Article

Brief Communication

Ann Lab Med 2022; 42(1): 105-109

Published online January 1, 2022 https://doi.org/10.3343/alm.2022.42.1.105

Copyright © Korean Society for Laboratory Medicine.

Choice of ABO Group for Blood Component Transfusion in ABO-Incompatible Solid Organ Transplantation: A Questionnaire Survey in Korea and Guideline Proposal

Yousun Chung, M.D.1 , Dae-Hyun Ko, M.D., Ph.D.2 , Jihyang Lim, M.D., Ph.D.3 , Kyeong-Hee Kim, M.D., Ph.D.4 , and Hyungsuk Kim, M.D.5

1Department of Laboratory Medicine, Kangdong Sacred Heart Hospital, Seoul, Korea; 2Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea; 3Department of Laboratory Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea; 4Department of Laboratory Medicine, Dong-A University College of Medicine, Busan, Korea; 5Department of Laboratory Medicine, Seoul National University Hospital, Seoul, Korea

Correspondence to: Hyungsuk Kim, M.D.
Department of Laboratory Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea
Tel: +82-2-2072-3500
Fax: +82-2-747-0359
E-mail: hyungsuk.kim79@gmail.com

Dae-Hyun Ko, M.D., Ph.D.
Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea
Tel: +82-2-3010-4504
Fax: +82-2-478-0884
E-mail: daehyuni1118@amc.seoul.kr

Received: December 30, 2020; Revised: February 17, 2021; Accepted: July 20, 2021

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

The number of ABO-incompatible solid organ transplantations (ABOi SOTs) has markedly increased worldwide since the early 2000s. We investigated the choice of ABO group for blood component transfusion in ABOi SOT. We conducted a survey by e-mailing a questionnaire to blood bank specialists at 77 major hospitals in Korea, among whom 34 responded to the survey. In major ABOi SOT, for red blood cells (RBCs), the recipient’s type (70.6%) was the most common choice, followed by group O (29.4%); for platelets, group AB (50.0%) was the most common choice, followed by the donor type (38.2%); for plasma, group AB (55.9%) was the most common choice, followed by the donor type (32.4%). In bidirectional ABOi SOT, for RBCs, the recipient’s type (55.9%) was the most common choice, followed by group O (44.1%); for platelets and plasma, group AB was the most common choice (94.1% and 97.1%, respectively). The policies for transfusion in ABOi SOT were diverse. We suggest a guideline on the choice of ABO group for transfusion in ABOi SOT to secure patient health and enable an efficient use of blood components.

Keywords: ABO incompatible, Solid organ transplantation, Transfusion, Donor, Recipient, Blood component, Survey, Guideline, ABO blood group

Since the adoption of methods, such as plasmapheresis, and administration of immunosuppressive drugs that can successfully prevent hyperacute rejection, the number of ABO-incompatible solid organ transplantations (ABOi SOTs) has markedly increased in many countries. In Korea, in 2018, major and bidirectional ABO-incompatible transplantation accounted for 26.3% (342/1,301) and 22.9% (253/1,106) of living-donor kidney and living-donor liver transplantations, respectively [1]. Blood banks play an important role in the success of ABOi SOT, because they are responsible for the supply of various blood components during the perioperative period, including plasma for plasmapheresis. To avoid donor organ rejection or hemolytic transfusion reactions, it is important to select the appropriate ABO group for blood components. While transfusion guidelines for ABO-incompatible hematopoietic stem cell transplantation are well established [2], there is a lack of evidence-based guidance on blood component transfusion in ABOi SOT. To our knowledge, suggestions regarding the choice of ABO group for transfusion in ABOi SOT have been provided in only three sets of guidelines or textbooks [3-5], and the content and depth of the information given in these few existing publications differs. We investigated the ABOi SOT status in Korea and proposed guidelines on the choice of ABO group for blood component transfusion in ABOi SOT.

We conducted a survey from March to April 2020 by e-mailing a questionnaire to blood bank specialists at 77 major general hospitals in Korea. This study did not apply for ethics approval, as the information was based on professional opinion and did not involve clinical or animal experimentation. The survey items included information about the following: organs for which ABOi SOT was performed, average annual numbers of kidney and liver transplants, number of hospital beds, choice of ABO group for each blood component (red blood cells [RBCs], platelets, and plasma) for transfusion in major and bidirectional ABOi SOTs, duration of ABO non-identical transfusion after ABOi SOT, personnel who determine the ABO group for transfusion in ABOi SOT, and process for requesting blood components from blood banks in ABOi SOT. Additional descriptive survey questions were as follows: “(1) In case of transplanting organs of group A or B patients to group O patients, there are two opinions for the transfusion of platelets or plasma: platelets or plasma of group AB or that of the donor’s ABO group should be given. Which of these opinions do you support and why?” and “(2) If you have any additional suggestions on the choice of ABO group of blood components for transfusion in ABOi SOT, please feel free to describe.”

