Rev. Bras. Hematol. Hemoter. vol.38 número4

w w w . r b h h . o r g

Revista

Brasileira

de

Hematologia

e

Hemoterapia

Brazilian

Journal

of

Hematology

and

Hemotherapy

Review

article

Structural

diversity

and

biological

importance

of

ABO,

H,

Lewis

and

secretor

histo-blood

group

carbohydrates

Luiz

Carlos

de

Mattos

FaculdadedeMedicinadeSãoJosédoRioPreto(FAMERP),SãoJosédoRioPreto,SP,Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received30May2016 Accepted21July2016

Availableonline5September2016

Keywords:

Histo-bloodgroups ABOsystem Lewissystem Carbohydrateantigen Glycosyltransferases

a

b

s

t

r

a

c

t

ABO, H,secretor andLewishisto-bloodsystem genescontroltheexpressionofpartof the carbohydraterepertoire presentin areasof thebodyoccupied by microorganisms. Thesecarbohydrates,besideshavinggreatstructuraldiversity,actaspotentialreceptors forpathogenicandnon-pathogenicmicroorganismsinfluencingsusceptibilityand resis-tancetoinfectionandillness.Despitetheknowledgeofsomestructuralvariabilityofthese carbohydrateantigensandtheirpolymorphiclevelsofexpressionintissueandexocrine secretions,littleisknownabouttheirbiologicalimportanceandpotentialapplicationsin medicine. Thisreviewhighlightsthe structuraldiversity,the biologicalimportanceand potentialapplicationsofABO,H,Lewisandsecretorhisto-bloodcarbohydrates.

©2016Associac¸ ˜aoBrasileiradeHematologia,HemoterapiaeTerapiaCelular.Published byElsevierEditoraLtda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Therelationshipsbetweenhumansandmicroorganismsthat colonizetheirbodysurface,cavitiesandmucousmembranes beginatbirthandcontinuethroughoutlife.These relation-shipsincludeacontinuumofmutuallybeneficialconditions orotherwise(symbiosis,commensalism)aswellasinjuryto oneoftheparties(parasitism).1_{Someofthecarbohydrates}

expressedbytheepithelialcellsofthebodysurfaceaswell asinthegastrointestinal,respiratoryandgenitourinary sys-temsare closelyinvolvedintheserelationshipsand playa criticalroleinthesymbiosis,commensalismandparasitism continuum.2,3

∗ _{Correspondingauthorat:LaboratóriodeImunogenética,DepartamentodeBiologiaMolecular,AvenidaBrigadeiroFariaLima,5416,São}

JosédoRioPreto,SP,Brazil.

E-mailaddress:luiz.demattos@famerp.br

ABO (ABO, 9q34.1), H (FUT1, 19q13.3), secretor (FUT2, 19q.13.3)andLewis(FUT3:19p13.3)histo-bloodsystemgenes control the expression of part of the carbohydrate reper-toirepresentinareasoccupiedbymicroorganisms.2,4 _These

carbohydrates besides havinggreatstructuraldiversity, act as potential receptors for pathogenic and non-pathogenic microorganismsinfluencing susceptibilityandresistanceto infectionandillness.Itisbelievedthatthisstructuraldiversity results from environment pressure and plays an impor-tant role in the symbiosis, commensalism and parasitism continuum.2,5

Evidence supports the proposition that ABO, H, Lewis and secretor histo-blood group carbohydrates are related

http://dx.doi.org/10.1016/j.bjhh.2016.07.005

tosusceptibilityand resistancetoinfections andinfectious diseases.5–9 _{Experimental analyzes have clarified the}

bio-chemical and molecular basis underlying some of these relationships.10–12_{Thisreviewhighlightsthestructural}

diver-sityandbiologicalimportanceofABO,H,Lewisandsecretor histo-bloodcarbohydrates.

Histo-bloodgroupsystems

Theexpression“histo-bloodsystem” wasfirstproposed for the ABO system.13 _{Later, it was extended to H,Lewis and}

secretorsystems astheir carbohydrates arealso expressed inothertissuesandexocrinesecretions.14_{Thesehisto-blood}

groupsystemshavestrong relationshipsatgenomic, enzy-matic,biochemical,tissueandimmunelevels. Knowingthe structuralvariabilityoftheircarbohydrateantigensallowsus tounderstandtheevolutionaryimportanceandbiologicalrole especiallyintermsofdiseases.2

The International Society for Blood Transfusion (ISBT) WorkingPartyonRedCellImmunogeneticsandBloodGroup Terminologyidentifieseachbloodgroupsystemaccordingto its discovery ( http://www.isbtweb.org/working-parties/red-cell-immunogenetics-and-blood-group-terminology/). ABO, LewisandHhisto-bloodgroupsystemsareidentifiedbythe numbers001,007and018,respectively.Assecretorisnota trueblood groupsystem, it wasnotincludedamongthose recognizedbytheISBTWorkingParty.However,asitcontrols the expression ofABO and Lewis carbohydrates in tissues andexocrinesecretionsitmustbeconsideredanalloantigen system.15

Phenotypingofhisto-bloodgroupsystems

Histo-blood group systems are commonly identified by or inferred from red blood cell phenotyping. Different phe-notypes are known including ABO [A, B, AB, O], H [H, H-deficient], secretor [secretor, non-secretor] and Lewis [Le(a+b−),Le(a−b+),Le(a+b+), Le(a−b−)].16 TheABOsystem

is characterizedby the presenceor absence oftwo carbo-hydrateantigens(AandB)ontheredbloodcellmembrane andthreeregularantibodies(Anti-A,anti-B,anti-A,B)inthe bloodplasma.15 _{TheHsystemischaracterizedbythe}

pres-enceofonlyonecarbohydrateantigen(H)ontheredblood cell membrane.H-deficient individuals containoneregular antibody(anti-H) inthe blood plasma. Three rare typesof H-deficient phenotypes have been described: the classical Bombayphenotypewhichisnon-secretor,theH-partially defi-cientphenotypewhichisnon-secretorandthePara-Bombay phenotypewhichissecretor.15,16

SecretorsexpresstheABOcarbohydratesinexocrine secre-tions inaddition to inred blood cells.On the other hand, non-secretorsexpressABOcarbohydrates onlyinredblood cells.Le(a+b−)phenotypecorrelatestoanon-secretor

pheno-typewhileLe(a−b+)correlatestoasecretorphenotypeand

Le(a+b+)correlatestoaweaksecretorphenotype.Le(a−b−)

can besecretor or non-secretor. However,due to potential cross-reactivitybetweenanti-Lea _andanti-Leb _antiseraand eventheweakadsorptionofLea_andLeb_{carbohydratesinthe} redbloodcellmembrane,thiscorrelationisnotalwaystrue, particularlyindiseases.17,18

