The Association Between ABO Blood Type and Mortality Among Severely Injured Trauma Patients

The association between ABO blood type and outcomes following sudden cardiac arrest: a multicenter observational study

Background

ABO blood type has been associated with various disease outcomes, but its relationship with outcomes in patients with sudden cardiac arrest (SCA) remains unexplored.

Methods

This was a retrospective analysis of adult out-of-hospital cardiac arrest patients with SCA treated at three major branches of the National Taiwan University Hospital between January 2016 and July 2023. The variables examined for their possible influence on the neurological and survival outcomes of patients with SCA were sociodemographic characteristics, pre-existing diseases, resuscitation events, and blood type. The results of a multivariable logistic regression were reported as adjusted odds ratios (aORs) and 95% confidence intervals (CIs). Neurological outcomes were determined by the Cerebral Performance Category (CPC) scale at hospital discharge.

Results

No significant differences were found in the prevalence of each blood type between those who survived and those who did not or between those with good (CPC 1-2) or poor (CPC 3-5) neurological outcomes. There was no significant association between survival and blood type; however, patients with blood type AB had a higher probability of good neurological outcomes than those with blood type O (aOR: 1.98, 95% CI: 1.02-3.83, p = 0.042). A sensitivity analysis of the data from patients with aseptic etiologies also showed a significantly higher likelihood of good neurological outcomes among those with blood type AB (aOR: 2.21, 95% CI: 1.12-4.35, p = 0.023).

Conclusion

ABO blood type is not associated with survival in patients with SCA, but blood type AB is associated with better neurological outcomes than type O.

Association Between Blood Type and Mortality Among Severely Injured Patients Enrolled in the Pragmatic Randomized Optimal Platelet and Plasma Ratios Trial

INTRODUCTION

Previous studies suggested that type O blood may be associated with increased mortality and/or thrombotic complications among trauma patients. The purpose of this analysis was to evaluate the relationship between endogenous blood type, mortality, and complications among patients receiving massive transfusions, using data from the Pragmatic Randomized Optimal Platelet and Plasma Ratios trial.

MATERIALS AND METHODS

This was a secondary analysis of the Pragmatic Randomized Optimal Platelet and Plasma Ratios trial that included patients with the reported blood type (A, AB, B, or O) data. Outcomes were early and late mortality and clinical complications. Endogenous von Willebrand Factor (vWF) antigen levels, vWF activity, and factor VIII levels were measured with admission labs and compared. Logistical regression was used to assess associations between mortality and blood type.

RESULTS

Among 680 patients, 655 who had admission blood type data were included. 322 (49.2%) were type O, 186 (28.4%) were type A, 27 (4.1%) were type AB, and 120 (18.3%) were type B. The mean age, gender distribution, mechanism of injury, injury severity, and injury patterns were similar between blood types. There were significant racial and ethnic differences (P < 0.001 and P < 0.0018, respectively), and patients with endogenous type O blood had decreased levels of vWF activity and vWF antigen (P = 0.022 and P = 0.016, respectively). Logistical analyses showed no significant associations between blood type and complications, and type O blood was not associated with increased mortality.

CONCLUSIONS

We found that endogenous blood type was not associated with increased mortality or clinical complications in severely injured patients requiring massive transfusion based on the data from a large multicenter trial.

ABO blood type is not a risk factor of outcome in aneurysmal subarachnoid hemorrhage patients

BACKGROUND

The association between ABO blood types and outcome of aneurysm subarachnoid hemorrhage (aSAH) has not reached a conclusion. This study was performed to testify the difference of outcome between ABO blood types.

METHODS

663 aSAH patients hospitalized in the West China hospital were enrolled. The association between ABO blood types and outcomes including mortality and delayed cerebral ischemia (DCI) was verified by the univariate and multivariate logistic regression. Glasgow Outcome Score (GOS) at discharge, length of ICU stay, length of hospital stay were also compared between different ABO blood types.

