Anemia To Blood Doping: What’s The Latest Thomas M. Best, MD, PhD, FACSM

Anemia To Blood Doping: What’s
The Latest
Thomas M. Best, MD, PhD,
February 22, 2014
I have no commercial, financial, or
research relationships or interests within
the past 12 months that affect my ability to
provide a fair and balanced presentation
for the proposed CME activity.
 Laboratory Evaluation of Anemia
 Sports Anemia (Dilutional Pseudoanemia)
 Iron Deficiency Anemia
 Foot Strike Hemolysis
 Sickle Cell Trait
 Blood Doping/EPO
What Is Ideal Hematocrit?
 ~ 40% for a long life?
 ~ 50% to win the big
 ~ 60% to climb Mt.
Everest without an
oxygen tank?
 ~ 60% to die from blood
Sports Medicine
Who Gets Anemia?
Heavy menses
Calorie cutter
Breakfast skipper
Sky-high carb diet
Sports Medicine
Work up for Anemia - Principles
 Detailed history
– Symptoms of: fatigue, sob, decreasing
performance, palpitations, tachycardia, pica
– GI, urinary bleeding
– Menstrual history
– Nutritional practices
– Training
– Use of medications and
Sports Medicine
Physical Exam
Resting bp, pulse, orthostatics
Skin – pallor, jaundice
Possibly rectal exam
Sports Medicine
Laboratory Studies
Hemoglobin/Hct including MCV, MCH
Reticulocyte count
Peripheral smear
Serum iron, ferritin
Total iron-binding capacity/transferrin
LDH, bilirubin, haptoglobin
Possibly further GI/GU evaluation
Consider CRP, ESR, TSH, electrophoresis if
ruling out other disease
Sports Medicine
Exercise-Induced Iron Loss
 Gastrointestinal bleeding – decrease in visceral
blood flow with possible ischemia
 Hematuria – mechanical trauma to the glomerulus,
bladder motion during running
 Sweating – some iron loss, particularly during
periods of extreme heat
 Hemolysis – foot-strike hemolysis
Sports Medicine
Sports Anemia
 Also called “Dilutional Pseudoanemia”
 Not true anemia
 Increased plasma volume in response to
Increase in aldosterone, renin, ANF, vasopressin
increased renal retention of water and salts
Increase in plasma proteins
Increased hydration
Sports Medicine
Sports Anemia
Endurance athletes mainly
Expanded plasma volume
Dilutes Hgb down 1.0-1.5 g/dl
In men, most common “anemia”
Waxes and wanes with training
Benefit, not a detriment
Shaskey & Green, “Sports Haematology,” Journal
Sports Medicine 29 (1):27-38, 2000
Sports Medicine
Iron Deficiency Anemia
 #1 Nutritional Deficiency in U.S.
– Iron Deficiency ~ 11% of women
– Iron Deficiency Anemia 1-2% adults
 #1 cause of Anemia in Athletes
– Up to 12.5% of athletes
  Dietary intake
 Menstruation
  Loss from other sources (GI, GU, hemolysis,
  Absorption
Sports Medicine
Iron Deficiency Anemia
 Hg <12g/dL (36 Hct) Female
 Hg < 14 g/dL (42 Hct) Male
 MCV < 75
(if < 60 consider hemoglobinopathy)
 Ferritin <12
 Low Serum Iron w/ High TIBC
 High Hg – think doping/steroids
Sports Medicine
Iron Deficiency Anemia
 Stage 1- “prelatent anemia”
– Depleted Iron Stores
– Ferritin NL-TIBC/Iron NL-HCT
 Stage 2- “iron-deficient erythropoeisis”
– above plus Ferritin TIBC IRON, Mild HCT
– Normocytic to mildly microcytic, mild Hypochromic
 Stage 3- overt Microcytic and Hypochromic anemia
–  Ferritin TIBC IRON HCT
Sports Medicine
Gastrointestinal Hemorrhage in Athletes
 Particularly in distance runners, triathletes
 Following endurance events stool occult
positive 13-85%
– Overt hematochezia was reported in 6%
 Increased blood loss with increased intensity