The identification of red blood cell phenotypes is com-monly based on an agglutination reaction with tests performed withslides,tubes, microplates,gelcolumn, and automation.19_{However,theresultsareaffectedbythemethod}

usedandthequalityofantiseraandcanbeinaccurate espe-ciallyinrelationtotheLewishisto-bloodgroupsystem.15,17

Therefore, red cell serologytechniques aloneare not suffi-cient to characterizethe structural diversityofhisto-blood group carbohydrates intissuesand exocrine secretions.As thegenesofthesehisto-bloodgroupsystemsallinteract,the combinationofserologyandgenotypingisagoodstrategyto predictthediversityofcarbohydratesexpressedintissuesand exocrinesecretions.17_{Additionally,immunochemistry,proton}

nuclearmagneticresonance(NMR)imagingandmass spec-trometry(MALDIandQ-TofMS/MS)areusefultoolstoresolve thecarbohydratestructureanddiversity;however,these tech-niquesandsomeofthereagents requiredarenotroutinely available.2

Histo-bloodgroupphenotypefrequenciesinpopulations

Sincethebeginningofthelastcentury,studiesonpopulation variability demonstratedthatthe histo-bloodgroup pheno-typesoccurinallpopulationsbuttheirfrequenciesvarywidely fromoneethnicitytoanother.20_{TheOphenotypeiscommon}

amongAfricansandSouthAmericannativeswhileAandB arecommoninNorthEuropeanandAsiancountries, respec-tively.H-deficientphenotypesarerareinallpopulationsbut theyaremorefrequentinIndiaandReunionIsland,located intheIndianOcean.Althoughpresentinallpopulations,the secretorphenotypeoccursin80%ofCaucasians.TheLe(a+b−)

phenotypeisfoundinmorethan20%ofCaucasiansandBlacks butitisrareinAsians.Le(a−b+)isfrequentinallpopulations

butLe(a+b+)ismorecommoninAsiansandPolynesiansthan populationsfromtheWesternworld.Le(a−b−)israrein

Cau-casiansbutiscommonamongBlacks.16,21 _{Thereasonswhy}

thedifferentialdistributionofhisto-bloodphenotypesoccurs atpopulationlevelarenotfullyunderstoodbutitisbelieved thatselectivepressureimposedbydisease-causing microor-ganismscontributedtothisprocess.9

Biochemicalbasisofhisto-bloodgroupcarbohydrates

ABO, H, secretor and Lewis histo-blood group carbohy-dratesarenotprimarygeneproducts.Theyaresynthesized by specificglycosyltransferases encodedbythe ABO, FUT1,

FUT2andFUT3genes.15_{Theseenzymesincorporate}

sequen-tially,monosaccharideunitstolinearorbranchedprecursor oligosaccharidechains,modifyingandcreatingnewantigenic specificities.16

Table1–Linearstructureofprecursoroligosaccharide chainsoftheABO,H,Lewisandsecretorhisto-blood groupsystems.

Types Terminalstructures Expressedforms

1 Gal␤1→3GlcNAc␤1-R Glycoproteins,glycolipids 2 Gal␤1→4GlcNAc␤1-R Glycoproteins,glycolipids 3 Gal␤1→3GalNAc␣1-R Glycolipids

4 Gal␤1→3GalNAc␤1-R Glycolipids 5 Gal␤1→3Gal␤1-R Syntheticstructure

6 Gal␤1→4Glc␤1-R Glycoproteins,glycolipids

Source:AdaptedfromOriol.16

Carbohydrateunitsandprecursoroligosaccharidechains

SixtypesofmonosaccharidesarefoundintheABO,H,Lewis and secretor histo-blood group carbohydrates: ␤-d-glucose (Glc),␤-d_{-N-acetylglucosamine(GlcNAc),␤-}d_{-galactose(Gal),} ␤-d-N-acetylgalactosamine (GalNAc), ␣-fucose (Fuc) and d -mannose (Man). Another monosaccharide carrying nine carbonatoms,␣-d-N-acetylneuraminicacid(NeuAc)mayalso befoundinthesecarbohydrates.l-Fucoseisthe immunodom-inantmonosaccharidepresentinH,Lea_andLeb_{carbohydrates} whileN-acetylgalactosamine(GalNAc)andgalactose(Gal)are the immunodominant monosaccharides present in A and ALeb_,andBandBLeb_{carbohydrates,respectively.}23

Sixtypesofprecursoroligosaccharide chainshavebeen characterized.Type1isfoundintheepitheliumofthe gas-trointestinal,respiratory,genitourinarytractsandinexocrine secretions.Type2ispredominantinhematopoietictissueand vascularendothelium.Type3canbefoundlinkedtomucins orasanextensionoftheAType2carbohydrateduetothe additionofaGalactosetotheterminalN-acetylgalactosamine. Type4isabundantinrenaltissue. Type5issyntheticand has not yet been isolated from human tissues. Type 6 is foundinhumanintestinalcells.Theglycosylationofanyof theseprecursoroligosaccharidechainsgiverisetodifferent carbohydrateantigens,whichmaydifferinthespatial con-formationand affinity to monoclonalantibodies.13,16,18,23,24

Table 1 shows the linear structures of the six precursor oligosaccharidechains.

ThestructuraldiversityoftheABO,H,Lewisandsecretor histo-blood group carbohydrates is enormous and influ-enced by a range of factors. The type of monosaccharide and the glycosidic bond between them, the ionic charge,

thecarbon ringsize,thelinearityand branching,thechain extension, and ␣ and ␤ anomeric conformations, result in more than 1.05×1012 possible structural combinations

that can be obtained from the combinations of these six monosaccharides.25_{Additionally,thestructuraldifferencesin}

these precursoroligosaccharides favorstructuralvariability and raise the complexity of the carbohydrate repertoirein tissuesandexocrinesecretions.2

Histo-bloodgroupglycosyltransferases

TheglycosyltransferasesactingonthebiosynthesisofABO,H, secretorandLewishisto-bloodgroupcarbohydratesare struc-turallyrelatedtotypeIItransmembraneglycosyltransferases andhavesomecommoncharacteristics.23_Theyrequire

uri-dinediphosphate(UDP)andguanidinediphosphate(GDP)as nucleotidesugardonorsaswellasdivalentionsto sequen-tially incorporatemonosaccharide units into the precursor oligosaccharidechains.26_{TomodifyandcreatenewABO,H,}

Lewisandsecretorhisto-bloodgroupcarbohydratestructures, some of these enzymes compete for the same precursor. Thereforethepresence,absenceorcombinationofthese gly-cosyltransferaseswilldeterminethequalityandthequantity ofcarbohydratesexpressedbyindividuals.2,15_{Table2presents}

generalcharacteristicsofthehisto-bloodgroup glycosyltrans-ferasesandthecarbohydrateantigenssynthesized.