In total, 34 specialists performing ABOi SOTs at their hospital responded to the survey, and the major survey results are summarized in Table 1. For major ABOi SOT, the recipient’s ABO group was the most common choice of ABO group for RBCs (70.6%), followed by group O (29.4%); group AB was the most common choice for platelets (50.0%) and plasma (55.9%). For bidirectional ABOi SOT, the recipient’s ABO group was the most common choice of ABO group for RBCs (55.9%), followed by group O (44.1%); group AB was the most common choice for platelets (94.1%) and plasma (97.1%). ABO non-identical transfusion was maintained permanently in most of the hospitals (58.9%). Transfusion medicine specialists most commonly took the decision (70.6%) on the ABO group for transfusion in ABOi SOT. For the method for requesting blood components from the blood bank for transfusion in ABOi SOT, consultation with the transfusion medicine specialist was the most common answer (52.9%) (Table 2).

Table 1 . Characteristics of the 34 respondents performing ABOi SOT

VariableN (%)
Type of organ for which ABOi SOT was performed
Kidney and liver30 (88.3)
Kidney3 (8.8)
Liver1 (2.9)
Average annual number of kidney transplants
> 100 cases6 (17.7)
51–100 cases1 (2.9)
11–50 cases17 (50.0)
< 11 cases9 (26.4)
Not performed1 (2.9)
Average annual number of liver transplants
> 100 cases5 (14.7)
51–100 cases2 (5.9)
11–50 cases13 (38.2)
< 11 cases11 (32.4)
Not performed3 (8.8)
The number of hospital beds
> 1,500 beds4 (11.8)
1,000–1,500 beds7 (20.6)
500–999 beds23 (67.6)

Abbreviation: ABOi SOT, ABO-incompatible solid organ transplantation.



Table 2 . Policies for transfusion in ABO-incompatible solid organ transplantation among the 34 respondents

VariableN (%)
Choice of ABO group for blood component transfusion in major ABOi SOT
RBC
Recipient’s group24 (70.6)
Group O10 (29.4)
Platelets
Group AB17 (50.0)
Donor’s group13 (38.2)
Group AB or donor’s group2 (5.9)
Recipient’s group2 (5.9)
Plasma
Group AB19 (55.9)
Donor’s group11 (32.4)
Group AB or donor’s group3 (8.8)
Recipient’s group except for plasmapheresis in which group AB plasma was transfused1 (2.9)
Choice of ABO group for blood component transfusion in bidirectional ABOi SOT
RBC
Recipient’s group19 (55.9)
Group O15 (44.1)
Platelets
Group AB32 (94.1)
Recipient’s group2 (5.9)
Plasma
Group AB33 (97.1)
Recipient’s group except for plasmapheresis in which group AB plasma was transfused1 (2.9)
Duration of ABO non-identical transfusion after ABOi SOT
Permanent20 (58.9)
Six months1 (2.9)
Four weeks4 (11.8)
Three weeks1 (2.9)
Two weeks3 (8.8)
Depending on the patients’ condition3 (8.8)
No criteria1 (2.9)
No incompatible transfusion except for plasmapheresis1 (2.9)
Personnel who determine the ABO group of blood components
Specialist in transfusion medicine24 (70.6)
Physician5 (14.7)
Both by consultation5 (14.7)
Process for requesting blood components from blood banks
Consulting transfusion medicine specialist18 (52.9)
Specific system for ABOi SOT other than consultation8 (23.5)
By phone6 (17.7)
No difference from general transfusion request2 (5.9)

Abbreviations: ABOi SOT, ABO-incompatible solid organ transplantation; RBC, red blood cell.



For the descriptive question (1), approximately half of the respondents (19/34, 55.9%) answered “the donor’s ABO group” for the transfusion of platelets or plasma; of these, 11 chose this answer due to the lack of group AB plasma and platelets. Eleven of the 34 (32.4%) respondents answered “group AB;” of these eight chose this answer due to the need for workflow simplification to minimize transfusion accidents. Three of the 34 (8.8%) respondents answered that both group AB and the donor’s ABO group could be transfused, while one respondent of the 34 (2.9%) did not answer the question. For question (2), 11 respondents gave suggestions, nine among whom suggested a need for guidelines on the choice of ABO group for blood component transfusion in ABOi SOT. The other two respondents described difficulties in blood supply due to a shortage of group AB plasma.

