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Original Article

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Blood Res 2023; 58(3):

Published online September 30, 2023

https://doi.org/10.5045/br.2023.2023122

© The Korean Society of Hematology

ABO blood group and rhesus factor association with inpatient COVID-19 mortality and severity: a two-year retrospective review

Alexander T. Phan1, Ari A. Ucar1, Aldin Malkoc2, Janie Hu1, Luke Buxton3, Alan W. Tseng1, Fanglong Dong4, Julie P.T. Nguyễn5, Arnav P. Modi5, Ojas Deshpande5, Johnson Lay5, Andrew Ku5, Dotun Ogunyemi4, Sarkis Arabian3

Author Info. +

1Department of Internal Medicine, 2Department of General Surgery, 3Department of Critical Care Medicine, 4Department of Graduate Medical Education, Arrowhead Regional Medical Center, 5School of Medicine, California University of Science and Medicine, Colton, CA, USA

Correspondence to : Alexander T. Phan, M.D.
Department of Internal Medicine, Arrowhead Regional Medical Center, 400 N. Pepper Avenue, Colton, CA 92324, USA
E-mail: PhanA1@armc.sbcounty.gov

Received: June 25, 2023; Revised: September 6, 2023; Accepted: September 14, 2023

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.

Abstract

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Background
Early reports have indicated a relationship between ABO and rhesus blood group types and infection with SARS-CoV-2. We aim to examine blood group type associations with COVID-19 mortality and disease severity.
Methods
This is a retrospective chart review of patients ages 18 years or older admitted to the hospital with COVID-19 between January 2020 and December 2021. The primary outcome was COVID-19 mortality with respect to ABO blood group type. The secondary outcomes were 1. Severity of COVID-19 with respect to ABO blood group type, and 2. Rhesus factor association with COVID-19 mortality and disease severity. Disease severity was defined by degree of supplemental oxygen requirements (ambient air, low-flow, high-flow, non-invasive mechanical ventilation, and invasive mechanical ventilation).
Results
The blood type was collected on 596 patients with more than half (54%, N=322) being O+. The ABO blood type alone was not statistically associated with mortality (P=0.405), while the RH blood type was statistically associated with mortality (P<0.001). There was statistically significant association between combined ABO and RH blood type and mortality (P=0.014). Out of the mortality group, the O+ group had the highest mortality (52.3%), followed by A+ (22.8%). The combined ABO and RH blood type was statistically significantly associated with degree of supplemental oxygen requirements (P=0.005). The Kaplan-Meier curve demonstrated that Rh- patients had increased mortality.
Conclusion
ABO blood type is not associated with COVID-19 severity and mortality. Rhesus factor status is associated with COVID-19 severity and mortality. Rhesus negative patients were associated with increased mortality risk.

Graphical Abstract

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Keywords: COVID-19, Infectious disease, Pulmonary medicine, Mechanical ventilation, SARS-CoV-2

Article

Original Article

Blood Res 2023; 58(3): 138-144

Published online September 30, 2023 https://doi.org/10.5045/br.2023.2023122

Copyright © The Korean Society of Hematology.

ABO blood group and rhesus factor association with inpatient COVID-19 mortality and severity: a two-year retrospective review

Alexander T. Phan1, Ari A. Ucar1, Aldin Malkoc2, Janie Hu1, Luke Buxton3, Alan W. Tseng1, Fanglong Dong4, Julie P.T. Nguyễn5, Arnav P. Modi5, Ojas Deshpande5, Johnson Lay5, Andrew Ku5, Dotun Ogunyemi4, Sarkis Arabian3

1Department of Internal Medicine, 2Department of General Surgery, 3Department of Critical Care Medicine, 4Department of Graduate Medical Education, Arrowhead Regional Medical Center, 5School of Medicine, California University of Science and Medicine, Colton, CA, USA

Correspondence to:Alexander T. Phan, M.D.
Department of Internal Medicine, Arrowhead Regional Medical Center, 400 N. Pepper Avenue, Colton, CA 92324, USA
E-mail: PhanA1@armc.sbcounty.gov

Received: June 25, 2023; Revised: September 6, 2023; Accepted: September 14, 2023

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.

Abstract

Background
Early reports have indicated a relationship between ABO and rhesus blood group types and infection with SARS-CoV-2. We aim to examine blood group type associations with COVID-19 mortality and disease severity.
Methods
This is a retrospective chart review of patients ages 18 years or older admitted to the hospital with COVID-19 between January 2020 and December 2021. The primary outcome was COVID-19 mortality with respect to ABO blood group type. The secondary outcomes were 1. Severity of COVID-19 with respect to ABO blood group type, and 2. Rhesus factor association with COVID-19 mortality and disease severity. Disease severity was defined by degree of supplemental oxygen requirements (ambient air, low-flow, high-flow, non-invasive mechanical ventilation, and invasive mechanical ventilation).
Results
The blood type was collected on 596 patients with more than half (54%, N=322) being O+. The ABO blood type alone was not statistically associated with mortality (P=0.405), while the RH blood type was statistically associated with mortality (P<0.001). There was statistically significant association between combined ABO and RH blood type and mortality (P=0.014). Out of the mortality group, the O+ group had the highest mortality (52.3%), followed by A+ (22.8%). The combined ABO and RH blood type was statistically significantly associated with degree of supplemental oxygen requirements (P=0.005). The Kaplan-Meier curve demonstrated that Rh- patients had increased mortality.
Conclusion
ABO blood type is not associated with COVID-19 severity and mortality. Rhesus factor status is associated with COVID-19 severity and mortality. Rhesus negative patients were associated with increased mortality risk.