Someglycosyltransferasesactingonthehisto-bloodgroup carbohydrate biosynthesis haveredundancy and degenera-tion. Redundancyisobserved whentwo separateenzymes synthesizethesameantigen.Forexample,FUT1gene-defined fucosyltransferaseandFUT2gene-definedfucosyltransferase arecapableofsynthesizingtheHType2carbohydratefromthe sameprecursoroligosaccharide(Type2).Degenerationoccurs whenthe same enzymesynthesizesdifferent carbohydrate structures.Forexample,FUT2gene-definedfucosyltransferase iscapableofsynthesizingHType1andHType2carbohydrates fromtheirrespectiveType1andType2precursor oligosaccha-rides.TherarephenotypesB(A)andA(B)whichillustratethe synthesisofsmallamountsofAcarbohydratebythegroupB galactosyltransferase(GTB)andviceversaisanother exam-ple of degeneration in the ABO histo-blood group system. Additionally,FUT3gene-definedfucosyltransferaseiscapable ofsynthesizingatleastfourdifferenthisto-bloodgroup car-bohydrates(Lea_{, Le}b_,ALea_{and ALe}b_{)derivedfromthetype}

Table2–ABO,H,Lewisandsecretorhisto-bloodgroupsystems,genelocation,glycosyltransferasesandsynthesized carbohydratestructuresoftype1andtype2precursoroligosaccharides.

Systems Genea _Chromosome

location

Enzyme Abbreviation ECb _Nucleotide

donor

Synthesized carbohydrate

H FUT1 19q13.3 ␣1,2-Fucosyltransferase FUTI 2.4.1.69 GDP Htype2

Secretor FUT2 19q13.3 ␣1,2-Fucosyltransferase FUTII 2.4.1.69 GDP Htype1

Lewis FUT3 19p13.3 ␣1,3/4-Fucosyltransferase FUTIII 2.4.1.65 GDP Lea_,Leb_,ALeb_,BLeb

ABO ABO 9q.34.1 ␣1,3-N-Acetylgalactosaminiltransferase GTA 2.4.1.40 UDP Atype1,Atype2

␣1,3-D-Galactosyltransferase GTB 2.4.1.37 UDP Btype1,Btype2

Source:AdaptedfromSchenkel-Brunner.23

EC:EnzymeCommissionNumber;GDP:guanidinediphosphate;UDP:uridinediphosphate.

1precursoroligosaccharide.27_{Redundancyanddegeneration}

create additional levels ofcomplexity in these histo-blood groupsystems.16_{Thelevelofexpressionaswellasthe}

loca-tionoftheseenzymesintheGolgicompartmentsinfluence theircompetitionformonosaccharidedonorsandacceptors, determiningvariationsinthetype,sizeandamountofeach synthesizedcarbohydratestructure.15

Biosynthesisofhisto-bloodgroupcarbohydrates

Thehisto-bloodgroupcarbohydratessynthesizedfromtype2 precursoroligosaccharidesareintrinsictotheredbloodcell membraneas theyare expressed byred blood cell precur-sorcells.However,thosesynthesizedfromtype1precursor oligosaccharide(A,B,H,Lea_andLeb_{)areextrinsicsincethey} originateintheliver,pancreas,kidneyandsmallintestine,are transportedfromtheirplaceofsynthesistothebloodplasma andthenadsorbedintotheredbloodcellmembrane.27,28

The biosynthesis of ABO, H, Lewis and secretor histo-blood carbohydrates is a complex event and dependent on interactions between FUTI, FUTII, FUTIII, group A N-acetylglucosaminyltransferase (GTA) and GTB proteins.27

FUTI,GTA and GTBallowthe synthesisofH,Aand B car-bohydratesfromtype2oligosaccharidesinmesodermaland hematopoietic tissues and vascular endothelium.29 _FUTII,

FUTIII,GTAandGTBallowthesynthesisofH,A,B,Lea_,Leb_, ALeb_andBLeb_{carbohydratesfromthetype1oligosaccharides} inectodermaltissuessuchasthegut,respiratoryandurinary mucosaeandexocrinesecretions.16_{Therefore,these}

interac-tionsresultinadifferenttissueprofileofcarbohydratestothat foundontheredbloodcellmembrane.2,15

Additionalcomplexitiesoccuratatissuelevel.For exam-ple,theexpressionofABOandLewiscarbohydratesonpyloric and duodenal mucosae isrelated to the migrationofcells fromBrunnerglands.30_{Cellsmigratingtothesurfaceofthe}

gastricandduodenalepitheliumexpressABOandLewis car-bohydratesunderthecontrolofFUTII,FUTIII,GTAandGTB. ThosemigratingtodeepareasoftheBrunnerglandsexpress these carbohydrates under the control of FUTI, GTA and GTB.16

ThesynthesisofABOcarbohydratesissimilarin mesoder-maltissuesasinectodermaltissuesbutunderdistinctgenetic control.FUTIactslikeFUTIIbutitgenerallyusestype2 pre-cursoroligosaccharidestoformtheHtype2carbohydrates.H type2carbohydratescanbeconvertedintoAtype2andBtype 2carbohydratesbyGTAandGTB,respectively.15,16_Despitethe

reduceddiversity,thesetype2carbohydratesare crucialin transfusionproceduresandsolidorgantransplantation.

Inectodermaltissues,FUTIItransfersaFucunitthrougha ␣1→2glycosidicbondtothecarbon2oftheterminalGalof

thetype1precursoroligosaccharidebuildinguptheHtype1 carbohydrate.ThisstructurecanbeconvertedintoAtype1or Btype1byGTAorGTB,respectively.GTAaddsaGal-NAcunit througha␣1→3glycosidicbondtocarbon3oftheterminalGal

oftheHtype1carbohydrate.GTBaddsaGalmonosaccharide througha␣1→3glycosidicbondtocarbon3oftheterminal

GaloftheHtype1carbohydrate.31

ThesynthesisofLewisantigensoccursindifferentorgans increasing the complexity of histo-blood group systems.

FUTIIIcreatesnewantigenicspecificityanddiversifiesthe pre-vious carbohydrates bythesynthesisofLea_{, Le}b_{, ALe}b _and BLeb_{.ItincorporatesaFucmoleculebya␣1→4glycosidicbond} tocarbon4ofthesubterminalGlc-NAcofthetype1 precur-soroligosaccharidetoformtheLea_{carbohydrate.Bythesame} reaction,FTUIIIformstheLeb_{carbohydratefromtheHtype1} antigen.FUTIIIcanaddasecondFucunitbya␣1→4glycosidic

bondtothecarbon 4oftheN-acetylglucosamine subtermi-nalantigensAand B,converting theminto ALeb _{and BLe}b carbohydrates,respectively.16

