Within-Subject Variation in Hemoglobin Mass in Elite Athletes

Indirect biomarkers of blood doping: A systematic review

The detection of blood doping represents a current major issue in sports and an ongoing challenge for antidoping research. Initially focusing on direct detection methods to identify a banned substance or its metabolites, the antidoping effort has been progressively complemented by indirect approaches. The longitudinal and individual monitoring of specific biomarkers aims to identify nonphysiological variations that may be related to doping practices. From this perspective, the identification of markers sensitive to erythropoiesis alteration is key in the screening of blood doping. The current Athlete Biological Passport implemented since 2009 is composed of 14 variables (including two primary markers, i.e., hemoglobin concentration and OFF score) for the hematological module to be used for indirect detection of blood doping. Nevertheless, research has continually proposed and investigated new markers sensitive to an alteration of the erythropoietic cascade and specific to blood doping. If multiple early markers have been identified (at the transcriptomic level) or developed directly in a diagnostics' kit (at a proteomic level), other target variables at the end of the erythropoietic process (linked with the red blood cell functions) may strengthen the hematological module in the future. Therefore, this review aims to provide a global systematic overview of the biomarkers considered to date in the indirect investigation of blood doping.

Molecular Mechanisms of High-Altitude Acclimatization

High-altitude illnesses (HAIs) result from acute exposure to high altitude/hypoxia. Numerous molecular mechanisms affect appropriate acclimatization to hypobaric and/or normobaric hypoxia and curtail the development of HAIs. The understanding of these mechanisms is essential to optimize hypoxic acclimatization for efficient prophylaxis and treatment of HAIs. This review aims to link outcomes of molecular mechanisms to either adverse effects of acute high-altitude/hypoxia exposure or the developing tolerance with acclimatization. After summarizing systemic physiological responses to acute high-altitude exposure, the associated acclimatization, and the epidemiology and pathophysiology of various HAIs, the article focuses on molecular adjustments and maladjustments during acute exposure and acclimatization to high altitude/hypoxia. Pivotal modifying mechanisms include molecular responses orchestrated by transcription factors, most notably hypoxia inducible factors, and reciprocal effects on mitochondrial functions and REDOX homeostasis. In addition, discussed are genetic factors and the resultant proteomic profiles determining these hypoxia-modifying mechanisms culminating in successful high-altitude acclimatization. Lastly, the article discusses practical considerations related to the molecular aspects of acclimatization and altitude training strategies.

Removal of the influence of plasma volume fluctuations for the athlete biological passport and stability of haematological variables in active women taking oral contraception

The haematological module of the athlete biological passport (ABP) monitors longitudinal haematological variations that could be indicative of blood manipulation. This study applied a multi‐parametric model previously validated in elite cyclists to compare inferred and actual PV variations, whereas the potential influence of the oral contraceptive pill (OCP) cycle on the ABP blood biomarkers and plasma volume (PV) in 14 physically active women taking OCPs was also investigated. Blood and serum samples were collected each week for 8 weeks, and the ABP haematological variables were determined according to the World Anti‐Doping Agency guidelines. Transferrin (sTFN), ferritin (FERR), albumin (ALB), calcium (Ca), creatinine (CRE), total protein (TP) and low‐density lipoprotein (LDL) were additionally computed as ‘volume‐sensitive’ variables in a multivariate analysis to determine individual estimations of PV variations. Actual PV variations were indirectly measured using a validated carbon monoxide rebreathing method. We hypothesised ABP markers to be stable during a standard OCP cycle and estimated PV variations similar to measured PV variations. Measured PV variations were in good agreement with the predictions and allowed to explain an atypical passport finding (ATPF). The ABP biomarkers, Hbmass and PV were stable over 8 weeks. Significant differences occurred only between Week 7 and Week 1, with lower levels of haemoglobin concentration ([Hb]), haematocrit (HCT) and red blood cell count (RBC)(−4.4%, p < 0.01; −5.1%, p < 0.01; −5.2%, p < 0.01) and higher levels of PV at week 7 (+9%, p = 0.05). We thus concluded that estimating PV variations may help interpret individual ABP haematological profiles in women.

Impact of Menstrual Blood Loss and Oral Contraceptive Use on Oxygen-carrying Capacity

PURPOSE

The effect of menstrual blood loss on oxygen-carrying capacity remains equivocal. The purpose of this study was to determine the effect of menstrual blood loss on hemoglobin mass in young, healthy women.