RESULTS

663 aSAH patients were divided into four groups according to their ABO blood types: AB type (46, 6.9%), A type (211, 31.8%), B type (169, 25.4%),O type (237, 35.7%). The GCS, WFNS, Hunt Hess, modified Fisher, aneurysm location and incidence of intraventricular hemorrhage did not show different distribution among ABO blood types. Among four coagulation indexes, only the activated partial thromboplastin time (APTT) showed different distribution among ABO blood types (p < 0.001). The AB group had the lowest level of APTT while O group had the highest level of APTT. Outcomes including delayed cerebral ischemia, mortality, GOS, length of ICU stay, and length of hospital stay did not show any significant differences among ABO types. Univariate logistic regression showed the ABO blood type was not associated with the development of DCI (p = 0.654) and the mortality (p = 0.430). The multivariate logistic regression showed ABO blood types were still not associated with DCI and mortality after adjusting confounding effects of significant risk factors.

CONCLUSIONS

The ABO blood type is not associated with the prognosis of aSAH patients. ABO blood types may not be helpful on risk stratification of aSAH.

Trauma patients with type O blood exhibit unique multiomics signature with decreased lectin pathway of complement levels

BACKGROUND

Patients with type O blood may have an increased risk of hemorrhagic complications because of lower baseline levels of von Willebrand factor and factor VIII, but the transition to a mortality difference in trauma is less clear. We hypothesized that type O trauma patients will have differential proteomic and metabolomic signatures in response to trauma beyond von Willebrand factor and factor VIII alone.

METHODS

Patients meeting the highest level of trauma activation criteria were prospectively enrolled. Blood samples were collected upon arrival to the emergency department. Proteomic and metabolomic (multiomics) analyses of these samples were performed using liquid chromatography-mass spectrometry. Demographic, clinical, and multiomics data were compared between patients with type O blood versus all other patients.

RESULTS

There were 288 patients with multiomics data; 146 (51%) had type O blood. Demographics, injury patterns, and initial vital signs and laboratory measurements were not different between groups. Type O patients had increased lengths of stay (7 vs. 6 days, p = 0.041) and a trend toward decreased mortality secondary to traumatic brain injury compared with other causes (traumatic brain injury, 44.4% vs. 87.5%; p = 0.055). Type O patients had decreased levels of mannose-binding lectin and mannose-binding lectin-associated serine proteases 1 and 2, which are required for the initiation of the lectin pathway of complement activation. Type O patients also had metabolite differences signifying energy metabolism and mitochondrial dysfunction.

CONCLUSION

Blood type O patients have a unique multiomics signature, including decreased levels of proteins required to activate the lectin complement pathway. This may lead to overall decreased levels of complement activation and decreased systemic inflammation in the acute phase, possibly leading to a survival advantage, especially in traumatic brain injury. However, this may later impair healing. Future work will need to confirm these associations, and animal studies are needed to test therapeutic targets.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Impact of ABO blood group on mortality in trauma patients: A systematic review

BACKGROUND

Haemorrhage is a significant cause of death in trauma patients. There is evidence that individuals with blood group O have higher rates of non-traumatic haemorrhage. It has been suggested that blood group O may be associated with higher mortality in trauma, however existing evidence is limited and conflicting.

OBJECTIVE

A systematic review was conducted to evaluate the impact of ABO blood group on mortality in trauma patients.

METHODS

MEDLINE via OVID, the Cochrane library and grey literature were searched to identify studies investigating the effect of ABO blood group on mortality of trauma patients admitted to hospital. PRISMA guidelines were followed throughout, study quality was assessed using CASP checklists and certainty of evidence was evaluated using GRADE. Meta-analysis was precluded by significant study heterogeneity.

RESULTS

180 relevant records were screened and seven studies met inclusion criteria, representing 12,240 patients. Two studies found that there was a higher mortality in blood group O compared to other ABO groups. Included studies had substantial variability in methods and population. Study quality was variable with certainty of evidence rated as very low.

CONCLUSIONS

There is insufficient evidence to definitively establish an association between mortality and ABO group in trauma patients. In an age of increasingly individualised care, there is a need to determine the existence and cause for any association through further studies across multiple settings, trauma mechanisms and populations.

Blood group O is associated with ARDS development but exhibits lower mortality in the intensive care unit - A retrospective multicentre study

Background

Acute respiratory distress syndrome (ARDS) is a common cause of respiratory failure in the intensive care unit (ICU). Previous studies have suggested that blood group A increases the risk of developing ARDS following sepsis and major trauma. This study investigated the association between ABO and Rh blood groups and ARDS development and mortality in ARDS.