 Mixed results on increased blood loss with
concurrent use of NSAIDs
 Blood loss can be trivial to severe
Sports Medicine
Gastrointestinal Hemorrhage in Athletes
 Visceral ischemia due to decreased
splanchinc perfusion
 Gastritis and espohagitis most frequently
noted abnormalities on endoscopy – but also
cases of small bowel and colonic ischemia
– Exercising at 70% of VO2 max reduces blood flow
to the gastrointestinal tract by 60-70%; more
intense exercise may cause reductions in excess
of 80% - worsened by dehydration
– Up and down motion of running appears to be risk
factor - ? Direct trauma to viscera
Sports Medicine
Genitourinary System Losses
Exercise-induced hematuria
Typically microscopic
Usually resolves within a few days of event
Renal causes
– Renal vasoconstriction
– decreased renal plasma flow with damage to
– direct trauma to GU system
 Intravascular hemolysis causing
Sports Medicine
Iron Deficiency Anemia - Impact on
 Reduction in aerobic capacity, endurance and
energetic efficiency due to decreased oxygen
 Correction of anemia with iron
supplementation improves performance
 ? No improvement in performance shown
with iron supplementation in nonanemic, irondeficient athletes
Sports Medicine
Iron Deficiency Anemia - Treatment
 Discuss Dietary Consumption
– Males require 10mg/day, female 15mg/day
– Heme iron (meats) more bioavailable (10-35%) vs non-hem
iron (2-5%)
– Handouts/Websites -
 Consider Iron Replacement
– Stage 1&2?, Stage 3 yes
Sports Medicine
Iron Replacement
need 150-200mg/day
Ferrous vs Ferric
Ferrous is absorbed better
sulfate 325mg (65mg)
gluconate 325mg (36mg)
Replace w/ palatable forms
Increased absorption w/
Vitamin C (Ascorbic Acid)
 GI side effects
– Take w/ food (but can absorptio
up to 65%)
 Do not use enteric coated
forms (do not dissolve in
 Drug Interactions (H2 blockers
PPI, tea and coffee tannates,
caffeinated drinks)
Sports Medicine
Iron Deficiency Anemia - Treatment
 Re-evaluate
– CBC in 1 month
– Reticulocytes and MCV increase first
– If HCT not up despite therapy – consider further evaluation
 Replaced Iron stores complete when Ferritin
= 50
 Can take 4-6 months to treat then
maintenance therapy
Sports Medicine
To Prevent Anemia
Lean red meat
No coffee at meals
OJ with breakfast
Iron cookware
Mixed meals
Eichner ER, Curr Sports Med Rep 9:122-23, 2010
Sports Medicine
Intravascular Hemolysis
• Also called “Foot Strike Hemolysis”
 Caused by RBC destruction from repeated
• Elevated temperature in muscle, turbulence
and acidosis may also be involved
Robinson et al, MSSE 38:480-83, 2006
Sports Medicine
Foot Strike Hemolysis
 Bilirubin
 Haptoglobin
 Schistocytes
Slight  MCV & Reticulocytes
– Preferential breakdown of older rbcs
 Hemoglobinuria
 Anemia resolves w/ d/c exercise
Telford RD et al, J Appl Physiol 94:38-42, 2003
Sports Medicine
Foot Strike Hemolysis
 Change Shoes
 Change Running Surfaces
 Modification of Training Program
• Search for other causes of hemolysis
- Drugs (ABX, INH)
- Acute Illnesses (Mycoplasma, Mono, Sepsis, Viral)
- Chronic Illnesses (Autoimmune)
- Heredity (G6PD, Thalassemia, Sickle Cell)
Sports Medicine
Intravascular hemolysis in non-foot strike
 Swimmers
– Compression from contracting
 Cyclists, other sports
- ? Increase in body temperature may
increase red cell turnover
- oxidative and osmotic stress
Sports Medicine
Sports Anemia – Fact or Fiction?