METHODS

Twenty-one women (age, 23 ± 6 yr; height, 168 ± 7 cm; weight, 66.1 ± 12.6 kg) with regular menstrual cycles, either using (n = 10) or not using oral contraceptives, participated in the study. Hemoglobin mass was assessed using carbon monoxide rebreathing on three separate occasions over the course of one menstrual cycle.

RESULTS

Visits for women not using oral contraceptives were performed in the early follicular phase (3 ± 1 d after the onset of menses), late follicular phase (1 ± 1 d after the surge of luteinizing hormone in urine), and luteal phase (9 ± 1 d after the late follicular visit). Visits for women using oral contraceptives were performed in the early follicular phase (3 ± 1 d after the onset of menses), late follicular phase (15 ± 3 d after the onset of menses), and luteal phase (9 ± 2 d after the late follicular visit). Hemoglobin mass was not affected by menstrual cycle phase (early follicular, 618 ± 61; late follicular, 610 ± 65; luteal, 607 ± 68 g; P = 0.52). Interestingly, when normalized to weight, hemoglobin mass was 12% higher in women using oral contraceptives in comparison to nonusers (10.0 ± 1.2 vs 8.9 ± 1.2 g·kg, P < 0.05).

CONCLUSION

Menstrual blood loss had no measurable effect on hemoglobin mass in eumenorrheic women. However, oral contraceptive use resulted in a greater oxygen-carrying capacity, potentially leading to a greater maximal oxygen uptake.

Effect of Endurance Training on Hemoglobin Mass and V˙O2max in Male Adolescent Athletes

Supplemental digital content is available in the text.

Purpose

It is unknown, whether endurance training stimulates hemoglobin mass (Hb_mass) and maximal oxygen uptake (V˙O_2max) increases during late adolescence. Therefore, this study assessed the influence of endurance training on Hb_mass, blood volume parameters, and V˙O_2max in endurance athletes and control subjects from age 16 to 19 yr.

Methods

Hemoglobin mass, blood volume parameters, V˙O_2max and anthropometric parameters were measured in male elite endurance athletes from age 16 to 19 yr in 6-month intervals (n = 10), as well as in age-matched male controls (n = 12).

Results

Neither the level of Hb_mass per lean body mass (LBM) (P = 0.80) nor the development of Hb_mass during the 3 yr (P = 0.97) differed between athletes and controls. Hb_mass at age 16 yr was 13.24 ± 0.89 g·kg⁻¹ LBM and increased by 0.74 ± 0.58 g·kg⁻¹ LBM (P < 0.01) from age 16 to 19 yr. There was a high correlation between Hb_mass at age 16 and 19 yr (r = 0.77; P < 0.001). Plasma volume, blood volume, and V˙O_2max were higher in athletes compared to controls (P < 0.05). Blood volume and V˙O_2max increased with age (P < 0.01, similarly in both groups).

Conclusions

Endurance training volumes do not explain individual differences in Hb_mass levels nor Hb_mass and V˙O_2max development in the age period from 16 to 19 yr. The higher V˙O_2max levels of athletes may be partially explained by training-induced higher plasma and blood volumes, as well as other training adaptations. Since Hb_mass at age 16 yr varies substantially and the development of Hb_mass in late adolescence is comparably small and not influenced by endurance training, Hb_mass at age 16 yr is an important predictor for Hb_mass at adult age and possibly for the aptitude for high-level endurance performance.

Replicating measurements of total hemoglobin mass (tHb-mass) within a single day: precision of measurement; feasibility and safety of using oxygen to expedite carbon monoxide clearance