Keywords: COVID-19, Infectious disease, Pulmonary medicine, Mechanical ventilation, SARS-CoV-2

Fig 1.

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Figure 1.Consort diagram detailing the selection of patients with COVID-19 and their respective blood types.
Blood Research 2023; 58: 138-144https://doi.org/10.5045/br.2023.2023122

Fig 2.

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Figure 2.Histogram of patient mortality separated by combined ABO and Rh blood type. Green bars indicate the number of patients who were alive, which are separated by blood group types. Purple bars indicate the number of patients who died, which are separated by blood group types.
Blood Research 2023; 58: 138-144https://doi.org/10.5045/br.2023.2023122

Fig 3.

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Figure 3.Kaplan-Meier survival probability based on RH status demonstrating higher risk of mortality for RH-patients where seven-day mortality risk for Rh-patients was 42% while seven-day mortality risk for Rh+ patients was 37% (P=0.025).
Blood Research 2023; 58: 138-144https://doi.org/10.5045/br.2023.2023122

Baseline patient characteristics based upon ABO blood type and Rh status separately with mortality data presented for each..


Blood type O
(N=349)		Blood type B
(N=69)		Blood type AB
(N=21)		Blood type A
(N=159)		PRh positive
(N=541)		Rh negative
(N=54)		P
Demographics
Age51.48±19.551.55±19.6848.05±20.6553.48±20.200.57848.81±19.1452.21±19.870.221
Body mass index30.65±7.828.7±5.627.5±7.0929.35±7.730.04730.20±6.3529.94±7.740.785
Gender0.6420.126
Female176 (51%)30 (43%)12 (57%)77 (48%)263 (49%)32 (61%)
Male173 (49%)39 (57%)9 (43%)82 (52%)281 (51%)22 (39%)
Ethnicity0.1680.655
Caucasian208 (60%)27 (39%)14 (67%)91 (57%)310 (57%)30 (56%)
African American21 (6%)6 (9%)08 (5%)34 (6%)1 (2%)
Asian5 (1.5%)3 (4%)04 (2.5%)11 (2%)1 (2%)
Hispanic112 (32%)33 (48%)7 (33%)53 (33%)184 (34%)21 (39%)
Other3 (0.5%)0005 (1%)1 (1%)
Comorbid conditions
Diabetes mellitus77 (22%)16 (23.2%)4 (19%)36 (22.6%)0.981119 (22%)14 (25.9%)0.495
Tobacco use7 (2%)1 (1.4%)0 (0%)2 (1.3%)0.8549 (1.7%)1 (1.9%)0.914
Cancer12 (3.4%)1 (1.4%)0 (0%)7 (4.4%)0.56118 (3.3%)2 (3.7%)0.878
Hypertension48 (13.8%)10 (14%)3 (14.3%)127 (79.9%)0.32487 (16.1%)6 (11.1%)0.345
Obesity56 (16%)8 (11.6%)2 (9.5%)21 (13.2%)0.62176 (14%)11 (20.4%)0.203
Chronic lung disease14 (4%)3 (4.3%)1 (4.8%)3 (1.9%)0.62921 (3.9%)0 (0%)0.142
Cirrhosis8 (2.3%)0 (0%)0 (0%)4 (2.5%)0.53211 (6.9%)1 (1.9%)0.932
Chronic kidney disease19 (5.4%)4 (5.8%)3 (14.3%)6 (3.8%)0.24829 (5.4%)3 (5.6%)0.944
Hospitalization mortality0.405<0.001
Alive258 (73.9%)57 (82.6%)17 (81%)117 (73.6%)419 (77.4%)30 (55.6%)
Dead91 (26.1%)12 (17.4%)4 (19%)42 (26.4%)125 (23.1%)24 (44.4%)

Respiratory requirements of patients based on ABO blood type and Rh status separately..