 Miller et al Int J Sports Med 1988 – force dependent
relationship between heel strike and degree of hemolysis
 Lippi and Guidi Blood Trans 2012 – 15 ultramarathon runners
– no change in Hb, hematocrit, RBC count, potassium
 Post exercise decrease in haptoglobin, reduction in MCV
 ? Compensatory shift of intracellular water outside the RBC to
counterbalance loss of fluid
 Conclusions
- No evidence that iron supplementation improves athletic
Ottomano and Franchini Blood Transf 2012
Sports Medicine
Sports Anemia – Fact or Fiction?
 Athletes with low serum ferritin without anemia – iron
supplementation might be useful
 Serum ferritin should be monitored in conditioned athletes
 Most studies have NOT shown benefit of iron supplementation
on performance, “the uncontrolled use of iron should be
 Risk factors for iron deficiency include; adolescence, female
sex, vegetarian diet, Helicobacter pylori infection
Ottomano and Franchini Blood Transf 2012
Sports Medicine
Sickle Cell
 Inherited disease of abnormal hemoglobin S
– Polymerizes under physiologic stress = destruction of rbcs
 Sickle disease – usually incompatible with
participation in intense physical activity
 Sickle Trait - Heterozygous state where Hgb S is
present with Normal Hgb A in RBC
< 50% Hgb is Hgb S
Usually Asymptomatic w/ no anemia
Up to 8% of African Americans
1/10,000 Whites
Sports Medicine
Sickle Cell Risks
 Gross hematuria
 Splenic infarction
 Exertional heat illness
– Rhabdomyolysis
– heat stroke
– renal failure
 Idiopathic sudden death
 Physiologic changes associated with exercise
– (regional hypoxemia, acidosis, dehydration,
hyperthermia) – all increase risk of sickling
Sports Medicine
Adverse Events Associated With SCT
 Renal
Hyposthenuria, hematuria. papillary necrosis
 Spleen
Splenic infarction
 Pregnancy
Fetal loss, low birth weight, preeclampsia, premature
 Hyphema
 Venous thromboembolic events
Sports Medicine
Sickle Cell Trait
 Pathophysiology of SCT events not entirely clear
 Cascade of events leading to microvascular sickling,
vascular occlusion, endothelial damage, decreased
blood flow to muscles, rhabdomyolysis, DIC
 Rare in sickle cell trait – 47 reported cases
 Likely due to microvascular occlusion
 Severe hypoxia - elevations > 10,000 feet
 Descend to lower height, O2, hydration
Sports Medicine
Sickle Cell Trait And Sudden Death
In Athletes
 Kark et al NEJM 1987 – military recruits
 2010 – NCAA mandated screening for D1
 Harmon et al Br J Sport Med 2012 – SCT associated with a
relative risk of death of 37 times in NCAA football athletes
 Harris et al Am J Cardiol 2012 – Minneapolis Heart Institute
Foundation database
- 31 yr injury registry, 2462 athlete deaths
- 23 deaths in association with SCT, college
football highest risk (7% of 271 AA football
players, 8% of players estimated to carry the trait in this
- distinctive clinical picture of gradual
deterioration over several mins, early in training season,
conditioning drills, temp > 80F
Sports Medicine
Sickle Cell – Treatment/Prevention
Train wisely
Stay hydrated
Avoid heat and elevation
Rest when sick
Report hematuria
Respect pain – abdominal, muscles, cardiac
Screen or not screen?
- NCAA D1 (?D2, D3)
- American Society of Hematology
Sports Medicine
Blood Doping
Sports Medicine
Erythropoietin (EPO)
Glycoprotein hormone regulating RBC production
Produced by renal cortex (90%), brain, lung & uterus
Binds to CFU erythroid stem cells in bone marrow
EPO regulation controlled by gene on chromosome 7
with hypoxic inducible factor
 New circulating erythrocytes seen 1-2 days after EPO
levels rise
Sports Medicine
Blood Doping
 Increasing the number of red blood cells in the
body to increase the oxygen carried to muscle
– Administration of blood, red blood cells, or related blood
– Erythropoietin (EPO) or rHuEPO
o Stimulates bone marrow to produce red blood cells
Sports Medicine
Blood Doping
 1968 Mexico City Olympics (Alt. 7300 ft)
– Most endurance race winners from highlands
– Athletes from high altitude had “thick blood”
 Elblom et al (1972)*
– 3 men, 800ml autologous transfusion (4 weeks)
o 13% increase in Hg
o 9% increase in VO2max
o Run time to exhaustion increase 23%
 1976 Blood Transfusions Banned by IOC
 1987 rHuEPO first available in Europe
 1990 – IOC prohibited use of EPO
*Eichner, ER. Sports Med (2007)
Sports Medicine
Blood Doping - Does It Work?
