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Abstract

BACKGROUND:

C-reactive protein (CRP)- and leukocyte levels are common parameters to evaluate the inflammatory response after orthopaedic surgery and rule out infectious complications. Nevertheless, both parameters are vulnerable to disturbing biases and therefore leave room for interpretation.

OBJECTIVE:

Since blood groups are repeatedly discussed to influence inflammatory response, our aim was to observe their impact on CRP and leukocyte levels after total hip and knee arthroplasty (THA/TKA).

METHODS:

Short term postoperative CRP and leukocyte levels of 987 patients, who received either primary TKH ( $n=$ 479) or THA ( $n=$ 508), were retrospectively correlated with their blood group. ABO, Rhesus and a combination of both blood groups were differentiated.

RESULTS:

CRP levels after TKA were significantly higher in blood type AB than in type A and O on day 2–4 and also than in type A on day 6–8. Leukocyte levels after THA were significantly higher in blood group type O than in type A on day 6–8 while still remaining in an apathological range. We observed no significant differences between Rhesus types and Rhesus types and CRP or leukocyte levels.

CONCLUSION:

We observed significantly increased CRP levels after TKA in patients with blood group AB. Since the elevated CRP levels do not account for early periprosthetic infection, surgeons should include this variation in their postoperative evaluation.

Keywords

Arthroplasty leukocytes C-reactive protein ABO blood-group system

1. Introduction

Total hip and total knee arthroplasty (THA and TKA) belong to the most frequently performed procedures in orthopaedic surgery [1]. With increasing numbers of implantation, the number of complications has risen as well [2, 3]. Among these, periprosthetic joint infections (PJI) play a major role accounting for one third of all revision operations [4].

Coming along with a high burden for affected patients, PJI often requires interdisciplinary treatment and long-term antibiotic therapy following mostly at least one surgical revision [5].

As it’s diagnostic delay affects the outcome negatively, early identification of PJI is crucial [4, 5, 6].

Apart from clinical assessment, inflammatory blood parameters play a dominant role to detect first signs of PJI [5, 6]. Therefore they are commonly monitored in perioperative management.

Leukocyte levels as well as C-reactive protein (CRP) levels are the most frequently used laboratory parameters due to their high sensitivity and its inexpensiveness and wide spread availability [6, 7]. Nevertheless, interpretation of these parameters can be challenging.

Irrespective of its clinical importance, CRP represents an unspecific inflammation parameter. Produced in the hepatocytes, elevated CRP levels can be observed in many different diseases and situations e.g. malignoma, acute and chronic infection, rheumatic inflammation and trauma [8]. Equally raised levels of leukocytes can be found in the named settings but they can also increase by specific medication (e.g. steroids), malignoma such as leukaemia, tobacco smoking and many more [9]. Postoperatively increased blood levels of CRP and leukocytes are observed on a usual basis, decreasing after the major surgery within the first postoperative week [10, 11].

Recently, Zhao et al. [12] raised attention to the topic of the influence of blood groups (BG) on the susceptibility of infectious diseases. Although being disproved by Latz et al. [13], the influence of BGs on the host’s increasing or decreasing susceptibility to many types of viral and microbiological infection has already been targeted before [14, 15, 16, 17]. As an example, BGs play a role play a role as a (co-)receptor for parasites, viruses like hepatitis B and C, or bacteria, e.g. Treponema pallidum and Staphylococcus aureus [18]. Furthermore, blood group antigens ease the intracellular signal transduction, adhesion or uptake and modify the congenital immune answer to infection [19]. Primary orthopaedic diseases like knee osteoarthritis also seem to be influenced by BGs, although their impact is controversially discussed [20].

Anyhow, the correlation between BGs and the named inflammatory blood parameters has not been investigated in neither the septical nor aseptical spectrum yet. The influence of BGs on the perioperative development of these parameters would be of value to improve its interpretation and therefor early identification of PJI. If specific blood groups would correlate to higher apathological CRP levels, their elevation after surgery could rather be tolerated.

Since TKA and THA are representative major orthopaedic operations, we correlated perioperative CRP- and leukocyte-levels of patients with TKA and THA with their BGs to address this issue. Among all 41 different BGs and their alleles known, the most commonly used in clinical practice are ABO and Rhesus blood groups. Since keeping blood reserves for every arthroplasty is part of clinic’s routine quality management, ABO and Rhesus blood groups are regularly identified before TKA and THA.

