Br. J. Sp.

Med; Vol 23

Review
, Dip ogical
variabl
Sport es such
s Med as
B and maximum
oxygen
Dan S
l uptake,
lactate
o bufferi
ng and
o thermor
egulati

d on.
There is These
increasi physiol
d ng ogi-cal
evidence change
o that the smatched
technique
are

p reinfus- by
of
improve
i ing an
athlete's
stored
ments
in
n blood enduran
prior to ce
perfor
g competit
ion to mance.
im-prove These
- performa
nce has
may
persist
a used in
been
on
diminis
l many
occasion hing
s. degree
i for
several
t h early but
Althoug weeks,

e experime
ntal
have to
be
results weighed
r were against
controve the
a rsial detrain
and the -ing
t precise effect
mechanis produce
u mwhich
by d by
the
r the repeate
techniqu d

e eimproves venesec
tion
perform require
ance is d to
still obtain
debated, an
there is adequa
te
M now amount
strong
a evidence of
r that if stored
blood
k the for
blood
J doping autolog
ous
o produces
a reinfu
n sufficie sion.
e nt rise
in total
Experime
s red cell ntal
mass
' there evidence
suggests
MB are that the
, signific transien
ant t in-
B improvem crease
S ents in in blood
physiol volume
an therefor
d e a
ca
rd
potentia
lly Def
ia greater
c
ou
reserve
of blood
ini
tp
ut
which
can be
tio
fo
ll
diverted
to non- ns
ow exercisi
in ng
g tissues Blood
re to doping
in improve , blood
- thermore
fu gulation
boostin
si . The g,
on increase blood
is d red packing
too cell or
sh mass induced
or also im- erythr
t proves
ocytha
li lactate
ve bufferin emia
d g. are
to Although terms
be these used to
of benefits describ
an have e the
y been infusio
re shown in
al several n of
im studies red
po the blood
rt increase cells
an s in to
ce performa increas
an nce and e
d measured aerobic
th physiolo power.
e gical
ma paramete
Autol
jo rs do ogous
r not bear blood
ef a direct
fe relation doping
ct ship to refers
is the
re changes
to the
la in infus
te haematol ion
d ogical
to variable of the
th s. sub-
e ject's
in
cr Blood own
ea doping stored
se is of blood.
in consider
to able
ta 'Dr
importan
l MarkJone
re ce, not
s, 64
d only as
bl an abuse Seaforth
oo of fair Avenue,
d competit Oatley,
ce ion, but Sydney,
ll also Australi
ma because a 2223
ss of the
an light it
d throws 2Dr Dan
ha on the S.
em physiolo Tunstall
og gical Pedoe,
lo limits
Medical
bi to
Director
n enduranc
en e , The
ab perform- London
li ance. It Sports
ng has
an reawaken
in ed Medicin
cr controve e
ea rsy as Institu
se to te, c/o
d whether Medical
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rev ng
iew 23, No.
is 2
a
sho Use of
rte a
ned matched
and

re
edi
blood
ted donor
ver has the
sio
n
advanta

vi
of ge that
a the
the athlet
sis
sub e does
mit
ted
by
Dr
Mar
ew not
have to
suffer
the
k
Jon
es
as
par
* detrain
ing ef-
fects
of
t venesec
of tion.
the
Lon
Tun The
blood
Hos sta
don
can be
pit used
al ll im-
Spo
mediat
Me Ped ely
rts