This survey revealed that hospitals have different policies for blood component transfusion in ABOi SOT and that guidelines on the choice of ABO group for transfusion in ABOi SOT would be beneficial for clinical practice. We also found differences in the existing literature regarding the choice of ABO group for transfusion in ABOi SOT [3-5]. The recommendations of the British Society of Haematology (BSH) Guidelines on the spectrum of fresh frozen plasma and cryoprecipitate products [3] are summarized: following minor ABOi SOT, plasma components should be of the recipient’s ABO group; following major ABOi SOT, plasma should be of the donor’s ABO group until organ accommodation (usually four weeks after transplantation); and following bidirectional ABOi SOT, group AB plasma should be given until organ accommodation (usually four weeks after transplantation). These are grade 1C (strong) recommendations; however, they are based on low-quality evidence. The Australian and New Zealand Society of Blood Transfusion (ANZSBT) provides guidance regarding ABOi kidney transplantation, which relies on the understanding of the following basic principles of ABO incompatibility: during transplantation, recipients of a kidney from an ABOi donor should be transfused with blood products, particularly, plasma products, in which the ABO antibodies are compatible with the ABO group of the graft [4]. They also suggest that recipients should remain on their transplant transfusion protocol indefinitely, and specific product requirements should be determined in consultation with their nephrologist. Stotler, et al. [5] described that transfusion services should establish procedures to avoid the administration of plasma-rich blood components containing anti-A or anti-B antibodies directed against antigens expressed on donor organs. For example, they suggest a protocol utilizing not only group AB plasma and platelets, but also group A or B depending on the recipient and donor blood groups. One article describing the protocol used in a single institution in India suggested a relatively liberal use of group O RBCs and that the use of group AB plasma should be prioritized [6].

The transfusion of “universal” group AB platelets or plasma without consideration of donor and recipient ABO groups may be considered an easy way to avoid ABO antibody-mediated rejection; however, not only does it create problems, such as supply shortages, but it may also affect the quality of patient care [7]. Group AB plasma contains soluble A and B antigens that can bind to circulating anti-A or anti-B antibodies in the recipient, forming soluble high-molecular-weight immune complexes. These complexes can bind to RBCs, causing hemolysis, and to platelets, resulting in their activation and premature clearance from the circulation [8, 9]. Group O recipients transplanted with group A- or B-derived kidneys and transfused with “universal” group AB plasma reportedly had unfavorable outcomes when compared with group O recipients transplanted with group A- or B-derived kidneys and transfused with group A or B plasma identical to the donor’s ABO group [10].

Based on our survey results and previous publications, we suggest a guideline on the choice of ABO group for transfusion in major and bidirectional ABOi SOTs, considering the recipient’s and donor’s ABO groups (Table 3). For platelets and plasma, when group AB and the donor’s ABO group are both compatible, based on serologic principles of ABO incompatibility, e.g., in cases of group O recipients and group A or B donors, we suggest transfusion of the donor’s ABO group rather than group AB as the first choice. Not only would this help relieve the group AB plasma supply shortage, but it would also be prudent to deviate minimally from the donor’s ABO group, considering the abovementioned immunological problems. As for RBCs, we suggest transfusion of the recipient’s ABO group rather than the routine use of group O as the first choice, as unnecessary infusion of anti-A or anti-B antibodies against the recipient may induce hemolytic reactions, and should be avoided whenever possible. The BSH and ANZSBT have suggested the use of ABO non-identical plasma up to four weeks after transplantation and indefinitely, respectively [3, 4]. Although the isoagglutinin titer in patients after ABOi kidney transplantation remains at a significantly lower level than the initial level after such treatment [11], we believe there is insufficient long-term evidence to support these suggestions. As the mechanism of accommodation is not yet fully understood, reverting to the use of the recipient type plasma should be cautiously contemplated. We hope that this guideline on the choice of ABO group for transfusion in ABOi SOT will contribute towards securing patient health and enable an efficient use of blood components in the era of unpredictable blood supply shortage, especially for group AB plasma.

Table 3 . Choice of ABO group for blood component transfusion in ABOi SOT (modified from Ref. [12] with permission)

Type of incompatibilityRecipientDonorRBCsPlatelets and plasma


First choiceSecond choiceFirst choiceSecond choice
MajorOAONAAAB
OBONABAB
OABONAABNA
AABAOABNA
BABBOABNA
BidirectionalABAOABNA
BABOABNA

Abbreviations: ABOi SOT, ABO-incompatible solid organ transplantation; RBC, red blood cell; NA, not available.


We express our sincere gratitude to all the blood bank specialists who participated in the survey. We would also like to thank Editage (www.editage.co.kr) for English language editing.


Chung Y summarized the data and wrote the manuscript. Ko D-H designed the study and provided advice regarding the research methodology. Lim J and Kim K-H critically revised and supported the study. Kim H designed and supervised the study. All authors have reviewed and approved the manuscript.


The authors declare no potential conflicts of interest relevant to this article.


This study was supported by the research fund of the Quality Control Committee, Korean Society for Laboratory Medicine (KSLM Research Project 2020-02-007).

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