Hemoglobin concentration ([Hb]) is a function of total hemoglobin mass (tHb-mass) and plasma volume. [Hb] may fall by dilution due to plasma volume expansion and changes in the perioperative period may therefore correlate poorly with blood loss. A simple, reliable, repeatable way to measure plasma volume and tHb-mass would have substantial clinical utility. The "optimized carbon monoxide re-breathing method" (oCOR) meets these criteria. However, it is recommended that a minimum of 12 h (when breathing room air) is left between repeat measurements. Twenty-four subjects underwent 3 days of testing. Two oCOR tests were performed (T1 and T2), 3 h apart, with a different CO clearance method employed between tests aiming to keep the carboxyhemoglobin level below 10%. The primary aim was to ascertain whether tHb-mass testing could be safely repeated within 3 h if carboxyhemoglobin levels were actively reduced by breathing supplemental oxygen (PROCA ). Secondary aims were to compare two other clearance methods; moderate exercise (PROCB ), or a combination of the two (PROCC ). Finally, the reliability of the oCOR method was assessed. Mean (SD) tHb-mass was 807.9 ± (189.7 g) (for T1 on day 1). PROCA lowered the carboxyhemoglobin level from the end of T1 (mean 6.64%) to the start of T2 (mean 2.95%) by a mean absolute value of 3.69%. For PROCB and PROCC the mean absolute decreases in carboxyhemoglobin were 4.00% and 4.31%, respectively. The fall in carboxyhemoglobin between T1 and T2 was greatest in PROCC ; this was statistically significantly lower than that of PROCA (P = 0.0039) and PROCB (P = 0.0289). The test-retest reliability for the measurement of total hemoglobin mass was good with a mean typical error (TE) of 2.0%. The oCOR method is safe and can be repeated within 3 h when carbon monoxide is suitably cleared between tests. Using oxygen therapy alone adequately achieves this.

Influence of Endurance Training During Childhood on Total Hemoglobin Mass

Elite endurance athletes are characterized by markedly increased hemoglobin mass (Hbmass). It has been hypothesized that this adaptation may occur as a response to training at a very young age. Therefore, the aim of this study was to monitor changes in Hbmass in children aged 8–14 years following systematic endurance training. In the first study, Hbmass, VO2max, and lean body mass (LBM) were measured in 17 endurance-trained children (13 boys and 4 girls; aged 9.7 ± 1.3 years; training history 1.5±1.8 years; training volume 3.5 ± 1.6 h) twice a year for up to 3.5 years. The same parameters were measured once in a control group of 18 age-matched untrained children. Hbmass and blood volume (BV) were measured using the optimized CO-rebreathing technique, VO2max by an incremental test on a treadmill, and LBM by skin-fold measurements. In the second pilot study, the same parameters were measured in 9 young soccer athletes (aged 7.8 ± 0.2 years), and results were assessed in relation to soccer performance 2.5 years later. The increase in mean Hbmass during the period of study was 50% which was closely related to changes in LBM (r = 0.959). A significant impact of endurance training on Hbmass was observed in athletes exercising more than 4 h/week [+25.4 g compared to the group with low training volume (<2 h/week)]. The greatest effects were related to LBM (11.4 g·kg⁻¹ LBM) and overlapped with the effects of age. A strong relationship was present between absolute Hbmass and VO2max (r = 0.939), showing that an increase of 1 g hemoglobin increases VO2max by 3.6 ml·min⁻¹. Study 2 showed a positive correlation between Hbmass and soccer performance 2.5 years later at age 10.3 ± 0.3 years (r = 0.627, p = 0.035). In conclusion, children with a weekly training volume of more than 4 h show a 7% higher Hbmass than untrained children. Although this training effect is significant and independent of changes in LBM, the major factor driving the increase in Hbmass is still LBM.

Spot Sample Urine Specific Gravity Does Not Accurately Represent Small Decreases in Plasma Volume in Resting Healthy Males

BACKGROUND

Urine specific gravity (U_SG) is often used to assess hydration status, particularly around athletic competition, but it is unknown whether high U_SG is indicative of plasma volume (PV) reduction (i.e., hypohydration). We tested the hypothesis that if high U_SG is reflective of reduced PV, subsequent fluid ingestion would increase PV.

PURPOSE

The purpose of this study was to examine 24-hour changes in U_SG and PV in individuals presenting with high and low spot U_SG.

METHODS

Nineteen healthy males were provided food and water over 24 hours with a total water volume of 35 ml·kg^-1 body mass. Absolute PV and blood volume (BV), measured using the CO-rebreathe technique, along with U_SG were measured before and after a 24-hour intervention period. Based on a preintervention morning spot U_SG, subjects were post hoc assigned to groups according to U_SG (≤1.020 or >1.020; low and high U_SG, respectively).

RESULTS

Despite presenting with an elevated spot U_SG (1.026 ± 0.004), subsequent fluid ingestion over 24 hours did not lead to changes (∆) in PV (-75 ± 234 ml) or BV (-156 ± 370 ml) in the high U_SG group (p > 0.05). However, a spot U_SG after the 24-hour intervention in this group decreased (p = 0.018) to a level indicating improved hydration status (1.017 ± 0.007). In the low U_SG group, there were no changes in PV (-39 ± 274 ml), BV (-82 ± 396 ml), or U_SG (0.003 ± 0.007) over the 24-hour fluid intervention (all p > 0.05).