We had postulated, that there is no significant difference in leukocyte and CRP-Levels depending on the patient’s BGs regarding the ABO- and Rhesus-system.

2. Materials and methods

This study was approved by the institutional review board of the medical faculty of the University of Cologne (Ethical committee study number 20-1710; approved on January 10^th, 2021) and complies with the Declaration of Helsinki. Due to the retrospective nature of this investigation, written consent was waived. All blood samples were clinically indicated and not performed for study purposes.

2.1 Investigated data

For the present study we retrospectively identified 1015 patients, who underwent primary THA or TKA between 2013 and 2018 due to high grade osteoarthritis. Exclusion criteria were rheumatic diseases, revision-procedures, chronic infections and partial joint replacements.

Of those patients we excluded all, who underwent revision surgery within the first 12 months after primary surgery.

In conclusion, we analysed the data of 508 THA-recipients (227 male, 280 female) with a mean age of 65.8 years (Min. 14.7 years, Max. 95.8 years, $\pm$ 14.4 years) and 479 TKA-recipients (193 male, 286 female) with a mean age of 66.6 years (Min. 28.0 years, Max. 89.1 years, $\pm$ 10.4 years).

2.2 Data

Following data were collected from the clinical intern electronic archive:

•
Sex
•
Age at date of surgery
•
Type of surgery (TKA/THA)
•
C-reactive protein (CRP) in mg/l in the serum and leukocytes in the blood per $\mu$ l
•
Blood group (BG) according to the ABO (A/B/AB/O) and Rhesus system (Rh $+$ / Rh $-$ )

Besides preoperative and imminent postoperative blood-examination, further timepoints varied slightly due to a change of postoperative examination protocol in our clinic within the studied years. Additional blood examination was occasionally indicated by clinical evaluation.

We therefore formed four time periods, in which measurements were grouped:

•
preoperative (one to three days before operation)
•
day 1 (first postoperative day)
•
day 2–4 (second to fourth postoperative day)
•
day 6–8 (sixth to eighth postoperative day)

CRP-measurements were performed according to standard procedures of this hospital’s Institute for laboratory medicine using a third generation Latex-test in an automated process (Cobas C 702, Roche Diagnostics, Mannheim, Germany). Until 2016, the lower limit for detection of CRP, was defined as $<$ 3 mgl/l, since 2016 the lower limit was defined as $<$ 0.6 mg/l, the standard value was $<$ 5 mg/l. For statistical analysis, values were equalled at the lower detection limit at the time of measurement.

Leukocytes were counted with an automated analysing-system (Sysmex XN-9100 and Sysmex XN-1000, Sysmex, Norderstedt, Germany), the standard value was 4.4–11.3/ $\mu$ l.

ABO Blood Group type and Rhesus Blood Group was identified by the Institution of transfusion medicine, by standardized, accredited procedures (Bio-Rad IH-500 and Bio-Rad IH-1000 Blood Bank Testing System for Blood grouping ABO/D and Phenotyping Rh/K).

Through obtaining both ABO and Rhesus blood groups, we were able to analyse the differences not only within its’ blood group system, but also in combination. By combining ABO and Rhesus system, eight subgroups were created and therefore compared to each other.
2.3 Statistical methods

Statistical analysis was performed using SPSS version 26.0 (SPSS Inc., Chicago, IL, USA). Non-parametric tests were used to detect statistically significant correlations. A $p$ -value less than 0.05 was regarded statistically significant.

At first, we showed via Kolmogorov-Smirnov-Test, that none of the parameters followed a normal distribution.

Mann-Whitney U tests were applied to evaluate differences in CRP- and leukocyte values regarding Rhesus-factor.

Kruskal-Wallis tests were used to determine, if CRP- or leukocyte values differed significantly divided either by the ABO system or a combination of ABO and Rhesus system.

3. Results

3.1 THA

The patient’s distribution regarding each blood group system is shown in Table 1. Average values of each blood group’s CRP and leukocyte level are shown in Table 3.