Methods

Patients admitted to the ICUs at Skåne University Hospital in Lund and Malmö, Sweden, in 2016 were retrospectively screened for ARDS according to the Berlin definition. Clinical data, patient characteristics, lab results, and survival data were collected from medical records and registry data. In addition, chest radiographs were reviewed by radiologists. ARDS development and 30-day mortality were analysed using multivariable logistic regression.

Results

A total of 1439 ICU patients were included. Of these, 10% had ARDS. Blood group O was associated with an increased risk of having or developing ARDS compared to blood group A (odds ratio [OR] 1.79, 95% confidence interval [CI] 1.13-2.84, p = 0.014). Among ARDS patients, blood group O had decreased 30-day mortality compared to blood group A (OR 0.25, 95% CI 0.09-0.67, p = 0.007). The Rh blood group was not associated with ARDS development or mortality.

Conclusion

In this study of ICU patients, blood group O was associated with an increased risk of having or developing ARDS but a decreased mortality in ARDS compared to blood group A. Further studies are needed to clarify the relationship and underlying mechanisms of the ABO blood group and ARDS.

Group B or not group B? An association between ABO, early mortality, and organ dysfunction in major trauma patients with shock

BACKGROUND

ABO blood group alters coagulation profiles in the general population and may influence outcomes after trauma. The relationship between trauma-induced coagulopathy, severe injury with hemorrhagic shock, and survival with respect to ABO group is unknown.

OBJECTIVES

In severe hemorrhagic trauma, we aimed to characterize the association of ABO group with admission coagulation profiles, mortality, and immune-mediated complications.

METHODS

Clinical and laboratory variables were examined from severely injured adult patients enrolled in a perpetual observational cohort study at a UK Major Trauma Center. Univariate and multivariate analyses were performed to determine differences in clinical outcomes (mortality, organ dysfunction, and critical care support). In a shock subgroup, we performed an exploratory analysis of rotational thromboelastometry parameters and coagulation biomarkers.

RESULTS

In 1119 trauma patients, we found no difference in mortality between ABO groups. In patients with shock, 24-hour mortality was significantly lower in group B vs non-B groups (7% vs 16%, adjusted odds ratio [aOR], 0.19; P = .030), but there were increased rates of invasive ventilation (aOR, 3.34; P = .033), renal replacement therapy (aOR, 2.55; P = .037), and a trend for infection (aOR, 1.85; P = .067). Comparing patients with shock, group B vs non-B patients had 40% higher fibrinogen, 65% higher factor (F) VIII, 36% higher FIX, 20% higher FXIII, and 19% higher von Willebrand factor.

CONCLUSION

In this observational study limited by single time-point sampling and subgroup analysis of trauma hemorrhage with shock, group B patients have enhanced hemostatic capability associated with early survival but with increased risk of immune-mediated complications.

Factor VIII: A Dynamic Modulator of Hemostasis and Thrombosis in Trauma

A trace amount of thrombin cleaves factor VIII (FVIII) into an active form (FVIIIa), which catalyzes FIXa-mediated activation of FX on the activated platelet surface. FVIII rapidly binds to von Willebrand factor (VWF) after secretion and becomes highly concentrated via VWF-platelet interaction at a site of endothelial inflammation or injury. Circulating levels of FVIII and VWF are influenced by age, blood type (nontype O > type O), and metabolic syndromes. In the latter, hypercoagulability is associated with chronic inflammation (known as thrombo-inflammation). In acute stress including trauma, releasable pools of FVIII/VWF are secreted from the Weibel-Palade bodies in the endothelium and then augment local platelet accumulation, thrombin generation, and leukocyte recruitment. Early systemic increases of FVIII/VWF (>200% of normal) levels in trauma result in a lower sensitivity of contact-activated clotting time (activated partial thromboplastin time [aPTT] or viscoelastic coagulation test [VCT]). However, in severely injured patients, multiple serine proteases (FXa plasmin and activated protein C [APC]) are locally activated and may be systemically released. Severity of traumatic injury correlates with prolonged aPTT and elevated activation markers of FXa, plasmin, and APC, culminating in a poor prognosis. In a subset of acute trauma patients, cryoprecipitate that contains fibrinogen, FVIII/VWF, and FXIII is theoretically advantageous over purified fibrinogen concentrate to promote stable clot formation, but comparative efficacy data are lacking. In chronic inflammation or subacute phase of trauma, elevated FVIII/VWF contributes to the pathogenesis of venous thrombosis by enhancing not only thrombin generation but also augmenting inflammatory functions. Future developments in coagulation monitoring specific to trauma patients, and targeted to enhancement or inhibition of FVIII/VWF, are likely to help clinicians gain better control of hemostasis and thromboprophylaxis. The main goal of this narrative is to review the physiological functions and regulations of FVIII and implications of FVIII in coagulation monitoring and thromboembolic complications in major trauma patients.