TheroleofthefunctionalFUTIIiscrucialtotheactionof other histo-bloodgroup glycosyltransferasesindiversifying thehisto-bloodgroupcarbohydratesinsecretors.It synthe-sizesthe Htype1carbohydrate,thecommon substratefor GTA,GTBandFUTIII.Thus,theseenzymescompeteforthe samesubstrateandtheirefficiencywilldeterminethelevelof expressionofeachcarbohydratestructure.Forexample,due totheabsenceofGTAandGTB,theOphenotypeexpressesa highleveloftheLeb_{carbohydrate.Ontheotherhand,theA,B} andABphenotypesexpressmoreALeb_andBLeb_thanLeb car-bohydrates.Sincenon-secretorsdonotexpressanactiveFUTII theywillformtheLea_{carbohydratefromthetype1precursor} oligosaccharideiftheycarryafunctionalFUTIIIindependent oftheirABO phenotype.15,16,21 _{For example,this setof}

gly-cosylation processes seems to modulate innate immunity responsesinthemucosaandmaycontributetotheriskof gas-tricdiseasebyreducingthebacterialdensityandassociated inflammationinHelicobacterpyloriinfection.32

Alternativenomenclatureforhisto-bloodgroup carbohydrates

ABO, secretor and Lewis carbohydrates can be named by thenumberofmonosaccharideunitspresentintheir struc-ture and by the type of precursor oligosaccharide. For instance, A-4-6 refers to A carbohydrate antigen carrying fourmonosaccharideunitsderivedfromthetype6precursor oligosaccharide whileH-5-2 referstoH carbohydrate speci-ficity with five monosaccharide units derived from type 2 precursor oligosaccharide.31 _{All these carbohydrates react}

withcommercialpolyclonalandmonoclonalantibodies but they present distinct spatial conformations which can be recognized bysomespecific monoclonalantibodiesas well asmicrobialadhesins.18,33,34 _{Figure1illustratesthe}

biosyn-thesis of histo-blood group carbohydrates from the type1 precursoroligosaccharide.Table3containsthecombinations ofhisto-bloodgroupglycosyltransferases,thecarbohydrates expressed,andthemucosaandredbloodcellphenotypes.

Carbohydratestructuralvariationsincommonandrare histo-bloodgroups

Galβ1→3GlcNAc-R

Galβ1→3GlcNAc-R

Galβ1→3GlcNAc-R

GalNAcα1→3Galβ1→3GlcNAc-R

GalNAcα1→3Galβ1→3GlcNAc-R

Galα1→3Galβ1→3GlcNAc-R

Galα1→3Galβ1→3GlcNAc-R

Galβ1→3GlcNAc-R

Fuc Fuc α1→2

α1→2 α1→2

α1→2 α1→4 α1→2 α1→4

α1→2 α1→4 α1→4

FUTIII

FUTII

FUTIII

FUTIII _FUTIII

H type 1

A type 1 Fuc B type 1

Fuc Fuc BLeb Fuc Fuc

ALeb

Fuc Fuc

GTA GTB

Fuc Lea

Leb

Figure1–BiosynthesisofABH-Lewisfromtype1precursoroligosaccharides.Guanidinediphosphateanduridine diphosphateindicatethemonosaccharidedonors.

Source_{:AdaptedfromOriol}16_{andSchenkel-Brunner.}23

Anti-A,Bantibodiescanreactwiththecommonportionsof thesecarbohydrates.25

A1,A2andsomerareABOsubgroupsalsopresent struc-tural differences in their carbohydrates as revealed by an analysisofglycolipids.Immunochemicalstudiesbythinlayer chromatographyandmonoclonalantibodiesdemonstrateda predominanceoftheAtype4carbohydrateintheA1 com-paredtotheA2subgroup.34_{Additionally,novelcarbohydrate}

structuralvariationswereobservedinweakAsubgroups.33

ThesestudiessuggestthatmutationsintheAgeneallowthe

expressionofvariantGTAwhichseemstobepotentiallyable tosynthesizeanovelABOcarbohydratestructure.

Lea_andLeb_{differnotonlybythenumberofFucunits,but} alsobythelengthoftheoligosaccharidechains.TheLea car-bohydrateismonofucosylatedandLeb_{isdifucosylated.While} thesechainsareshortinLeb_{theyareelongatedinmost} car-bohydratescarryingLea_specificity.24,35_{Thesedifferencesare}

coincident, respectively, withthe presence and absence of afunctionalFUT2gene-definedfucosyltransferase.The rea-sonsforthesedifferencesarenottotallyunderstoodfromthe

Table3–Histo-bloodgroupglycosyltransferases,carbohydratesandmucosaandredbloodcellphenotypes.

ABO FUTII FUTIII Carbohydrates Mucosaphenotypes Redbloodcell phenotypes

A,B,AB,O Active Active H,Aand/orB Lea_,Leb_,ALeb_,BLeb

Secretor Lewispositive

A,B,AB,O Le(a−b+)

A,B,AB,O Active Inactive H,Aand/orB Secretor Lewisnegative

A,B,AB,O Le(a−b−)

A,B,AB,O Inactive Active Lea _Non-secretor

Lewispositive

A,B,AB,O Le(a+b−)

A,B,AB,O Inactive Inactive POa _Non-secretor

Lewisnegative

A,B,AB,O Le(a−b−)

evolutionaryperspectivebutitispossiblethattheyresultfrom biologicalpressurebymicroorganismsthatcolonizeareasof thebodywherethesecarbohydratesareexpressed.2

Appar-ently,theepitopesofLea_{extendedcarbohydratesofferbetter} accesstoanti-Lea _{antibodies,reducingcrossreactivity} com-paredtoanti-Leb_.18

Variabilityandbiologicalimportanceofhisto-bloodgroup carbohydrates

Theenvironmentexertsconstant pressureon livingbeings anddrivesthemtocreatediversityinordertoevolveandbe perpetuatedinnaturewiththemaintenanceofdiversitybeing regulatedbytheselectionofthebestadaptation.Since diver-sityresultsdirectlyfromgeneticvariations,microorganisms anddiseasesareessentialfactorsthatactintheselectionand maintenanceofspeciesdiversity.36–39

Theactivity ofFUTI, FUTII,FUTIII, GTA and GTB inthe glycosylation of precursor oligosaccharides, besides creat-ing new antigenic structures, diversifies the pre-existent structuresallowingahighdegreeofvariability.2_The

variabil-ity ofhisto-bloodgroup carbohydrates extends beyondthe boundariesofgeneandglycosyltransferasepolymorphisms.40

Distinctlevelsofglycosylationinprecursoroligosaccharides areresponsibleforthecarbohydratestructuraldiversityand thepolymorphismsseenintheseantigenicsystems.Thefirst level,controlledbyFUTIII,resultsinthesynthesisoftheLea carbohydrate.Thesecondlevel,controlledbyFUTIandFUTII, resultsintheexpressionofHtype2andHtype1 carbohy-drates,respectively.Atthethirdlevel,controlledbyFUTIII,the Htype1antigenisconvertedintoLeb_{.GTAandGTBactatthe} fourthlevelallowingthesynthesisofAtype1andBtype1, andAtype2andBtype2carbohydratesfromHtype1and type2carbohydrates,respectively.Finally,thefifthlevel,also controlledbytheFUTIIIenzyme,resultsintheconversionof Atype1intoALeb_{andBtype1intoBLe}b_.16