Table 1
Distribution (number of patients (n)) of each blood group among THA and TKA patients

	THA			TKA
Blood-group	Rh $+$	Rh $-$	Total	Rh $+$	Rh $-$	Total
O	183	35	208	162	36	198
A	183	27	210	178	34	212
B	46	7	53	34	6	40
AB	24	3	27	24	5	29
Total	436	72	508	398	81	479

3.2 THA – ABO system

Via Kruskal-Wallis test a significant difference between ABO blood types was only shown for leukocyte values on day 6–8 ( $p=$ 0.023). In the described time period leukocyte levels in patients with blood type O (average $=$ 8,1/ $\mu$ l, $n=$ 206) were significantly higher than in patients with blood type A (average $=$ 7,7/ $\mu$ l, $n=$ 201).

3.3 THA – Rhesus system

Mann-Whitney U test showed no significant differences between different Rhesus factors regarding leukocytes and CRP at any timepoint.

3.4 THA – Combination of ABO and rhesus system

Kruskal-Wallis test showed significant differences between the groups in leukocyte levels at the first postoperative day ( $p=$ 0.03) and the sixth to eighth postoperative day ( $p=$ 0.044). Anyhow, two-sided testing showed no significant differences for specific subgroups of blood group type ( $p<$ 0.05).

3.5 TKA

The distribution of the blood group systems among TKA patients is shown in Table 1. Average values of each blood group’s CRP and leukocyte level are shown in Table 3.

Table 2
Average CRP (mg/l) and leukocyte levels (/ $\mu$ l) after THA depending on their blood group; the table reads as: average/standard deviation/quantity (n). Levels of significance ( $p$ -value) are given for comparison of blood groups ^, Rhesus factor (^) and the combination of blood group and Rhesus factor (^)

Blood group		Preoperative				Day 1				Day 2–4				Day 6–8
		CRP		Leukocytes		CRP		Leukocytes		CRP		Leukocytes		CRP		Leukocytes
A	Rh $+$	6.9/20.7/209	6.2/16.6/182	7.3/2.2/209	7.2/2.1/182	47.5/33.4/192	46.7/31.3/168	8.7/2.5/195	8.5/2.5/170	84.1/52.0/172	81.6/52.1/150	8.0/2.7/171	7.8/2.6/149	38.0/32.8/200	37.3/32.8/173	7.7/4.6/201	7.6/4.8/174
	Rh $-$		11.5/38.7/27		8.3/2.0/27		52.4/45.7/24		9.7/2.2/25		102.4/48.6/22		9.6/2.7/22		42.6/33.1/27		8.5/3.2/27
B	Rh $+$	9.0/13.6/53	8.8/12.5/46	7.2/2.1/52	7.1/2.1/46	54.7/43.5/51	51.4/43.4/45	8.6/2.9/51	8.4/3.0/45	94.7/65.4/44	89.5/65.7/40	8.1/4.2/44	8.1/4.4/40	36.8/30.9/50	36.2/31.5/44	7.7/4.6/50	7.6/4.9/44
	Rh $-$		9.7/20.6/7		7.9/1.9/6		80.1/38.3/6		9.8/2.6/6		147.0/33.2/4		8.7/1.4/4		41.1/28.3/6		8.5/2.7/6
AB	Rh $+$	7.2/8.4/27	7.8/8.7/24	7.6/2.3/27	7.6/2.3/24	59.6/32.9/25	58.2/31.9/22	9.4/3.7/26	9.1/3.1/23	100.2/65.1/23	97.6/63.5/21	8.0/2.9/23	7.9/2.7/21	39.8/27.7/27	39.3/29.2/24	7.7/2.8/27	7.7/2.6/24
	Rh $-$		2.6/2.9/3		7.8/2.9/3		70.4/46.2/3		11.7/7.5/3		127.8/104.1/2		8.8/6.1/2		44.0/10.7/3		8.0/5.1/3
0	Rh $+$	6.7/20.8/216	7.0/21.9/181	7.3/2.4/216	7.3/2.5/181	48.4/27.4/200	48.5/28.5/167	9.4/3.0/203	9.6/3.0/170	91.1/50.0/176	91.5/49.3/152	8.4/2.9/178	8.5/4.5/154	41.0/32.7/205	41.4/33.2/173	8.1/2.3/206	8.1/3.1/175
	Rh $-$		5.0/7.2/35		7.2/1.8/135		47.5/23.1/33		8.6/2.8/33		88.5/57.4/24		7.8/3.1/24		38.7/34.5/32		7.8/2.0/31
$p$ -value (^*)		0.307		0.863		0.156		0.147		0.450		0.952		0.336		0.023
$p$ -value (^**)		0.723		0.058		0.264		0.361		0.068		0.107		0.692		0.249
$p$ -value (^***)		0.174		0.219		0.223		0.030		0.064		0.090		0.490		0.044