Mortality and outcomes by blood group in trauma patients: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

Blood group O contains lower levels of factor VIII and von Willebrand factor. Higher incidence of bleeding among group O is reported in multiple contexts. Results of studies vary regarding outcomes stratified by blood group in trauma. We systematically reviewed the literature for outcomes related to blood group in trauma patients. Meta-analysis of studies evaluating mortality related to blood group was performed.

MATERIALS AND METHODS

The PubMed and Embase databases were searched for studies analysing relationships between blood group and outcomes in trauma patients. Preferred Reporting Items in Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. We synthesized outcomes data related to blood group. Meta-analysis compared mortality rates between group O and non-O patients.

RESULTS

Inclusion criteria were met by 13 studies. Statistically significant differences by blood group were reported in 3 of 10 (30%) studies evaluating mortality, 2 of 3 (66.7%) evaluating mortality from haemorrhage and 2 of 9 (22.2%) evaluating transfusion requirement. Meta-analysis was performed on seven studies evaluating mortality (total n = 11,835). There was significant heterogeneity among studies (I²  = 86%, p < 0.00001). No difference was found in mortality between group O and non-O patients (relative risk = 1.21, 95% confidence interval = 0.89-1.64, p = 0.23).

CONCLUSION

Existing literature does not consistently demonstrate a mortality difference between trauma patients with O and non-O blood groups. High variability in the methods and results among studies limits this conclusion, and further research is needed to delineate under what circumstances blood group may influence outcomes.

Is Low-Titer Group O Whole Blood Truly a Universal Blood Product?

BACKGROUND

Whole blood was historically transfused as a type-specific product. Given recent advocacy for low-titer group O whole blood (LTOWB) as a universal blood product, we examined outcomes after LTOWB transfusion stratified by recipient blood groups.

STUDY DESIGN

Adult trauma patients receiving prehospital or in-hospital transfusion of LTOWB (November 2017 to July 2020) at a single trauma center were prospectively evaluated. The patients were divided into blood type groups (O, A, B, and AB). Major complications and survival to 30 days were compared. Univariate analyses among blood groups were followed by purposeful regression modeling, reflecting 6 variables of significance: male sex, White race, injury severity, arrival lactate, arrival systolic blood pressure, and emergency department blood products.

RESULTS

Of 1,075 patients receiving any LTOWB, 539 (50.1%) were Group O, 340 (31.6%) were Group A, 150 (14.0%) were Group B, and 46 (4.3%) were Group AB. There were no statistically significant differences in demographics, injury severity, hemolysis panels, prehospital vitals, or resuscitation parameters (all p > 0.05). However, arrival systolic pressure was lower (91 vs 102, p = 0.034) and lactate was worse (5.5 vs 4.1, p = 0.048) in Group B patients compared to other groups. While survival and most major complications did not differ across recipient groups, acute kidney injury (AKI) initially appeared higher for Group B. Stepwise regression did not show a difference in AKI rates. This analysis was repeated in patients receiving only component products. Group B again showed no significantly increased risk of AKI (13%) compared to other groups (O 7%, A 7%, AB 5%; p = 0.091).

CONCLUSIONS

LTOWB appears to be a safe product for universal use across all blood groups. Group B recipients arrived with worse physiologic values associated with hemorrhagic shock whether receiving LTOWB or standard component products.