FUTI, FUTII, FUTIII, GTA and GTB create ␣-glycosidic bondstoincorporateeachmonosaccharideunitinprecursor oligosaccharides.However, the inner core of these precur-sorscontains␤-glycosidicbonds.23 _{Maybethisfeaturestops}

pathogenicmicroorganismsabletoproduce␤-glucosidaseto usehisto-bloodgroupcarbohydrates asreceptorsby break-ingglycosidebondsof␤-glycosylatedoligosaccharidechains. This suggests a potential reason for the abundance of ␣-carbohydrate structuresin the gastrointestinal,respiratory, andgenitourinarytractsandexocrinesecretions.Thesesites areinhabitedbygreatdiversityofmicroorganismsand itis possiblethat the ␣-glycosidicbondsprotect the inner core oftheprecursoroligosaccharidesfrommicrobial exoglycosi-dasesattack.2

Currently,thereisstrongevidencethatthesehisto-blood group carbohydrates and the microbial adhesins that rec-ognize them are important links in the relationship that humans have withthe microorganisms that colonizetheir bodysurface,cavitiesandmucosa.5,8,41,42 _{Thenatureofthe}

interactions betweenparasites and their hostsis complex, but it is also possible that the ABO, secretor and Lewis histo-bloodgroupcarbohydratesrepresentimportantpieces inthisprocess.Maybe thehisto-bloodgroup glycosyltrans-ferases have evolved to control the part of synthesis of

oligosaccharidesexpressedinthegastrointestinal,respiratory and genitourinary tracts through glycosylation and struc-turaldiversification.Thisstrategymayrepresentanimportant biological event in the change of potential receptors for pathogenic microorganisms. Therefore, the contribution of ABO, H, secretor and Lewis histo-blood group systems in thediversityofpopulationsmaybeassociatedwithgreater chanceofsuccessofourspeciesinepidemicevents.2

In thisscenario, ABO,H,secretor and Lewishisto-blood group systems contribute withtheir different polymorphic levels tothe ethnic diversity ofthe humanspecies acting throughmechanismsofevolutionsuchasgeneflow,genetic drift, founder effect, and natural selection.36,43 _Through

glycosylation and structural diversification of precursor oligosaccharides,thesesystemsinfluencetheglycoconjugate repertoireexpressedinmucosaeandexocrinesecretions.40,42

Consequently,theyaffecttheinnateimmuneresponse, sus-ceptibility to infections and the parasitism,symbiosis and commensalismcontinuum.1,42,44

Medicalimportanceofhisto-bloodgroupcarbohydrates

Thecarbohydratevariabilityresultingfromthesehisto-blood group systemshas importantimplications insusceptibility toinfections,innateand adaptive immuneresponses, can-cer,solidorgantransplantationaswellasnewtechnologies appliedtobloodtransfusion.Due tothe simplicityandlow costofidentifyinghisto-bloodgroupphenotypesinredblood cells,alargenumberofindependent,quick,simplestudies explored them as potential markers fordiseases. Many of themdidnotconsiderthediversityofcarbohydratesinthe tissuesinfectedbymicroorganismsaswellasthestrainsor serotypesofthesamemicroorganismamongotherpossible confoundingfactors.44_{However,somewell-designedstudies}

providedabetterunderstandingofthepotentialrelationships between histo-blood group carbohydrates and microorgan-ismsaswellastheirethnicdistributionworldwide.

Helicobacterpyloristrainsexpressingthebloodgroup

bind-ingadhesin(BAbA)areabletobindtotheLeb _carbohydrate thatishighlyexpressedingastricepithelialcellsrelatedtoO andsecretorhisto-bloodgroups.45_{Additionally,the}

observa-tionthatSouthAmericanspecialiststrainsofH.pyloriaremore abletobindtoHtype1andLeb_{carbohydratesthangeneralist} strainsthatareabletobindtootherhisto-bloodgroup carbo-hydratesiscoincidentwiththepredominanceoftheOblood groupinAmerindians.46_{Thesestudiesofferedone}

explana-tionforanoldenigma:WhyindividualswiththeObloodgroup aremorepronetogastroduodenaldiseasessuchasgastritis andpepticulcers.

ItisbelievedthatthelowandhighfrequenciesofOand B blood groups, respectively, in some areas ofBangladesh are relatedtoselectivepressureimposed bytheseverityof cholera.47_{Theseverityofthisdiseaseisrelatedtothecholera}

toxin secreted by Vibrio cholera that binds more strongly to the H type 1 carbohydrate than the B carbohydrate.48

AnothersuggestionisthatthehighfrequencyoftheOblood group in endemic areas of malaria results from selective pressure related to the severity of this disease caused by

Plasmodiumfalciparum.49_{Theseauthorshypothesizethat}

Table4–Examplesofassociationsbetweensomehisto-bloodgroupphenotypesandmicroorganisms.

Microorganisms Histo-bloodgroupphenotypes Biologicaleffects

Gastrointestinaltract

Helicobacterpylori O,Le(a−b+) Pepticulcers,Gastritis

Escherichiacoli B Gastrointestinalinfection

Giardialamblia A Re-infestation

Toxoplasmagondii B Notdetermined

Candidaalbicans O,non-secretor Gastricinflammation

Vibriocholera O,Le(a+b−) Severediarrhea

Salmonellatyphimurium B Typhoidfever

Norovirus Non-secretor Gastroenteritis

Respiratorytract

Streptococcuspneumoniae AandO Pneumonia

Streptococcuspyogenes A,non-secretor Rheumaticfever

InfluenzaA O Influenza

Mycobacteriumtuberculosis O Tuberculosis

Genitourinarytract

Escherichiacoli A,B,Le(a+b−) Urinaryinfection

Pseudomonasaeruginosa B Upperurinaryinfection

Neisseriagonorrhoeae B Urethralinfection

Source:AdaptedfromBlackwelletal.44

of P. falciparum to red blood cells and consequently have

somesurvivaladvantagecomparedtoindividualswith non-Oandnon-Le(a−b−)phenotypeswhotendtodevelopsevere

malaria.

Cholera,malariaandH.pyloriinfectionaffectindividuals atanyage.However,thefirsttwotendtobemoreseverethan thegastricdiseasescausedbyH.pylori.Therefore,itispossible thatcholeraandmalariaexertgreaterselectivepressureby deathbeforereproductiveagethan H. pyloriinfection,thus contributingtothelowandhighfrequenciesofObloodgroup individualsinendemicareasofthesediseases.