CONCLUSIONS

Despite a high preintervention U_SG and subsequent decrease after 24-hour fluid intake, measures of PV and BV were not indicative of this seemingly improved hydration status. This suggests that a highly concentrated spot sample U_SG and subsequent changes are not accurately representative of PV or BV.

Within-subject haemoglobin variation in elite athletes: a longitudinal investigation of 13 887 haemoglobin concentration readings

The Athlete Biological Passport (ABP) estimates individualized reference ranges for key blood markers, such as haemoglobin concentration ([Hb]), using predetermined population mean, between- and within-subject variances. Here, we aim to reassess previously published estimates for within-subject [Hb] variance and determine whether sex-, analyzer-, sport-, or season-specific values are required. Our reference population contains 7723 male (mean ± SD, 22.3 ± 4.6 years of age) and 6164 female (21.6 ± 4.3) athlete observations from 49 sports. [Hb] was calculated using one of three cytometers; Bayer-H3 (1997-1999, n = 4554), ADVIA-120 (1999-2010, n = 8636) and Sysmex XT-2000i (2010-2012, n = 697). The final model was a linear mixed model for [Hb] with analyzer (H3, ADVIA, Sysmex), sex (male, female), sport (power-endurance, endurance, skill, team, disabled and non-athletes), season (summer, winter), and the interaction between sex and sport as fixed effects and athlete as a random effect. The model included an exponential correlation structure to allow for within-subject autocorrelation, and allowed different within-subject variances for each sport. Within-subject [Hb] variance (g(2) /L(2) ) was significantly less for power endurance (35.09, 95% CI 33.50 to 36.76), disabled (25.82, 95% CI 21.71 to 35.28) and non-athletes (34.30, 95% CI 28.53 to 35.87) than for endurance (40.35, 95% CI 39.62 to 47.22) and team sports (38.70, 95% CI 37.68 to 39.76) athletes. No new evidence was found to justify adjusting the current within-subject [Hb] variance estimate.

Year-to-year variability in haemoglobin mass response to two altitude training camps

Aim

To quantify the year-to-year variability of altitude-induced changes in haemoglobin mass (Hb_mass) in elite team-sport athletes.

Methods

12 Australian-Footballers completed a 19-day (ALT1) and 18-day (ALT2) moderate altitude (∼2100 m), training camp separated by 12 months. An additional 20 participants completed only one of the two training camps (ALT1 additional n=9, ALT2 additional n=11). Total Hb_mass was assessed using carbon monoxide rebreathing before (PRE), after (POST₁) and 4 weeks after each camp. The typical error of Hb_mass for the pooled data of all 32 participants was 2.6%. A contemporary statistics analysis was used with the smallest worthwhile change set to 2% for Hb_mass.

Results

POST₁ Hb_mass was very likely increased in ALT1 (3.6±1.6%, n=19; mean±∼90 CL) as well as ALT2 (4.4±1.3%, n=23) with an individual responsiveness of 1.3% and 2.2%, respectively. There was a small correlation between ALT1 and ALT2 (R=0.21, p=0.59) for a change in Hb_mass, but a moderately inverse relationship between the change in Hb_mass and initial relative Hb_mass (g/kg (R=−0.51, p=0.04)).

Conclusions

Two preseason moderate altitude camps 1 year apart yielded a similar (4%) mean increase in Hb_mass of elite footballers, with an individual responsiveness of approximately half the group mean effect, indicating that most players gained benefit. Nevertheless, the same individuals generally did not change their Hb_mass consistently from year to year. Thus, a ‘responder’ or ‘non-responder’ to altitude for Hb_mass does not appear to be a fixed trait.

Altitude training and haemoglobin mass from the optimised carbon monoxide rebreathing method determined by a meta-analysis

OBJECTIVE

To characterise the time course of changes in haemoglobin mass (Hbmass) in response to altitude exposure.

METHODS

This meta-analysis uses raw data from 17 studies that used carbon monoxide rebreathing to determine Hbmass prealtitude, during altitude and postaltitude. Seven studies were classic altitude training, eight were live high train low (LHTL) and two mixed classic and LHTL. Separate linear-mixed models were fitted to the data from the 17 studies and the resultant estimates of the effects of altitude used in a random effects meta-analysis to obtain an overall estimate of the effect of altitude, with separate analyses during altitude and postaltitude. In addition, within-subject differences from the prealtitude phase for altitude participant and all the data on control participants were used to estimate the analytical SD. The 'true' between-subject response to altitude was estimated from the within-subject differences on altitude participants, between the prealtitude and during-altitude phases, together with the estimated analytical SD.