BLOOD TYPE O IS A RISK FACTOR FOR HYPERFIBRINOLYSIS AND MASSIVE TRANSFUSION AFTER SEVERE INJURY

ABSTRACT

Background: Blood type O is the most common blood type and has lower von Willebrand factor (vWF) levels (25%-35% lower than non-O blood types). von Willebrand factor is important for initiating platelet attachment and binding factor VIII. We hypothesized that patients with type O blood are at an increased risk of trauma-induced coagulopathy and bleeding post injury. Study Design: Adult trauma activations with known blood type at a level I trauma center with field systolic blood pressure < 90 mm Hg were studied retrospectively. The relationships of blood group O versus non-O to coagulation assays, massive transfusion (MT), ventilator-free days, and mortality were adjusted for confounders. Hyperfibrinolysis (HF) was defined as thromboelastogram of percent lysis in 30 min > 3%, and fibrinolysis shutdown was defined as percent lysis in 30 min < 0.9%. von Willebrand factor activity was quantified on 212 injured patients using a STAGO apparatus. Results: Overall, 268 patients met criteria. Type O patients were more likely to develop HF than non-type O blood patients (43% vs. 29%, P = 0.06) and had significantly lower vWF activity (222% vs. 249%, P = 0.01). After adjustment for New Injury Severity Score and blunt mechanism, type O had higher odds of HF (odds ratio, 1.94, 95% confidence interval, 1.09-3.47) and increased odds of MT (odds ratio, 3.02; 95% confidence interval, 1.22-7.49). Other outcomes were not significantly affected. Conclusion: Type O patients with hypotension had increased HF and MT post injury, and these were associated with lower vWF activity. These findings have implications for the monitoring of HF in patients receiving type O whole-blood transfusions post injury.

Time to Hemostasis After Trauma and Transfusion by Patient Blood Type

BACKGROUND

Although evidence supports an increased risk of mortality after major trauma among patients with type O blood, the relationship between patient blood type and clinical outcomes aside from mortality has not been fully elucidated.

OBJECTIVE

To examine the relationship between patient blood type and time to hemostasis after trauma and massive transfusion.

METHODS

A secondary analysis of the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial was performed (N = 544). Blood type was dichotomized into type O versus non-type O. It was hypothesized that patients with non-type O blood would achieve hemostasis more quickly owing to the theoretical presence of increased clotting factors. Bivariate analysis and multiple Cox regression were conducted to test this assumption.

RESULTS

No significant difference was found in time to hemostasis between patients with type O blood and those with non-type O blood. However, mechanism of injury, diastolic blood pressure, and international normalized ratio affected the time to hemostasis in these trauma patients.

CONCLUSION

This study showed no significant difference in time to hemostasis by blood type.

ABO and RhD blood group are not associated with mortality and morbidity in critically ill patients; a multicentre observational study of 29 512 patients

Background

The ABO and RhD blood group represent antigens on the surface of erythrocytes. The ABO blood group antigens are also present on multiple other cells. Interestingly, previous studies have demonstrated associations between the blood group and many types of disease. The present study aimed to identifying associations between the ABO blood group, the RhD blood group, and morbidity and mortality in a mixed cohort and in six pre-defined subgroups of critically ill patients.

Methods

Adult patients admitted to any of the five intensive care units (ICUs) in the Scania Region, Sweden, between February 2007 and April 2021 were eligible for inclusion. The outcomes were mortality analysed at 28– and 90–days as well as at the end of observation and morbidity measured using days alive and free of (DAF) invasive ventilation (DAF ventilation) and DAF circulatory support, including vasopressors or inotropes (DAF circulation), maximum Sequential Organ Failure Assessment score (SOFAmax) the first 28 days after admission and length of stay. All outcomes were analysed in separate multivariable regression models adjusted for age and sex. In addition, in a sensitivity analysis, five subgroups of patients with the main diagnoses sepsis, septic shock, acute respiratory distress syndrome, cardiac arrest and trauma were analysed using the same separate multivariable regression models.

Results

In total, 29,512 unique patients were included in the analyses. There were no significant differences for any of the outcomes between non-O blood groups and blood group O, or between RhD blood groups. In the sensitivity analysis of subgroups, there were no differences in mortality between non-O blood groups and blood group O or between the RhD blood groups. AB was the most common blood group in the COVID-19 cohort.