 Performance Studies- (Williams and
Branch summarized study findings)
– 7% increase in Hgb
– 5% increase in VO2 max
– 34% increase in time to exhaustion at 95% VO2
– 44 second improvement in 5 mile treadmill run
– 69sec decrease in 10K time
Blood Doping - Side Effects
 Infections with transfusions
 Inhibit endogenous EPO production
 Increased viscosity of blood
– Stroke, MI, venous thromboses. PE
– HTN (direct relation to dose), CHF
Recombinant Human Erythopeietin
 rHuEPO isolated from chineese hampster ovaries
– SQ administration, 50-300 u/kg, 2-3/week
– Hct increases noted after 2-6 weeks
 Clinical Applications:
– treatment of anemias related to renal failure,
chemotherapy, HIV infection, prematurity,
hemoglobinopathies, autoimmune disease and
 Adverse Effects:
– headache, fever, nausea, anxiety, lethargy
– hypertension & hyperkalemia in dialysis population
– hyperviscosity syndromes
– seizures and hyperkalemia (rare)
Sports Medicine
 1987-1991, 20 top European cyclists died
unexpectedly, suspected EPO use
 1998-2000, 18 more cyclists with suspected EPO use
died of thromboembolic complications (PE, CVA, MI)
 Ergogenic Effectiveness*
– Birkeland et al (1999) EPO vs placebo, 20 athletes
o Hct increase from 43% to 51%
o 7% increase VO2max
o 9% increase in run time to exhaustion
o Effects lasted up to 3 weeks after EPO stopped
*Eichner, ER. Sports Med (2007)
Sports Medicine
Detection of rHuEPO Misuse
 1990 rHuEPO banned by IOC, later USOC & NCAA
 Nearly identical in structure and metabolism to endogenous
EPO form, rapid half life (24 hours)
– Cleared from body within 2-3 days
 1997 International Cycling Union created Hct cutoffs
– Males (50%), Females (47%)
 2000 Mathematical Model
– measuring indirect blood markers associated with rHuEPO
– Hb, EPO level, reticulocyte %, soluble transferrin
 2000 Isoelectric Focusing & Immunoblotting
– possible to separate rHuEPO and endogenous EPO based
on differences in charge status of glycosylated side chains
– rHuEPO slightly more acidic than EPO
– Also able to detect Darbopoietin (rHuEPO analogue)
Sports Medicine
Detection of Blood Transfusion
 Advancement of rHuEPO testing, indirectly leads to
a return to older practices of blood transfusion
– Autologous transfusions currently undetectable
– Homologous transfusions can be detected by flow
cytometry after labeling RBC membrane proteins
o Multiple RBC populations
o Enhanced production of RBC line
Additional Blood-Boosting Methods
 High Altitude Training / Altitude Tents
– In low pO2, Hg binds O2 more efficiently
– Natural stimulus for erythropoiesis, over 3-4
 Artificial Oxygen Carriers
– Hemoblobin Oxygen Carriers (ex. Hemopure)
o No positive effect on endurance or VO2max*
o Hypertension, GI hypertonicity, renal toxicity
– Perfluorocarbons Emulsions
o Synthetic liquid dissolves oxygen 100x greater
than plasma, requires oxygen supplementation
o Flu-like symptoms, thrombocytopenia, allergic
reactions, hepatosplenomegaly,
organ failure
*Aschenden MJ. Int J Sports Med (2007)
Sports Medicine
Gene Engineering And Gene Screening
 HERITAGE and GENATHLETE – genes responsible for
endurance capacity in humans
 Angiotensin-converting enzyme (ACE) coding gene, (185-bp)
gene code of the EPO receptor, gene code of α2 adrenergic
receptor all correlated with increased endurance capacity in
runners – Wolfarth et al Med Sci Sports Exer 2000
 Currently up to 214 autosomal dominant gene entries and trait
loci identified that are connected with endurance, muscle
strength, training response, exercise tolerance (Rankinen T et al
Med Sci Sports Exer 2010)
 PPARα and ACTN3 – potential risk for genetic screening abuse
given location on a single gene and important role in endurance
training and speed performance, respectively?
