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ABO Forward and Reverse – Tube Method

PRINCIPLE
Testing with both Anti-A and Anti-B is necessary to determine if red blood cells possess or lack A and/or B blood
group antigens. Absence of agglutination is a negative test result, which indicates the corresponding antigen is
not demonstrable. Agglutination of red blood cells with a given reagent is a positive test result, which indicates
the presence of the corresponding antigen on the red blood cells. (Forward Type)
Direct agglutination of A1 or B reagent red cells with the patient serum/plasma indicates the
presence of the appropriate ABO antibody. (Reverse type)
Forward and reverse typing will be performed on samples for all patients greater than four months
of age to allow for discovery of subtypes as well as to confirm typing. Individuals less than
four months old may not have developed sufficient antibody to allow for detection.

SPECIMEN:
No special preparation of the patient is required prior to specimen collection. The specimen should be tested as
soon as possible after collection, but EDTA and clotted specimens may be stored at 2 to 8C for up to 10 days if
there is a delay in testing. (Note: Storage may result in weaker-than-normal reactions) Bacterial
contamination of the specimen may cause false test results.

REAGENTS:
● Blood Grouping Reagent: Anti-A and Anti-B (forward cells)
● Reagent red blood cells: A1 and B cells (reverse cells)
● Do not use beyond expiration date. Store at 2 to 8C. May be at room temperature (20 to 30C) while in use.

QUALITY CONTROL
To recognize reagent deterioration the reactivity of all blood grouping reagents should be confirmed on each day
of use by testing known positive and negative controls.

MATERIALS AND EQUIPMENT NOT SUPPLIED


Test tubes (12 x 75 mm), pipettes, physiologic saline, timer, centrifuge, as well as an optical aid.

1
TUBE METHOD PROCEDURE: (Bring all reagents to room temperature before testing)
Note: Steps 2 and 3 may be interchanged, but do it one way or the other. Be consistent.

Directions: Front Grouping


Step Action
1 Prepare a 3-5% suspension of red blood cells to be tested in isotonic saline. (Washed or
unwashed cells may be used)
2 Place 1 drop of Anti-A and Anti-B respectively, in two small, properly labeled test tubes
3 Add one drop of rbc suspension into the tube and mix.
4 Centrifuge the test tube for appropriate centrifuge time.*
5 Completely resuspend cells and examine macroscopically for agglutination.
Note: Hemolysis may be a consequence of bacterial contamination and should not be
interpreted as a positive result.
6 Grade and record results

*Note: Centrifuge spin and wash time are noted on each centrifuge.

Directions: Reverse Grouping – performed on individuals greater than 4 months old


Step Action
1 Label a test tube for each rbc reagent to be tested. (A1 or B).
2 Place two (2) drops of the serum/plasma into each labeled tube.
3 Add one (1) drop each of A1 cells and B cells to the appropriate tube.
4 Mix gently. Centrifuge the test tubes for appropriate centrifuge time.*
5 Completely resuspend cells and examine macroscopically for agglutination.
6 Grade and record results

*Note: Centrifuge spin and wash time are noted on each centrifuge.

***INTERPRETATION OF TEST RESULTS: + (agglutination) 0 (no agglutination)


Unknown cells with: Unknown serum with Interpretation Caucasian Freq. (%)
Anti-A Anti-B A1 cells B cells Group
+ 0 0 + A 40
0 + + 0 B 11
0 0 + + O 45
+ + 0 0 AB 4

2
NOTES AND LIMITATIONS
If the expected reactions are not obtained an interpretation of the patient’s ABO group cannot be made
without further testing. ABO discrepancies should be resolved before reporting or prior to transfusion.
However, Group O red blood cells is the preferred transfusion alternative for any recipient whose ABO group is
in question.
● Serum reverse group may be unreliable in infants under 6 months. Antibodies detectable in the serum
of infants prior to this age are most commonly of maternal origin.
● Serum from persons with agammaglobulinemia may not contain detectable ABO antibodies.
● The reactivity of Reagent Red Blood Cells may diminish over the dating period.
● Aged samples, subgroups, cold agglutinins, some diseased states, or patient age may impair test
results. (See below)***

***WEAK OR MISSING REACTION


● A weak or missing reaction in reverse typing may be due to a decreased titer of antibody in the
serum/plasma. The titer may be affected by age of sample, age of the patient, or certain diseased
states. If the titer is too low, agglutination after centrifugation may be decreased.
● If an expected agglutination is not present (or very weak): Either allow the tubes to sit 15-30 minutes
at room temp or in the refrigerator for 10-15 minutes. Resuspend the tubes, spin, read and record results
of 4C reaction. At this point the reverse type should be correct if the titer was weakened.

***Cold Agglutinin (esp. Anti-M and Anti-P1)


● If the patient's antibody screen demonstrates a cold agglutinin, the serum/plasma and cells for the
reverse typing may need to be prewarmed prior to adding the two together. Prewarm serum/plasma
and cells separately for approximately 10 minutes prior to the combination. After the combination
of the prewarmed samples, spin and read reactions.
● For a strong cold agglutinin: The patient's cells may need to be washed with prewarmed saline and
typing reagents incubated for the forward type.

***Multiple Myeloma patients may have abnormally high concentrations of serum proteins which will cause
tubes containing the patient's serum to appear agglutinated. If both tubes of the reverse type appear
agglutinated and should not be---question rouleaux.
● To disperse rouleaux: Add 1 – 3 drops of saline to the tube(s) that have the rouleaux formation. Mix and
centrifuge. Rouleaux formations tends to disperse, but antibody-mediated agglutination remains.

***A SUBGROUP -- A2
● When blood typing: If the Anti-A is positive and A1 cells are positive, an A2 may be present.
● When crossmatching a Group A person with A units and the units are incompatible, an A2 may
be present.
● Refer to the "Anti-A1 (lectin)" procedure for testing and additional information.

3
Anti-A1 (Lectin) Procedure
Step Action
1 Prepare a 3-5% suspension of red blood cells in isotonic saline.
2 To a labeled test tube: Add one drop of Anti-A1 Lectin.
3 Using a transfer pipette, add one (1) drop of the cell suspension.
4 Mix well and centrifuge.
5 Resuspend the cells by gentle agitation and examine macroscopically for agglutination.
6 Grade and record results

Controls: The reactivity of Anti-A1 lectin should be confirmed on the day of use by testing red cells known to
be positive and negative for A1. The reverse cells A1 and B may be used.
Test and control results must be interpreted immediately upon test completion.

INTERPRETATION OF TEST RESULTS:(for Anti-A1 Lectin)

1. Agglutination constitutes a positive test result and indicates the presence of A1. Most reactions are clear-
cut; however, A1B cells may show somewhat weaker reactions that A1 cells.

2. No agglutination constitutes a negative test result and indicates the absence of A1. Weak agglutination
may occur with some cells that are most properly classified as A2.
● Use Group O blood for crossmatching A2 patients,
● Use Group B or O blood for crossmatching A2B patients.

REPORTING
If the results indicate the patient is not an A1, report out an A2 or A2B in a blood type comment. (Most of the
20% of non-A1 patients are A2)

References:
Product Insert: Anti-A, Anti-B, Biotestcell-A1, A2 Biotest, 186183/07 10/2010
Technical Manual, AABB 17th Edition 2011

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