ThereisconvincingevidencethattheHcarbohydrate in humanmilkcontributestotheprotectionofinfantsagainst

Campylobacter jejuni and other enteric pathogens. By

bind-ing to specific ligands, the H type 2 carbohydrate inhibits the attachmentofthese microorganismsto intestinalcells therebyprotectingbreastfeedingbabies.50_{Non-secretorsare}

relatively resistant to infection by norovirus and secretors presentavariabledegreeofsusceptibilitysincethisvirususes somehisto-bloodgroupcarbohydratesinthegastrointestinal tractasreceptors.Abouthalfofsecretorsaresusceptibleto infection,developanearlymucosalimmuneresponsewith specificIgAandbecomeprotected.Therestofthese individu-alsdevelopalatemucosalimmuneresponsewithspecificIgG anIgAantibodies.51 _{Histologicalanalysisofgastric mucosa}

fromO,non-secretorhisto-bloodgrouppatientsinfectedbyH.

pylorirevealedahigherleveloflymphocyteinfiltration

com-paredtoother phenotypes.52 _{Higher levels ofinterleukin-6}

(IL-6),tumornecrosisfactor alpha(TNF-␣) andnitric oxide (NO)areproducedbymonocytesofObloodgroup individu-alscomparedtonon-Obloodgroups.53_{Takingtogetherthese}

datademonstratethatthediversityofhisto-bloodgroup car-bohydrates can modulate, atleast in part, the innate and adaptiveimmuneresponses.Table4presentssomeexamples ofassociationsbetween histo-bloodgroup phenotypesand microorganisms.

Associations ofhisto-bloodgroups systems withcancer havebeenpublishedinthepastbutmanyofthemfoundlow

relativerisk.AnoldstudycarriedoutbyAirdetal.withalarge samplesizefoundthatAbloodgroupindividualshave20% higher riskofdevelopingstomachcarcinomathan Oblood groupsubjects.54_{Morerecently,twolarge,independent,and}

prospectivecohortsshowedthatpeoplewithA,BandABblood groupsaremorelikelytodeveloppancreaticcancerthanthose withObloodgroups.55

Somestudieshavereportedlossandaberrantexpressions ofhisto-bloodgroupcarbohydratesatdifferentstagesof can-cer.Lossofusualhisto-bloodgroupcarbohydratesseemsto correlatewithapoorprognosis.Leeetal.demonstratedthat thelossoftheAcarbohydrateinthetumorhasapoor progno-sisinnon-smallcelllungcancer.56_{Ithasbeendemonstrated}

thattheexpressionofHtype1carbohydratesinthenormal colonisunderthecontrolofFUT2gene-encoded fucosyltrans-ferase.HowevertheaberrantexpressionsofHtype2andH type3/4 carbohydratesin coloncancer tissuesofsecretors isregulatedbythesameenzyme.57 _{Thereasonsunderlying}

these changeshave notbeenclarified. Ithasbeen pointed out that arelative down-regulation ofglycosyltransferases, thelossofheterozygosityaswellashypermethylationofgene promotersarepossibleeventsinvolvedinthisprocess.58

Some ofthehisto-blood groupcarbohydrates have high immunogenicityandplayanimportantrolein histocompat-ibility. Aand Bcarbohydrates from ABO histo-blood group systempresent inthevascularendotheliumreact withthe potent naturalanti-A, anti-B, and anti-A,Bantibodies acti-vating the complement system and increasing the risk of antibody-mediatedrejectionofsolidorgantransplantations.59

However, transplantationof solidorgans from ABO incom-patible donorshas providedpromisingresults. Ithas been suggestedthatdistinctstructuraldifferencesand antigenic-ityofthecarbohydratespresentinthevascularendothelium compared to red blood cells can modulate the immune response of the recipient thus affecting engraftment.60

Theincreasingknowledgeaboutthestructuraldiversityof histo-bloodgroupcarbohydrateshascontributedtothe devel-opmentofnewtechnologiesappliedtotransfusionmedicine, cancerandtherapy.Theinsertionoffunctionspacerlipid con-structsallowsthecreationofredbloodcellswithacontrolled amount ofcarbohydrate foruse inlaboratory quality con-trolofcommon andrare ABO andLewishisto-bloodgroup phenotypes.61 _{Thistechnology facilitatesthe evaluation of}

monoclonalantibodyperformancein routineprocedures.18

Additionally,itimprovesourknowledgeofmanybasicaspects ofhemolytictransfusionsinanimalmodels.62

KnowingthebiologicalimplicationsofABO,H,secretorand Lewishisto-bloodgroupsystemsindiseasescanprovidethe basisfornewtherapeuticapplications.Anti-adhesiontherapy providesan opportunity touse histo-bloodgroup carbohy-dratesinthe treatmentofinfections; blockingadhesion to cellsexpressingthesecarbohydratesisanalternative strat-egytoantibiotics.Thesestrategiesmaybeusefulincasesof microbialresistancetoantibioticsand chemotherapy espe-ciallyinpatientsbeingtreatedforlongperiods.Thisformof therapycanhavedesirableeffectsatalowercostthanthe pro-ductionofspecificantibioticsandvaccines,includingincases wherevaccinationisstillnotsatisfactory.63,64_{Additionally,the}

useofcarbohydratemicroarraysisoneofthestrategiesused toexplorepotentialnaturalligandsofantitumormonoclonal antibodieswhichallowcancersubtypingtowardidentifying targetsforimmunotherapy.65

Concludingremarks

The expression ofABO, H, Lewis and secretor histo-blood groupcarbohydrates iscapableof producing atleast three biological effectsofmedical importance:structural modifi-cationofprecursoroligosaccharides,expressionofadistinct carbohydratetissueprofileand potentnaturalantibodies.15

Theseeffectsinfluencesusceptibilitytoinfections,sincethese carbohydratesactasreceptorsformicroorganismsorother substances(toxins,allergens,etc.).9 _{Thereforethese}

biolog-icalevents represent avast field formedicalresearch and technologies.

ThetissueexpressionofABH-Lewisantigensismore com-plexthanitappearswhenstrictlyanalyzedfromredbloodcell phenotypes.GenesencodingFUTI,FUTII,FUTIII,GTAandGTB areresponsibleforthequalitativeandquantitative variabil-ityoftheseantigensinmucosalandexocrinesecretions.15,16

Therefore,thedifferentpolymorphiclevelsofABO,H,secretor andLewishisto-bloodgroupsystemsmayhavegreater biolog-icalimportancethanitseemsfromthemerepresenceoftheir antigensintheredbloodcellmembrane.2,15

There hasbeen growing evidence that ABO, H,secretor andLewishisto-bloodgroupsystemsarenotneutral polymor-phismsastheyinfluencesusceptibilitytoinfections,disease progression and innate immune response.43,52 _{Despite the}

knowledgeofsome structuralvariability inthese carbohy-drateantigens, their polymorphiclevels of expressionand potentialapplicationsinmodernandpersonalizedmedicine inthe“-omics”era,littleisknownabouttheirbiological impor-tanceprogrammedinnature.Newstudiestounderstandthe relationshipofthesesystemswithmicroorganismsandthe environment may contribute to our understanding of the

evolutionary pressure thatcreated andmaintains the high variabilityofpolymorphismsinhumanbeings.