Table 3

Average CRP (mg/l) and leukocyte levels (/ $\mu$ l) after TKA depending on their blood group; the table reads as: average/standard deviation/quantity (n). Levels of significance ( $p$ -value) are given for comparison of blood groups ^*, Rhesus factor (^**) and the combination of blood group and Rhesus factor (^***)

Blood group		Preoperative				Day 1				Day 2–4				Day 6–8
		CRP		Leukocytes		CRP		Leukocytes		CRP		Leukocytes		CRP		Leukocytes
A	Rh $+$	4.4/7.1/212	4.7/7.6/178	7.2/2.2/211	7.2/2.2/177	64.4/34.4/193	63.5/34.1/163	9.4/2.6/193	9.4/2.6/164	109.6/65.5/172	110.1/67.2/142	8.3/4.1/173	8.5/4.4/143	42.6/30.7/209	42.6/30.8/176	7.5/2.3/209	7.5/2.3/176
	Rh $-$		3.0/3.0/34		7.1/2.3/34		69.1/36.2/30		9.4/2.7/29		107.6/57.9/30		7.8/2.1/30		42.9/30.7/33		7.2/2.0/33
B	Rh $+$	4.0/6.2/40	4.1/6.7/34	7.1/1.7/40	7.1/1.5/34	58.8/30.2/34	59.1/32.2/28	9.0/2.8/34	9.0/2.6/28	106.2/53.7/32	110.9/57.3/26	7.2/2.5/32	7.5/2.2/26	39.3/22. 4/40	41.6/23.0/34	7.2/2.4/40	7.1/2.0/34
	Rh $-$		3.3/2.0/6		6.7/2.8/6		57.5/20.4/6		9.0/4.2/6		85.7/29.1/6		7.8/3.9/6		26.8/14.8/6		7.7/4.1/6
AB	Rh $+$	5.7/9.5/29	6.8/10.1/24	7.5/2.0/29	7.4/2.0/24	77.5/38.5/27	79.2/41.3/22	10.5/2.9/27	10.4/3.1/22	164.8/86.5/23	160.9/87.6/18	8.6/3.3/23	8.7/3.6/18	65.5/43.4/28	62.6/41.3/23	8.3/2.8/28	8.3/2.9/23
	Rh $-$		0.2/0.5/5		7.8/1.9/5		69.9/23.6/5		10.5/2.1/5		179.0/90.6/5		8.4/2.0/5		79.0/55.3/5		8.1/2.6/5
0	Rh $+$	5.4/8.9/198	4.8/5.7/162	7.6/2.6/195	7.6/2.7/159	60.7/31.5/179	61.4/32.8/148	9.9/3.0/181	9.9/3.2/149	115.1/67.9/161	117.6/71.7/131	8.6/2.8/161	8.6/3.0/131	54.2/43.5/186	55.3/45.9/151	7.9/3.3/186	7.9/3.4/151
	Rh $-$		8.1/17.0/36		7.8/2.2/36		57.1/24.7/31		9.8/2.4/32		103.9/47.2/30		8.2/2.1/30		49.5/31.6/35		7.9/2.6/35
$p$ -value (^*)		0.267		0.29		0.15		0.155		0.021		0.271		0.004		0.163
$p$ -value (^**)		0.774		0.586		0.801		0.802		0.927		0.565		0.998		0.891
$p$ -value (^***)		0.171		0.630		0.481		0.582		0.149		0.713		0.032		0.573

3.6 TKA – ABO system

Via Kruskal-Wallis test, significant differences among CRP-levels on day 2–4 ( $p=$ 0.021) and day 6–8 ( $p=$ 0.004) were shown.