Blood type O
(N=349)		Blood type B
(N=69)		Blood type AB
(N=21)		Blood type A
(N=159)		PRh positive
(N=541)		Rh negative
(N=54)		P
Respiratory treatment0.0920.094
Room air143 (41%)30 (43%)5 (24%)63 (40%)222 (41%)18 (33%)
Low flow oxygen82 (23%)26 (38%)7 (33%)42 (26%)147 (27%)10 (19%)
High flow oxygen35 (10%)7 (10%)3 (14%)10 (6%)50 (9%)5 (9%)
NIMV14 (4%)2 (3%)2 (9%)9 (7%)22 (4%)5 (9%)
Intubated75 (22%)4 (6%)4 (20%)35 (21%)102 (19%)16 (30%)

Patient characteristics and mortality data of combined ABO and Rh blood types..


Blood type O+
(N=322)		Blood type B+
(N=63)		Blood type AB+
(N=19)		Blood type A+
(N=140)		Blood type O-
(N=27)		Blood type B-
(N=6)		Blood type AB-
(N=2)		Blood type A-
(N=19)		P
Demographics
Age51.80±19.4952.63±19.9148.21±21.6553.5±20.5947.74±20.7140.17±13.4946.5±30.453.32±17.570.637
Body mass index30.56±7.9828.74±5.828.16±6.829.31±7.9631.7±6.628.35±3.221.15±8.2729.6±5.850.184
Gender0.299
Female160 (49.6%)25 (39.6%)10 (52.6%)68 (48.6%)16 (59.3%)5 (83.3%)2 (100%)9 (47.4%)
Male162 (50.4%)38 (60.4%)9 (47.4%)72 (51.4%)11 (40.7%)1 (16.7%)0 (0%)10 (52.6)
Ethnicity0.597
Caucasian192 (59.6%)25 (39.7%)13 (68.4%)80 (57.1%)16 (59.3%)2 (33.3%)1 (50%)11 (57.8%)
African American21 (6.5%)6 (9.5%)0 (0%)7 (5%)0 (0%)0 (0%)0 (0%)1 (5.3%)
Asian5 (1.6%)3 (4.8%)0 (0%)3 (2.1%)0 (0%)0 (0%)0 (0%)1 (5.3%)
Hispanic101 (31.4%)29 (46%)6 (31.6%)48 (34.3%)11 (40.7%)4 (66.7%)1 (50%)5 (26.3%)
Other3 (0.9%)0 (0%)0 (0%)2 (1.5%)0 (0%)0 (0%)0 (0%)1 (5.3%)
Comorbid conditions
Diabetes mellitus70 (21.7%)15 (23.8%)3 (15.8%)31 (22.1%)7 (25.9%)1 (16.7%)1 (50%)5 (26.3%)0.961
Tobacco use7 (2.2%)1 (1.6%)0 (0%)1 (0.7%)0 (0%)0 (0%)0 (0%)1 (5.3%)0.815
Cancer11 (3.4%)1 (1.6%)0 (0%)6 (4.3%)1 (3.7%)0 (0%)0 (0%)1 (5.3%)0.951
Hypertension46 (14.3%)10 (15.9%)3 (15.8%)28 (20%)2 (7.4%)0 (0%)0 (0%)4 (21.1%)0.565
Obesity48 (14.9%)7 (11.1%)1 (5.3%)20 (14.3%)8 (29.6%)1 (16.7%)1 (50%)1 (5.3%)0.174
Chronic lung disease14 (4.3%)3 (4.8%)1 (5.3%)3 (2.1%)0 (0%)0 (0%)0 (0%)0 (0%)0.795
Cirrhosis7 (2.2%)0 (0%)0 (0%)4 (2.9%)1 (3.7%)0 (0%)0 (0%)0 (0%)0.867
Chronic kidney disease17 (5.3%)4 (6.3%)3 (15.8%)5 (3.6%)2 (7.4%)0 (0%)0 (0%)1 (5.3%)0.567
Hospitalization mortality0.014
Alive244 (75.8%)54 (85.7%)15 (78.9%)106 (75.7%)14 (51.9%)3 (50%)2 (100%)11 (57.9%)
Dead78 (24.2%)9 (14.3%)4 (21.1%)34 (24.3%)13 (48.1%)3 (50%)0 (0%)8 (42.1%)

Supplemental oxygen requirements of patients based on combined ABO and Rh blood types..


Blood type O+
(N=322)		Blood type B+
(N=63)		Blood type AB+
(N=19)		Blood type A+
(N=140)		Blood type O-
(N=27)		Blood type B-
(N=6)		Blood type AB-
(N=2)		Blood type A-
(N=19)		P
Respiratory treatment0.005
Room air134 (42%)27 (43%)4 (21%)58 (41%)9 (33%)3 (50%)1 (50%)5 (26%)
Low flow oxygen78 (24%)26 (41%)6 (32%)37 (27%)4 (15%)01 (50%)5 (26%)
High flow oxygen32 (10%)6 (10%)3 (16%)9 (7%)3 (11%)1 (17%)01 (6%)
NIMV11 (3%)02 (11%)9 (6%)3 (11%)2 (33%)00
Intubated67 (21%)4 (6%)4 (21%)27 (19%)8 (30%)008 (42%)
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