RESULTS

During-altitude Hbmass was estimated to increase by ∼1.1%/100 h for LHTL and classic altitude. Postaltitude Hbmass was estimated to be 3.3% higher than prealtitude values for up to 20 days. The within-subject SD was constant at ∼2% for up to 7 days between observations, indicative of analytical error. A 95% prediction interval for the 'true' response of an athlete exposed to 300 h of altitude was estimated to be 1.1-6%.

CONCLUSIONS

Camps as short as 2 weeks of classic and LHTL altitude will quite likely increase Hbmass and most athletes can expect benefit.

The effects of classic altitude training on hemoglobin mass in swimmers

Aim of the study was to determine the influence of classic altitude training on hemoglobin mass (Hb-mass) in elite swimmers under the following aspects: (1) normal oscillation of Hb-mass at sea level; (2) time course of adaptation and de-adaptation; (3) sex influences; (4) influences of illness and injury; (5) interaction of Hb-mass and competition performance. Hb-mass of 45 top swimmers (male 24; female 21) was repeatedly measured (~6 times) over the course of 2 years using the optimized CO-rebreathing method. Twenty-five athletes trained between one and three times for 3-4 weeks at altitude training camps (ATCs) at 2,320 m (3 ATCs) and 1,360 m (1 ATC). Performance was determined by analyzing 726 competitions according to the German point system. The variation of Hb-mass without hypoxic influence was 3.0 % (m) and 2.7 % (f). At altitude, Hb-mass increased by 7.2 ± 3.3 % (p < 0.001; 2,320 m) and by 3.8 ± 3.4 % (p < 0.05; 1,360 m). The response at 2,320 m was not sex-related, and no increase was found in ill and injured athletes (n = 8). Hb-mass was found increased on day 13 and was still elevated 24 days after return (4.0 ± 2.7 %, p < 0.05). Hb-mass had only a small positive effect on swimming performance; an increase in performance was only observed 25-35 days after return from altitude. In conclusion, the altitude (2,320 m) effect on Hb-mass is still present 3 weeks after return, it decisively depends on the health status, but is not influenced by sex. In healthy subjects it exceeds by far the oscillation occurring at sea level. After return from altitude performance increases after a delay of 3 weeks.

Biomarker monitoring in sports doping control

Biomarker monitoring can be considered a new era in the effort against doping. Opposed to the old concept in doping control of direct detection of a prohibited substance in a biological sample such as urine or blood, the new paradigm allows a personalized longitudinal monitoring of biomarkers that indicate non-physiological responses independently of the used doping technique or substance, and may cause sanctioning of illicit practices. This review presents the development of biomarker monitoring in sports doping control and focuses on the implementation of the Athlete Biological Passport as the current concept of the World Anti Doping Agency for the detection of blood doping (hematological module). The scope of the article extends to the description of novel biomarkers and future concepts of application.

The evolving science of detection of 'blood doping'

Blood doping practices in sports have been around for at least half a century and will likely remain for several years to come. The main reason for the various forms of blood doping to be common is that they are easy to perform, and the effects on exercise performance are gigantic. Yet another reason for blood doping to be a popular illicit practice is that detection is difficult. For autologous blood transfusions, for example, no direct test exists, and the direct testing of misuse with recombinant human erythropoietin (rhEpo) has proven very difficult despite a test exists. Future blood doping practice will likely include the stabilization of the transcription factor hypoxia-inducible factor which leads to an increased endogenous erythropoietin synthesis. It seems unrealistic to develop specific test against such drugs (and the copies hereof originating from illegal laboratories). In an attempt to detect and limit blood doping, the World Anti-Doping Agency (WADA) has launched the Athlete Biological Passport where indirect markers for all types of blood doping are evaluated on an individual level. The approach seemed promising, but a recent publication demonstrates the system to be incapable of detecting even a single subject as 'suspicious' while treated with rhEpo for 10-12 weeks. Sad to say, the hope that the 2012 London Olympics should be cleaner in regard to blood doping seems faint. We propose that WADA strengthens the quality and capacities of the National Anti-Doping Agencies and that they work more efficiently with the international sports federations in an attempt to limit blood doping.