Pairwise comparison revealed significantly higher CRP-levels on day 2–4 of patients with blood group type AB (average $=$ 164.8 mg/l, $n=$ 23) than of type 0 (average $=$ 115.1 mg/l, $n=$ 161) ( $p=$ 0.048) and type A (average $=$ 109.6 mg/l, $n=$ 172) ( $p=$ 0.013).

On day 6–8 CRP-levels of type AB (average $=$ 65.5 mg/l, $n=$ 28) exceeded those of type A (average $=$ 42.6 mg/l, $n=$ 209) significantly ( $p=$ 0.013).

3.7 TKA – Rhesus system

There were no significant differences between Rh $+$ and Rh $-$ , as analysed via Mann-Whitney U test at any timepoint.

3.8 TKA – Combination of ABO and rhesus system

Kruskal-Wallis test showed stand-alone significant differences in CRP-levels on day 6–8 ( $p=$ 0.032). However, evaluation of this difference through pairwise comparison showed no significant differences between two distinct groups.

3.9 Excluded patients with early revision

We excluded 13 patients with THA ( $n$ : 0 $+=$ 3, A $+=$ 6, B $+=$ 2, AB $+=$ 1, AB $-=$ 1) and 9 patients with TKA ( $n$ : 0 $+=$ 3, 0 $-=$ 2, A $+=$ 2, B $+=$ 1, AB $+=$ 1), who underwent revision surgery due to PJI within the first 12 months after primary surgery. As a matter of further information, their blood groups were also identified as shown. Statistical evaluation was waived due to the low number of individuals.

4. Discussion

Our study was designed to evaluate differences between CRP and leukocyte blood levels after TKA and THA depending on ABO and Rhesus blood group type.

While differences in ABO types have been correlated to varying vWF and FVIII [21], the role of the ABO system on inflammation remains subject of current investigation and hasn’t been solved in its entirety. As part of further understanding, separate aspects and factors of the inflammatory process have been investigated with its correlation to the ABO system. Hereby ABO-depending differences in the expression of H-antigen [22], IL-6 [23], TNF-Alpha [15] and ICAM-1 [16] have been shown.

On the orthopaedic field, ABO was linked to primary osteoarthritis (POA). While blood group AB showed to be associated with a higher risk of POA of the knee [20], blood group O had an inverse correlation with POA of the hip [24]. Further studies found ABO type to influence Postoperative Cognitive Dysfunction (POCD) after THA [25] and the risk of thromboembolism after total joint arthroplasty [26, 27].

Our study showed increased leukocyte levels in THA-patients with ABO-type O on day 6–8. It should be noted that both the elevated levels of type O as well as the low levels of type A are apathological, concerning a healthy interval of 4.5–11.0/ul. Therefore, this difference should not account for a clinical deduction.

CRP levels in TKA-patients with ABO-type AB were significantly higher on day 2–8. Li et al. found blood type AB to be associated with POA of the knee [20]. They found blood type AB to be associated with a lower synovial expression of H antigen. H antigen is related to Le^Y antigen, which is a proinflammatory factor. Since H antigen’s and Le^Y’s biosynthesis depends on same substrates [28], Li et al. hypothesised an inverse correlation between H antigen and Le^Y. Regarding our results, an increased Le^Y expression might also be the cause of the elevated CRP value in TKA patients type AB.

The difference in quantity was in parts a result of the retrospective nature of the study as well as of the ABO imbalance in the general population. Nevertheless, this difference between blood groups might have clinical importance, since it helps physicians to interpretate postoperative CRP level.

By superficial comparison of the blood groups of early revision patients, no prominent imbalance was noted. For that reason and due to the low number of cases, no statistical rested thesis can be made. Although the susceptibility to infections has been shown to be influenced by blood groups, a correlation between PJI and blood groups has not been under investigation, but would be of interest. A considerably higher number of patients is therefore required. The results of our study however do not allow for a recommendation regarding patient selection and there is no current literature supporting such a thesis.

By comparing Rhesus blood group type Rh $+$ and Rh $-$ to another, our study found no statistical difference in inflammation parameters after TKA and THA. Our results are supported by the fact that yet there was no correlation described between the Rhesus blood group and the host’s susceptibility to diseases and inflammation in the reviewed literature.

