Get Your Blood Pumping: High-Performance Hematology

In the “High-Performance Hematology: Elite Athletes and Weekend Warriors” session in this year’s Education Program, session chair Stephan Moll, MD, PhD, and speakers will provide expert perspectives on the complexities of managing hematologic issues in high-level athletes and “weekend warriors.”

“Hematologists are frequently asked to consult on athletes with various hematologic issues, including management of venous thromboembolism (VTE), sickle cell trait, and iron deficiency,” Dr. Moll told ASH Clinical News. “There are many struggles with treating blood clots in this population that we wanted to bring into the spotlight and open up for discussion – both in the medical community and in the lay press.”

Dr. Moll and Robert Liem, MD, will focus on difficult return-to-play decisions for people who have experienced VTE and for athletes living with sickle cell trait or sickle cell disease – each highlighting knowledge gaps in their respective areas.

In his presentation, Don Siegel, MD, PhD, from the University of Pennsylvania, will review the illicit practice of blood doping in athletics. He spoke with ASH Clinical News about how hematologists on each side of the issue have worked to develop new testing and detection methods to put an end to this practice.

When did the practice of blood doping in athletics start?

This goes back to scientists trying to combat hypoxia in servicemen during World War II; scientists observed that, by increasing blood’s red cell mass and oxygen-delivering capabilities, they could improve athletic performance and endurance. Eventually, athletes recognized the potential benefit of using transfusions to boost their performance.

For many years, through the 1970s, there were no rules against it. It wasn’t until the mid-1980s when various athletic organizations started to outlaw the practice of hypertransfusion.

Then erythropoietin, which is a hormone that was given to oncology patients to stimulate the production of red cells, came around. Again, athletes and their managers realized the performance-enhancing capabilities there. Also, unlike transfusions, erythropoietin could be taken secretly via a subcutaneous injection of a small volume of the hormone.

How are scientists using blood science to detect these performance-enhancing practices, and how are scientists on the other side using blood science to “trick” tests?

Since the introduction of erythropoietin, it’s been a cat-and-mouse game: As the various agencies that monitor sports and athletes began to develop tests to screen for the hormone, the athletic managers and scientists modified the performance-enhancing agents so that they were undetectable in laboratory tests.

Scientists working with athletes became well-acquainted with the laboratory methods that were used to detect banned substances. For example, if an antibody assay was being used to screen for a compound, they would figure out the exact part of the molecule that was being recognized by the antibody, then design a synthetic compound that would be undetectable on the assay.

They were also looking at ways to make transfusions unidentifiable. Athletes received transfusions of donated blood, so regulators started looking for the presence of transfused red cells in the athlete’s bloodstream. Athletes stored their own blood then re-transfused it, so regulators started looking for bumps in hemoglobin levels that signaled a transfusion. Athletes used albumin to expand blood volume and dilute hematocrit, so regulators started developing tests to detect the plasticizers from the plastic bag that the blood is stored in.

Can you give us a “sneak peek” at some of the information you will be sharing with attendees?

The session will provide hematologists with a primer of what not to do. I’m going to share some of the experiences of Bernard Kohl, an Austrian cyclist who was caught blood doping. He came in third place in the 2008 Tour de France, but officials screened his blood and found a synthetic form of erythropoietin. He eventually confessed everything and revealed the entire practice of performance-enhancing drugs and transfusions.

It was rampant among the Austrian team. As an 18-year-old athlete, he was handed an empty plastic bag and a needle and told to draw his own blood, without any training or assistance whatsoever, to be stored in a refrigerator in his dorm room and then frozen. Months later, the blood would be thawed out and shipped to the Tour de France where it would be used for transfusions.

This was all orchestrated by his manager who, as far as I can tell, was not a physician. It’s shocking because it goes against everything we know about safe practice of transfusion medicine. Cyclists would get sick with “food poisoning,” which was actually the transfusion reactions occurring as a result of these unsafe practices. It’s fascinating and sad. These athletes are being completely exploited to win races and make money for the people involved.

I’ll also be talking about the Athlete Biological Passport, which is an effort by the World Anti-Doping Agency to monitor an athlete’s biologic variables over time. Changes in these variables will indirectly reveal the effects of doping – rather than attempting to detect the doping substance or method itself. That includes simple tests, like measuring hemoglobin level as an indication of having taken erythropoietin, and more complex formulas, like the relationship between reticulocytes and transfused red cells. It’s an effort to put an end to the endless game of developing new tests and developing new ways to trick those tests.