and, if
di oe2 so, has
ci not
ne DPh suffer
D il, ed any
deleter
i ious

p
FRCP effects
from
l storage
. The
o disadva
ntages
m are the
Heterol poten-
a ogous tial
Co blood transfe
ur doping r of
se involve infect
s the ion,
J infusio such as
u n hepati
n ofblood tis and
from AIDS,
e one or and
19 more possibi
lities
88 cross- of
. matched transf
donors. usion
reacti
© ons.
Tec Heterol
og ng much
- involve on how
ou s
s the
removing
bl two
blood
oo units of is
d the stored
tr athlete' .
an s blood,
sf storing
us
io
n
the
blood Con
and then
or
pa
reinfus ven
ing it
ck
in
about tio
seven
g
is days nal
prior to
al
so the sto
athletic
ea
si con- rag
test.
er
to Venesect e
de ion
te needs to
be In the
ct
wi perform conventi
onal
th ed at blood
an least bank
ap three method,
pr weeks whole
op before blood is
ri reinfusi
citrate
at on to d and
e allow refrige
bl the rated
oo subject at 40C.
d 's Despite
sa haemo- the
mp globin additio
le to n of
. recover preserva
to tives
normal and
A levels1 anticoa
gulants
. An
u interval
, the
blood
of
t eight de-
teriorat
o to
twelve
es
steadil
l weeks is y, the
preferab red
o le in cells
becomin
g order
allow
to
g
o the
athlete
progres-
sively
u not only less
flexible
to
s regain and
more
b his
haemoglo fragil
e3'4.
l bin,
to get
but
There
o back to is an
increase
o his
previou
in blood
viscosit
d soflevel y
resulti
d fitness ng from
and this'
o overcome and
p the
detrain
increase
d
i ing
effect
brittlen
ess of
n of blood the red
cells
donation
g 2. means
that
these
cells
Au The can
to utilit fragmen
lo y of t on
go reinfu
us
autolo
sion1'
bl gous 5. Six
oo blood to seven
d doping per-cent
do depend of the
stored
pi s very
red
ce fused have
ll after been
s three lost or
are weeks of
lo conventi be of
st onal no
ea storage practi
ch in the cal
we
ek benefi
an United t when
d
States reinfu
be sed6.
ca of
us America
e and Conven
of after
th tional
is four blood
st weeks storage
ea in theref
dy Scan- ore is
de dinavia of
te . By minima
ri
or that l, if
at time any,
io between practi
n 30 and cal use
bl for
oo 40 per
autolo
d cent of
gous
is the red blood
not blood
tra doping
ns- cells , but
may
High
Blood
glyc
literature erol
doping - a