Limitations of our study include the observation of only CRP and leukocyte levels, as previously described findings showed differences in the inflammatory pathway depending on the blood group type. Our study also doesn’t emphasize additional parameters such as obesity [29], ASA score [30] and smoking habits [9], which influence CRP and leukocyte level. Anyhow, our aim was to describe the impact of blood groups on standard blood examination parameters. For that reason, the limitations of the blood parameters (e.g. interleukin-6) were intentional, since they play no role in standard postoperative evaluation after TKA or THA. Further bias such as smoking habits remained uncovered due to the retrospective nature of our study. The second limitation is the selection bias of the included patients. Most patients were referred to our university hospital, because they were rejected in other hospitals due to pre-existing conditions like obesity, pulmonary or cardiac diseases. These conditions however are often associated with aseptically elevated CRP values [29, 31]. The observed preoperative CRP values are therefore moderately above reference values. The final limitation of our study is the relatively small sample size in blood groups B and AB. Despite showing a profound difference in CRP values (TKA) of type AB, in total only 29 patients were part of this subgroup. Therefore, a sampling error cannot be ruled out.

To our knowledge, our study is the first to shine light on the relevance of ABO and Rhesus blood groups for the profound inflammatory blood parameters after THA and TKA. Since both are major orthopaedic surgeries, a relatively large patient collective was analysed. Furthermore, no studies focused on the blood group’s impact on postoperative inflammation.

5. Conclusion

While differences of the leukocyte levels only arose in an apathological range, we observed significantly increased CRP levels after TKA in patients with blood group AB. Surgeons should know, that blood group AB might lead to higher CRP levels after major orthopaedic surgery. Since the elevated CRP levels did not account for early periprosthetic infection, this might be a symptom of a potentially varying general inflammatory response. Surgeons should therefore include this variation in their postoperative evaluation.

Footnotes

Acknowledgments

The authors have no acknowledgments.

Conflict of interest

The authors declare that they have no conflict of interest.

Funding

The authors report no funding.

References

Kremers

Larson

Crowson

Kremers

Washington

Steiner

, et al. Prevalence of total hip and knee replacement in the United States. J Bone Jt Surg – Am Vol. 2014; 97(17): 1386-97.

Bozic

Kurtz

Lau

Ong

Chiu

Vail

, et al. The epidemiology of revision total knee arthroplasty in the united states. Clin Orthop Relat Res. 2010; 468(1): 45-51.

Singh

Chen

Cleveland

. Rates of total joint replacement in the United States: Future projections to 2020–2040 using the national inpatient sample. J Rheumatol. 2019; 46(9): 1134-40.

Izakovicova

Borens

Trampuz

. Periprosthetic joint infection: Current concepts and outlook. EFORT Open Rev. 2019; 4(7): 482-94.

Renz

Trampuz

. Management of periprosthetic joint infection. Hip pelvis. 2018 Sep; 30(3): 138-46.

Cooper

Della Valle

. Advances in the diagnosis of periprosthetic joint infection. Expert Opin Med Diagn. 2013 May; 7(3): 257-63.

Greidanus

Masri

Garbuz

Wilson

McAlinden

, et al. Use of erythrocyte sedimentation rate and C-reactive protein level to diagnose infection before revision total knee arthroplasty: A prospective evaluation. JBJS. 2007; 89(7).

Choudhry

Rice

Triffitt

Harper

Gregg

. Plasma viscosity and C-reactive protein after total hip and knee arthroplasty. J Bone Joint Surg Br. 1992 Jul; 74(4): 523-4.

Kabat

Kim

Manson

JAE

Lessin

Lin

Wassertheil-Smoller

, et al. White blood cell count and total and cause-specific mortality in the women’s health initiative. Am J Epidemiol. 2017; 186(1): 63-72.

10.

Santonocito

De Loecker

Donadello

Moussa

Markowicz

Gullo

, et al. C-reactive protein kinetics after major surgery. Anesth Analg. 2014; 119(3): 624-9.

11.

Haga

Beppu

Doi

Nozawa

Mugita

Ikei

, et al. Systemic inflammatory response syndrome and organ dysfunction following gastrointestinal surgery. Crit Care Med. 1997; 25(12).

12.

Zhao

Yang

Huang

, et al. Relationship between the ABO Blood Group and the COVID-19 Susceptibility. Clin Infect Dis. 2020 Aug.

