “B” Rh positive, respectively. The recipient had a single haplotype match with her mother and her crossmatch was negative for Class I and indeterminate for Class II antibodies (MFI-963) by the Luminex method. A day before surgery, blood grouping was repeated for confirmation, in the transplanting hospital by the column agglutination technique. The donor's and recipient's blood groups were now reported to be “A” Rh positive and “B” Rh positive, respectively. Due to this newly discovered blood group incompatibility, the transplant surgery was deferred.

The donor and recipient's blood and saliva samples were sent to the ICMR-National Institute of Immunohematology (NIIH), Mumbai, for advanced serological workup. A discrepancy in forward (cell) and reverse (serum) typing was observed [Table 1] by CTT. Confirmatory serological tests including absorption elution, ABO titers, and secretor status were carried out. Results showed the donor blood group as “A”weak RhD positive and recipient blood group as “AweakB” RhD positive. Both were nonsecretors for A, B, and H substances. Crossmatching between the donor's red cells and the recipient's serum was negative. The titer of anti-A antibody in the recipient was immunoglobulin G (IgG) 1:2 and immunoglobulin M (IgM) 1:4. Molecular testing identified gene mutations in both the donor and recipient.
Table 1: Serological findings of blood grouping, secretor status, and absorption elution found in renal transplant donor and recipient

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Having established compatibility, the patient was posted for the transplant surgery. She underwent two sessions of plasmapheresis out of abundant caution. This was followed by induction immunosuppression with antithymocyte globulin, 5 mg/kg over 3 days, to address the indeterminate Class II antibodies. She received maintenance immunosuppression with tacrolimus, mycophenolate mofetil, and steroids in standard dosages. The surgery was uneventful and renal recovery was good. The creatinine settled to 1 mg/dl on the 10th posttransplant day when she was discharged. Her anti-A titers were monitored periodically posttransplant [Table 2].
Table 2: Anti-A antibody titers in recipient serum before and after renal transplant

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  Discussion Top

The principles of ABO compatibility are fundamental to clinical solid organ transplantation.[1] Under certain circumstances, organs from donors with blood Group A2 can be transplanted across the ABO blood group barrier. During the past 25 years, the organ shortage has forced the development of desensitization protocols for ABO-incompatible kidney transplants.[2],[3],[4] However, the risks of infection and rejection are higher in such transplants.[5] Humans have naturally occurring IgM anti-A and/or anti-B in serum, constituting a major barrier against ABO-incompatible organ transplantation.[6],[7]

The two major subgroups of A, A1 and A2, are differentiated on the basis of reactivity of A1 cells but not A2 cells with anti-A1 lectin. Weak A are those blood Group A subjects whose erythrocytes give weaker reactions or are nonreactive with anti-A antisera and account for 0.02% of the people with blood group type A.[6] Similar subgroups have also be observed with B blood group subjects.[8],[9]

The first laboratory reported the donor blood group as O and the recipient blood group as B. However, results from the NIIH showed the presence of anti-A1 in the serum of both donor and recipient [Table 1]. In the donor, the forward typing with anti-A reagent was negative; and 1+ with anti-A, B reagent indicating the presence of a weak A blood group. In the recipient, forward typing showed 4+ agglutination with anti-B and negative with anti-A, respectively. Reverse typing in the recipient revealed +2 agglutination with anti-A1 cells. This suggests two possibilities – either the recipient's blood group is AweakB or the reverse typing was affected by cyclophosphamide that she received for her primary illness. The ICMR-NIIH results confirmed the donor to be Aweak and the recipient to be AweakB.

Townamchai et al. have reported successful kidney transplantation from AB para-Bombay blood type donor to O recipient without any complications.[10] Surendra et al. reported renal transplant from a mother with Bombay blood group to a daughter with A blood group and observed that desensitization is not required before transplantation.[11] Sachan et al. also reported the first case of successful live donor liver transplantation from a Bombay Rh positive donor to an A Rh positive recipient.[12] All these cases highlight the need to carry out cell/serum grouping and testing with lectins for A1 and H antigens routinely as a part of pretransplant workup.

In the present case, the recipient received two sessions of plasmapheresis pretransplant out of abundant caution. The preplasmapheresis titer of anti-A was 1:4 for IgM and 1:2 for IgG. Post plasmapheresis, the titers were zero, and the patient was transplanted. Post transplant, the titers were repeated at day 5 and weekly for the next 4 weeks [Table 2].