Financial

support

Coordenac¸ãodeAperfeic¸oamentodePessoaldeNívelSuperior –CAPES(Grant1542-03-6)andSãoPauloResearchFoundation –FAPESP(Grants:2009/17540-2;2011/08075-4).

Conflicts

of

interest

Theauthordeclaresnoconflictofinterest.

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1.ChowJ,LeeSM,ShenY,KhosraviA,MazmanianSK. Host-bacterialsymbiosisinhealthanddisease.Adv Immunol.2010;107:243–74.

2.HenrySM.MoleculardiversityinthebiosynthesisofGItract glycoconjugates.Abloodgrouprelatedchartmicroorganism receptors.TransfusClinBiol.2001;8:226–30.

3.CashHL,WhithamCV,BehrendtCL,HooperLV.Symbiotic bacteriadirectexpressionofanintestinalbactericidallectin. Science.2006;313:1126–30.

4.MaynardCL,ElsonCO,HattonRD,WeaverCT.Reciprocal interactionsoftheintestinalmicrobiotaandimmunesystem. Nature.2012;489:231–41.

5.ImbertyA,VarrotA.Microbialrecognitionofhumancell surfaceglycoconjugates.CurrOpinStructBiol.

2008;18:567–76.

6.AnsteeDJ.Therelationshipbetweenbloodgroupsand disease.Blood.2010;115:4635–43.

7.VarkiA,GagneuxP.Multifariousrolesofsialicacidsin immunity.AnnNYAcadSci.2012;1253:16–36.

8.KatoK,IshiwaA.Theroleofcarbohydratesininfection strategiesofentericpathogens.TropMedHealth. 2015;43:41–52.

9.CoolingL.Bloodgroupsininfectionandhostsusceptibility. ClinMicrobiolRev.2015;28:801–70.

10.GowdaAS,MadhunapantulaSV,AchurRN,ValiyaveettilM, BhavanandanVP,GowdaDC.Structuralbasisforthe adherenceofPlasmodiumfalciparum-infectederythrocytesto chondroitin4-sulfateanddesignofnovelphotoactivable reagentsfortheidentificationofparasiteadhesiveproteins.J BiolChem.2007;282:916–28.

11.BjörnhamO,BugaytsovaJ,BorénT,SchedinS.Dynamicforce spectroscopyoftheHelicobacterpyloriBabA-Lewisbbinding. BiophysChem.2009;143(1–2):102–5.

12.ParraGI,AbenteEJ,Sandoval-JaimeC,SosnovtsevSV,BokK, GreenKY.Multipleantigenicsitesareinvolvedinblockingthe interactionofGII.4noroviruscapsidwithABHhisto-blood groupantigens.JVirol.2012;86:7414–26.

13.ClausenH,HakomoriSI.ABHandrelatedhistobloodgroup antigens;immunochemicaldifferencesincarrierisotypes andtheirdistribution.VoxSang.1989;56:1–20.

14.NydeggerUE,TevaearaiH,BerdatP,RiebenR,CarrelT, MohacsiP,etal.Histo-bloodgroupantigensasallo-and autoantigens.AnNYAcSci.2005;1050:40–51.

16.OriolR,AboHh.Lewisandsecretion:serology,geneticsand tissuedistribution.In:CartronJP,RougerP,editors.Bloodcell biochemistry:molecularbasisofhumanbloodgroup antigens.NewYork:Plenum;1995.p.37–73.

17.PreviatoM,BorimMP,LiberatoreRDJr,PiresAC,DiasMA, BrandãodeMattosCC,etal.Lewishisto-bloodgroupsystem phenotypingandgenotypingrevealdivergenceinthe associationofLe(a−b−)phenotypeandtype1diabetes.Vox

Sang.2015;108:281–6.

18.WilliamsE,KorchaginaE,FrameT,RyzhovI,BovinN,HenryS. Glycomappingthefinespecificityofmonoclonaland polyclonalLewisantibodieswithtype-specificLewis kodecytesandfunction-spacer-lipidconstructsprintedon paper.Transfusion(Paris).2016;56:325–33.

19.MujahidA,DickertFL.Bloodgrouptyping:fromclassical strategiestotheapplicationofsyntheticantibodies generatedbymolecularimprinting.Sensors(Basel).2015;16.

20.MourantAE.Bloodrelations:bloodgroupsandanthropology. London:Oxford;1983.p.13–20.

21.HenryS,OriolR,SamuelssonB.Lewishisto-bloodgroup systemandassociatedsecretoryphenotypes.VoxSang. 1995;69:166–82.

22.MorganWTJ,WatkinsWM.Unravellingthebiochemicalbasis ofbloodgroupABOandLewisantigenicsubstances. GlycoconjJ.2000;17(7–9):501–30.

23.Schenkel-BrunnerH.Humanbloodgroups:chemicaland biochemicalbasisofantigenspecificity.Wien:Springer;2000. p.54–248.

24.AngstromJ,LarssonT,HanssonGC,KarlssonK,HenryS. Defaultbiosynthesispathwayforbloodgroup-related glycolipidsinhumansmallintestineasdefinedbystructural identificationoflinearandbranchedglycosilceramidesina groupOLe(a−b−)nonsecretor.Glycobiology.2004;14:1–12.

25.GillverLG,HenrySM.Review:biochemistryofcarbohydrate bloodgroupantigens.Immunohematology.2003;19:33–42.

26.GagnonSM,MeloncelliPJ,ZhengRB,Haji-GhassemiO,Johal AR,BorisovaSN,etal.Highresolutionstructuresofthe humanABO(H)bloodgroupenzymesincomplexwithdonor analogsrevealthattheenzymesutilizemultipledonor conformationstobindsubstratesinastepwisemanner.JBiol Chem.2015;290:27040–52.

27.OriolR,LePenduL,MolliconeR.GeneticsofABO,H,Lewis,X andrelatedantigens.VoxSang.1986;51:161–71.

28.HenrySM.Review:phenotypingforLewisandsecretor histo-bloodgroupantigens.Immunohematology. 1999;12:51–61.

29.OriolR.GeneticcontrolofthefucosylationofABHprecursor chains.Evidencefornewepistaticinteractionsindifferent cellsandtissues.JImmunogenet.1990;17(4–5):235–45.

30.MolliconeR,LePenduJ,BaraJ,OriolR.Heterogeneityofthe ABHantigensdeterminantsexpressedinhumanpyloricand duodenalmucosae.GlycoconjugateJ.1986;3:187–202.

31.HolgerssonJ,BreimerBE,SamuelssonB.Basicbiochemistry ofcellsurfacecarbohydratesandaspectsofthetissue distributionofhisto-bloodABHandrelated

glycosphingolipids.APMISSuppl.1992;27:18–27.

32.LindénS,MahdaviJ,Semino-MoraC,OlsenC,CarlstedtI, BorénT,etal.RoleofABOsecretorstatusinmucosalinnate immunityandH.pyloriinfection.PLoSPathog.2008;4:e2.