13.

Latz

DeCarlo

Boitano

Png

CYM

Patell

Conrad

, et al. Blood type and outcomes in patients with COVID-19. Ann Hematol. 2020; 99(9): 2113-8.

14.

Aird

Bentall

Roberts

JAF

. A relationship between cancer of stomach and the ABO blood groups. Br Med J. 1953 Apr; 1(4814): 799-801.

15.

Melzer

Perry

JRB

Hernandez

Corsi

Stevens

Rafferty

, et al. A genome-wide association study identifies protein quantitative trait loci (pQTLs). PLoS Genet. 2008; 4(5).

16.

Paré

Chasman

Kellogg

Zee

RYL

Rifai

Badola

, et al. Novel association of ABO histo-blood group antigen with soluble ICAM-1: Results of a genome-wide association study of 6,578 women. PLoS Genet. 2008; 4(7): 1-8.

17.

Y-J

Liang

X-F

Y-P

. Clinical application of ABO blood typing. Technol Heal care Off J Eur Soc Eng Med. 2023 Feb.

18.

Nurjadi

Lependu

Kremsner

Zanger

. Staphylococcus aureus throat carriage is associated with ABO-/secretor status. J Infect. 2012; 65(4): 310-7.

19.

Cooling

. Blood groups in infection and host susceptibility. Clin Microbiol Rev. 2015 Jul; 28(3): 801-70.

20.

Ouyang

Wang

Liang

, et al. Association between the ABO blood group and primary knee osteoarthritis: A case-control study. J Orthop Transl. 2020; 21(May 2019): 129-35.

21.

Swystun

Ogiwara

Rawley

Brown

Georgescu

Hopman

, et al. Genetic determinants of VWF clearance and FVIII binding modify FVIII pharmacokinetics in pediatric hemophilia A patients. Blood. 2019 Sep; 134(11): 880-91.

22.

Dean

. Blood Groups and Red Cell Antigens [Internet]. Bethesda (MD): National Center for Biotechnology Information (US). Blood Groups Red Cell Antigens [Internet] Bethesda Natl Cent Biotechnol Inf. 2005.

23.

Naitza

Porcu

Steri

Taub

Mulas

Xiao

, et al. A genome-wide association scan on the levels of markers of inflammation in sardinians reveals associations that underpin its complex regulation. PLoS Genet. 2012; 8(1).

24.

Lourie

. Is there an association between ABO blood groups and primary osteoarthrosis of the hip? Ann Hum Biol. 1983; 10(4): 381-3.

25.

Zhou

Wan

Liu

. Association between ABO blood type and postoperative cognitive dysfunction in elderly patients undergoing unilateral total hip arthroplasty surgery in China. Med Sci Monit. 2017; 23: 2584-9.

26.

Newman

Abola

Macpherson

Klika

Barsoum

Higuera

. ABO blood group is a predictor for the development of venous thromboembolism after total joint arthroplasty. J Arthroplasty. 2017 Sep; 32(9S): S254-8.

27.

Dahlén

Clements

Zhao

Olsson

Edgren

. An agnostic study of associations between abo and rhd blood group and phenome-wide disease risk. Elife. 2021; 10: 1-12.

28.

Hokke

Neeleman

Koeleman

van den Eijnden

. Identification of an alpha3-fucosyltransferase and a novel alpha2-fucosyltransferase activity in cercariae of the schistosome Trichobilharzia ocellata: Biosynthesis of the Fucalpha1–>2Fucalpha1–>3[Gal(NAc)beta1–>4]GlcNAc sequence. Glycobiology. 1998 Apr; 8(4): 393-406.

29.

Berg

Scherer

. Adipose tissue, inflammation, and cardiovascular disease. Circ Res. 2005 May; 96(9): 939-49.

30.

Doyle

Goyal

Bansal

Garmon

. American Society of Anesthesiologists Classification. In Treasure Island (FL); 2021.

31.

Silva

Gazzana

Knorst

. C-reactive protein levels in stable COPD patients: A case-control study. Int J Chron Obstruct Pulmon Dis. 2015; 10: 1719-25.

Impact of the blood group on postoperative CRP and leukocyte levels after primary total hip and knee arthroplasty