Data suggest that anti-ABO IgG titers are more important than IgM titers and recommend a titer < 1:8 for IgG antibodies in an ABO-incompatible transplant. Some studies suggest that IgM titers (>1:64) are associated with early acute rejection. Therefore, pretransplant anti-ABO IgG titers < 1:8 and anti-IgM < 1:64 would seem prudent.[13]

Our study was not without limitations. First, it represents the data from only one patient, and a pilot-scale study with a longer follow-up study would be more beneficial.

ABO genotyping is a valuable complement to serology for the correct determination of ABO blood group status. Thorough blood type evaluation must be carried out before transplantation and should also include A, B, and H antigens and antibodies. Traditional blood typing methods are simple, sensitive, and reliable, yet time-consuming and labor intensive. Molecular genetics can be an important tool to define an individual's ABO genotype and is less time-consuming.

In summary, accurate ABO typing is vital for kidney transplantation and should be confirmed with additional studies when initial blood grouping shows a discrepancy. Detailed workup on blood groups can help identify weaker subgroups of A and B or rare Bombay and para-Bombay phenotypes. To our knowledge, this is the first case of an apparent ABO incompatibility, where true compatibility was confirmed when weaker subgroups of A were identified in both the donor and recipient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity.


The authors would like to acknowledge:

  1. Dr. Manish Gandhi
  2. Dr. Swati Kulkarni
  3. Dr. Maya Parihar
  4. Dr. Manisha Madkaikar.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Rydberg L. ABO-incompatibility in solid organ transplantation. Transfus Med 2001;11:325-42.  Back to cited text no. 1
Uchida J, Machida Y, Iwai T, Naganuma T, Kitamoto K, Iguchi T, et al. Desensitization protocol in highly HLA-sensitized and ABO-incompatible high titer kidney transplantation. Transplant Proc 2010;42:3998-4002.  Back to cited text no. 2
Sivakumaran P, Vo AA, Villicana R, Peng A, Jordan SC, Pepkowitz SH, et al. Therapeutic plasma exchange for desensitization prior to transplantation in ABO-incompatible renal allografts. J Clin Apher 2009;24:155-60.  Back to cited text no. 3
Tobian AA, Shirey RS, Montgomery RA, Ness PM, King KE. The critical role of plasmapheresis in ABO-incompatible renal transplantation. Transfusion 2008;48:2453-60.  Back to cited text no. 4
Koo TY, Yang J. Current progress in ABO-incompatible kidney transplantation. Kidney Res Clin Pract 2015;34:170-9.  Back to cited text no. 5
Thakral B, Saluja K, Bajpai M, Sharma RR, Marwaha N. Importance of weak ABO subgroups. Lab Medi 2005;36:32-4.  Back to cited text no. 6
Landsteiner K, Levine P. On the inheritance and racial distribution of agglutinable properties of human blood. J Immunol 1930;18:87-94.  Back to cited text no. 7
Cartron JP, Gerbal A, Hughes-Jones NC, Salmon C. 'Weak A' phenotypes. Relationship between red cell agglutinability and antigen site density. Immunology 1974;27:723-7.  Back to cited text no. 8
Heier HE, Namork E, Calkovská Z, Sandin R, Kornstad L. Expression of A antigens on erythrocytes of weak blood group A subgroups. Vox Sang 1994;66:231-6.  Back to cited text no. 9
Townamchai N, Watanaboonyongcharoen P, Chancharoenthana W, Avihingsanon Y. A case of nearly mistaken AB para-Bombay blood group donor transplanted to a group 'O' recipient. BMJ Case Rep 2014 Oct 31;2014:bcr2014206374. doi: 10.1136/bcr-2014-206374.  Back to cited text no. 10
Surendra M, Raju SB, Reddy C. First case of renal transplantation involving a donor with Bombay phenotype blood group. Indian J Nephrol 2018;28:83-4.  Back to cited text no. 11
[PUBMED]  [Full text]  
Sachan D, Saha S, Kumar CK, Reddy SM, Kaliamoorthy I, Rela M. A rare Bombay (Oh) phenotype to 'A' blood group – Live donor liver transplant. Asian J Transfus Sci 2019;13:148-50.  Back to cited text no. 12
[PUBMED]  [Full text]  
Shin E, Kwon SW, Yang WS, Baeck C, Yu H, Cho H, et al. Long-term outcomes of ABO-Incompatible living donor kidney transplantation: A comparative analysis. Transplant Proc 2015;47:1720-6.  Back to cited text no. 13


  [Table 1], [Table 2]


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