33.SvenssonL,RydbergL,HellbergA,GilliverLG,OlssonML, HenrySM.Anovelglycolipidvariationsrevealedby

monoclonalantibodyimmunochemicalanalysisofweakABO subgroupsofA.VoxSang.2005;89:27–38.

34.SvenssonL,RydbergL,deMattosLC,HenrySM.Bloodgroup A1andA2revisited:animmunochemicalanalysis.VoxSang. 2009;96:56–61.

35.HenryS,JovallPA,GhardashkhaniS,ElmgrenA,Martinsson T,LarsonG,etal.Structuralandimmunochemical

identificationofLe(a),Le(b),Htype1,andrelatedglycolipids insmallintestinalmucosaofagroupOLe(a−b−)

nonsecretor.GlycoconjJ.1997;14:209–23.

36.MielkeJH,KonigsbergLW,RelethfordJH.Humanbiological variation.NewYork:OxfordUniversityPress;2006.

37.HaldaneJBS.Diseaseandevolution.LaRicercaScientifica. 1949;19supplA19:68–76.

38.PfennigKS.Evolutionofpathogenvirulence:theroleof variationinhostphenotype.ProcBiolSci.2001;268: 755–60.

39.RahimNG,HarismendyO,TopolEJ,FrazerKA.Genetic determinantsofphenotypicdiversityinhumans.Genome Biol.2008;9:215.

40.OriolR,MolliconeR,CouillinP,DalixAM,CandelierJJ.Genetic regulationoftheexpressionofABHandLewisantigensin tissues.APMIS.1992;27:28–38.

41.KarlssonKA.Microbialrecognitionoftarget-cell glycoconjugates.CurrOpinStructBiol.1995;5:622–35.

42.HooperLV,GordonJI.Glycansaslegislatorofhost–microbial interaction:spanningthespectrumfromsymbiosisto pathogenicity.Glycobiology.2001;11:1R–0R.

43.FumagalliM,CaglianiR,PozzoliU,RivaS,ComiGP,Menozzi G,etal.Widespreadbalancingselectionandpathogen-driven selectionatbloodgroupantigengenes.GenomeRes. 2009;19:199–212.

44.BlackwellCC,WierDM,BraumJM,AlmadaniOM,BusuttilA. Bloodgroupphenotypesandinfectiousdiseases.In:Belamy R,editor.Susceptibilitytoinfectiousdiseases:theimportance ofthehostgenetics.NewYork:CambridgeUniversityPress; 2004p.p.309–36.

45.IlverD,ArnqvistA,OgrenJ,FrickIM,KersulyteD,IncecikET, etal.Helicobacterpyloriadhesinbindingfucosylated histo-bloodgroupantigensrevealedbyretagging.Science. 1998;279:373–7.

46.Aspholm-HurtigM,DailideG,LahmannM,KaliaA,IlverD, RocheN,etal.FunctionaladaptationofBabA,theH.pylori

ABObloodgroupantigenbindingadhesin.Science. 2004;305:519–22.

47.GlassRI,HolmgrenJ,HaleyCE,KhanMR,SvennerholmAM, StollBJ,etal.PredispositionforcholeraofindividualswithO bloodgroup.Possibleevolutionarysignificance.AmJ Epidemiol.1985;121:791–6.

48.VasileF,ReinaJJ,PotenzaD,HeggelundJE,MackenzieA, KrengelU,etal.Comprehensiveanalysisofbloodgroup antigenbindingtoclassicalandElTorcholeratoxin B-pentamersbyNMR.Glycobiology.2014;24:766–78.

49.CsertiCM,DzikWH.TheABObloodgroupsystemand

Plasmodiumfalciparummalaria.Blood.2007;110: 2250–8.

50.Ruiz-PalaciosGM,CervantesLE,RamosP,Chavez-MunguiaB, NewburgDS.CampylobacterjejunibindsintestinalH(O) antigen(Fucalpha1,2Galbeta1,4GlcNAc),and

fucosyloligosaccharidesofhumanmilkinhibititsbinding andinfection.JBiolChem.2003;278:14112–20.

51.LindesmithL,MoeC,MarionneauS,RuvoenN,JiangX, LindbladL,etal.Humansusceptibilityandresistanceto Norwalkvirusinfection.NatMed.2003;9:548–53.

52.HeneghanMA,MoranAP,FeeleyKM,EganEL,GouldingJ, ConnollyCE,etal.EffectofhostLewisandABObloodgroup antigenexpressiononHelicobacterpyloricolonisationdensity andtheconsequentinflammatoryresponse.FEMSImmunol MedMicrobiol.1998;20:257–66.

53.AlkoutAM,BlackwellCC,WeirDM.Increasedinflammatory responsesofpersonsofbloodgroupOtoHelicobacterpylori.J InfectDis.2000;181:1364–9.

54.AirdI,BentallHH,RobertsJA.Arelationshipbetweencancer ofstomachandtheABObloodgroups.BrMedJ.

55.WolpinBM,ChanAT,HartgeP,ChanockSJ,KraftP,HunterDJ, etal.ABObloodgroupandtheriskofpancreaticcancer.JNatl CancerInst.2009;101:424–31.

56.LeeSJ,RoJY,SahinAA,HongWK,BrownBW,MountainCF, etal.Expressionofblood-groupantigenA—afavorable prognosticfactorinnon-small-celllungcancer.NEnglJMed. 1991;324:1084–90.

57.FujitaniN,LiuY,TodaS,ShirouzuK,OkamuraT,KimuraH. ExpressionofHtype1antigenofABOhisto-bloodgroupin normalcolonandaberrantexpressionsofHtype2andHtype 3/4antigensincoloncancer.GlycoconjJ.2000;17:331–8.

58.DabelsteenE,GaoS.ABOblood-groupantigensinoralcancer. JDentRes.2005;84:21–8.

59.MengelM,HusainS,HidalgoL,SisB.Phenotypesof antibody-mediatedrejectioninorgantransplants.Transpl Int.2012;25:611–22.

60.AikawaA,SaitoK,TakahashiK.TrendsinABO-incompatible kidneytransplantation.ExpClinTransplant.2015;13Suppl 1:18–22.

61.HenrySM.Modificationofredbloodcellsforlaboratory qualitycontroluse.CurrOpinHematol.2009;16: 467–72.

62.OliverC,BlakeD,HenryS.Modelingtransfusionreactions andpredictinginvivocellsurvivalwithkodecytes. Transfusion(Paris).2011;51:1723–30.

63.SunaseeR,AdokohCK,DarkwaJ,NarainR.Therapeutic potentialofcarbohydrate-basedpolymericandnanoparticle systems.ExpertOpinDrugDeliv.2014;11:867–84.

64.WangQ,LingCC.Addressingtheglobalneedtocombat multidrugresistance:carbohydratesmayholdthekey.Future MedChem.2014;6:1539–43.