Sports Medicine
Gene Treatment And Gene Manipulation
 Gene therapy – congenital or acquired muscular dystrophies,
diabetes, primary/secondary forms of anemia, cardiovascular
disease, growth deficiency
 Differentiation of key molecules produced from gene doping
from their ‘natural counterparts’ is a real challenge
 Delivery of genetic material
- direct transplant
- transfection - use of non-viral transporters (liposomes,
plasmids, plain DNA) for local injection
- transduction – with inactive viral vectors (adenovirus,
adeno-associated virus)
- other techniques – microinjection, bioballistics
Sports Medicine
IGF-1 and Myostatin Effects on Skeletal Muscle
Sports Medicine
IGF-1 And Myostatin –
Local Growth Factors And Effects On Skeletal Muscle
 Glucocorticoids inhibit production
of IGF-1 (in vitro and in vivo)
 Glucocorticoids stimulate
production of myostatin (growth
factor that inhibits muscle mass
development by downregulating
satellite cells and protein
 Myostatin – gene, when mutated,
is responsible for ‘double
muscling’ in certain breeds of
Sports Medicine
Growth Factors And Doping – Where Is The Line?
 Goldspink et al 2008 “This fact that MGF ‘kick starts’
the hypertrophy process clearly has potential for
abuse and has already attracted the attention of body
 MGF (derived from IGF-1) – expressed as pulse dose
for 2 days following injury resulting in longer lasting
expression of IGF-I
 WADA – continues to update and fine tune its
antidoping rules
OSU Sports Medicine
 Sports Anemia – dilutional due to increase plasma
– Rule out other causes
– No treatment needed
 Iron Deficiency Anemia
Order appropriate labs
Evaluate nutritional intake
Evaluate for possible losses including GI, GU
Training adaptations
 Hemolytic Anemia
– Order appropriate labs
– Training adaptations
 Sickle Cell Trait
– Higher risk for sickling crisis with heat, exertion, dehydration,
Sports Medicine
Ashenden MJ, Schumacher YO, Sharpe K et al. Effects of Hemopure on
Maximal Oxygen Uptake and Endurance Performance in Healthy Humans. Int J
Sports Med (2007) 28(5): 381-385.
Buzzini SR. Abuse of Growth Hormone Among Young Athletes. Pediatr Clin N
Am (2007) 54: 823-843.
Casavant MJ. Consequences of Use of Anabolic Androgenic Steroids. Pediatr
Clin N Am (2007) 54: 677-690.
Eichner ER. Blood Doping: Infusions, Erythropoietin and Artificial Blood. Sports
Med (2007) 37(4-5): 389-391.
Kerr JM, Congeni JA. Anabolic-Androgenic Steroids: Use and Abuse in
Pediatric Patients. Pediatr Clin N Am (2007) 54: 771-785.
Pommering TL. Erythropoietin and Other Blood-Boosting Methods. Pediatr Clin
N Am (2007) 54: 691-699.
Robinson N, et al. Erythropoietin and Blood Doping. Br J Sports Med (2006) 40:
Saugy M, et al. Human Growth Hormone Doping in Sport. Br J Sports Med
(2006) 40: 35-40
Smurawa, TM. Testosterone Precursors: Use and Abuse in Pediatric Athletes.
Pediatr Clin N Am (2007) 54: 787-796
Sports Medicine