Conclusions

The ABO and RhD blood group do not influence mortality or morbidity in a general critically ill patient population.

The impact of blood type on the mortality of patients with severe abdominal trauma: a multicenter observational study

Few studies have investigated the relationship between blood type and trauma outcomes according to the type of injury. We conducted a retrospective multicenter observational study in twelve emergency hospitals in Japan. Patients with isolated severe abdominal injury (abbreviated injury scale for the abdomen ≥ 3 and that for other organs < 3) that occurred between 2008 and 2018 were divided into four groups according to blood type. The association between blood type and mortality, ventilator-free days (VFD), and total transfusion volume were evaluated using univariate and multivariate regression models. A total of 920 patients were included, and were divided based on their blood type: O, 288 (31%); A, 345 (38%); B, 186 (20%); and AB, 101 (11%). Patients with type O had a higher in-hospital mortality rate than those of other blood types (22% vs. 13%, p < 0.001). This association was observed in multivariate analysis (adjusted odds ratio [95% confidence interval] = 1.48 [1.25–2.26], p = 0.012). Furthermore, type O was associated with significantly higher cause-specific mortalities, fewer VFD, and larger transfusion volumes. Blood type O was associated with significantly higher mortality and larger transfusion volumes in patients with isolated severe abdominal trauma.

The association of ABO blood groups and trauma outcomes: A retrospective analysis of 3779 patients

Background:

There is currently a lack of understanding regarding the link between ABO blood types with outcomes of traumatically injured patients. The purpose of this study was to determine the association of ABO blood types with outcomes in traumatically injured patients separated by injury type.

Methods:

This retrospective study evaluated trauma patients at an urban, Level 1 trauma center from January 1, 2017, through December 31, 2017. Patients were excluded if they were pregnant or <16 years old. Recorded outcomes included: ABO blood group, mortality, Injury Severity Score (ISS), race, injury type, mechanism of injury, and complications. Data analysis was performed using descriptive statistics including Chi-squared, Kruskal–Wallis, and F-test calculations.

Results:

A total of 3779 patients were included in this study. No significant differences were present in mean age or ISS between blood types. In patients with penetrating injuries, blood type O was associated with a significant increase in mortality (P = 0.017), red blood cell transfusion (P = 0.027), and massive transfusion protocol (MTP) (P = 0.026) compared to non-O blood types. In patients with blunt injuries, blood type AB was associated with a significant increase in mortality rate compared to non-AB blood types (P = 0.03).

Conclusion:

ABO blood type is connected with an underlying process which affects trauma outcomes, including mortality. Blood type O is associated with increased blood transfusion, MTP, and mortality during the initial hospitalization following a traumatic penetrating injury, while blood type AB is associated with increased mortality during the initial hospitalization following a blunt traumatic injury.

Trauma-induced coagulopathy

Uncontrolled haemorrhage is a major preventable cause of death in patients with traumatic injury. Trauma-induced coagulopathy (TIC) describes abnormal coagulation processes that are attributable to trauma. In the early hours of TIC development, hypocoagulability is typically present, resulting in bleeding, whereas later TIC is characterized by a hypercoagulable state associated with venous thromboembolism and multiple organ failure. Several pathophysiological mechanisms underlie TIC; tissue injury and shock synergistically provoke endothelial, immune system, platelet and clotting activation, which are accentuated by the 'lethal triad' (coagulopathy, hypothermia and acidosis). Traumatic brain injury also has a distinct role in TIC. Haemostatic abnormalities include fibrinogen depletion, inadequate thrombin generation, impaired platelet function and dysregulated fibrinolysis. Laboratory diagnosis is based on coagulation abnormalities detected by conventional or viscoelastic haemostatic assays; however, it does not always match the clinical condition. Management priorities are stopping blood loss and reversing shock by restoring circulating blood volume, to prevent or reduce the risk of worsening TIC. Various blood products can be used in resuscitation; however, there is no international agreement on the optimal composition of transfusion components. Tranexamic acid is used in pre-hospital settings selectively in the USA and more widely in Europe and other locations. Survivors of TIC experience high rates of morbidity, which affects short-term and long-term quality of life and functional outcome.