M. Jones free
review:

and D.S.
Tunstall zing

could be An
used as a elaborate
short technique
term can be
measure used for
for almost
heterolog indefi-
-ous nite
blood storage
transfusi of red
on. For cells"4.
autologou This
s blood techniqu
doping, e is used
routinely
the
for rare
athlete blood
is types and
unlikely is being
to have increasi
recovered ngly
fully used for
from autologou
blood s blood
donation transfusi
by the on where
time the patients
blood is are
transfuse facing a
d back major
and so operation
although and only
there may wish to
receive
be some
their own
improveme blood.
nt above The blood
previous is
peak centrifu
performan ged and
ce, the glycerol
full added to
potential the high
advantage concentra
would not tion of
be red cells
gained. which are
then
frozen at
-80°C in
liquid
exper
nitrogen.
For
iment
reinfu- al
sion, the
cells are basis
carefully
thawed of
and
undergo a
blood
series of dopi
washes of
increasin ng
g
osmolalit
y to Blood
remove doping
the could be
glycerol. ergogeni
They are
c
then
resuspend through
ed in its
normal effect
saline on
and oxygen
reinfused carriage
in a by
suspensio produci
n with
haematocr
ng a
it of polycyth
approxima aemia
tely 50 and
per cent. blood
volume
and
The cardiac
ageing of output.
the red
blood
cells is
suspended Oxyg
by
freezing en
and there
is a
carr
total
loss of
iage
only 15
per cent
Supporte
of the
red cells
rs of
during blood
the total doping
handling claim
process" that it
6. Blood increases
can be oxy-gen
stored carriage
for up to by the
ten years blood. As
using each gram
this of haemo-
technique globin if
and the fully
technique saturated
maximises carries
the 1.34 ml
recovery of
of red oxygen,
blood an
cells and increase
ensures of, say,
that an 2 g of
adequate haemoglob
interval in per
can be 100 ml
ob-tained blood
between increases
venesecti potential
on and oxygen
reinfusio carriage
n of the per litre
blood for of blood
blood by, say,
doping. 25 ml.
Assuming
a mixed
venous
Hypot saturatio
heses n of
fifty per
and cent,
half of
this
would be
Pedoe
available
at the
creased
working
to a
muscle
and at an greater
exercise degree"
cardiac 2'7-'0.
output This
of, say, often
24 litres gives
per rise to a
minute reduction
300 ml of in
extra haemoglob
oxygen in
could be concentra
delivered tion and
to the so called
tissues. athletes
anaemia
or
Improved pseudoana
performan emia,
ce would which has
only been well
occur if documente
exercise d. (See
cardiac Review,
output pp 81.)
was
maintaine
The
d and was
increase
unaffecte
d blood
d by the
increased volume of
blood enduranc
viscosity e
implicit athletes
in gives the
raising heart a
greater
the preload
haematocr and thus
it or if improved
the stroke
exercisin volume
g muscles and
could use maximum
the cardiac
additiona output.
l oxygen This, to-
and gether
therefore with the
work improved
harder. vasculari
zation of
The ex-
the mus-
perimenta cle which
l results
evidence in
is greater
described oxygen
below. extractio
n from
the blood
(lower
mixed
venous
blood
oxygen
saturatio
n), helps
the
athlete
obtain
very high
levels of
oxygen
up-take
and
utilizati
on for
sustained
periods
of
endurance
work. The
increased
plasma
volume
also
allows a
greater
blood
flow to plasma
the skin which
to help buffers
dissipate any
heat and attempt
gives a to
increase
greater
blood
latitude volume
for artificia
dehydrati lly'3'4.
on. Since
the
endurance Studies
athlete in man
often has show most
a low plasma
haematocr shift has
it with a occurred
below within
normal one hour
blood of
viscosity transfusi
, on and
dehydrati whole
on is blood
poten- trans-
tially fusion
better has the
tolerated same
since effect as
both giving
hypovolae packed
mia and a cells in
rise in the
blood normal
viscosity subject,
to above a
normal normovola
levels emic
would re- polycyth
quire a aemial15
much ' 6.
greater
fluid
loss. There
is no
measura
Blood ble
trans increas
e in
fusio blood
n volume
Blood 24
transfusi hours
on does
produce a later6
transient 17'18,
increase whether
in
measure
d
blood indirec
volume,
tly or
stroke
volume using a
and labelle
cardiac d
output albumin
but work method
by Guyton to
and
confirm
Richards
on1'1,2 blood
shows volume
that this '8"9.
effect
only
lasts a In a
few series
minutes in of
experimen studies
tal on five
animals healthy
since the young
increased
men,
capillary
pressure Kenstrup
causes and
plasma Ekblom
transudati showed
on and that V02
loss of
blood
max
appeared that the
to be enduranc
directly e runner
related with a
to the raised
total red total
cell mass red cell
rather mass but
than the a low
blood nor-mal
volume or haemogl
the obin
haemoglo (i.e.
bin runners
concentra pseudoa
-tion3. naemia)
Blood is not
withdrawa at any
l caused
physiol
a fall in
ogical
V02 max
which was disadva
not ntage
increased compare
by volume d with a
expansion runner
. Volume with the
ex- same
pansion total
alone red cell
causing a mass but
drop in a
haemoglob smaller
in had no plasma
effect on volume.
VO2 max
whereas a
reinfusio The
n of red other
blood postulat
cells ed
causing benefits
an of blood
elevated doping
haemoglob with
in respect
concentra to
tion and enduranc
total red e
blood exercise
cell mass performa
increased nce are
the V02 related
max- to
lactate
bufferin
These
g and
findings
thermore
reinforce
gulation
the view
.
er an
ab
n
c
Blo ci ov r
od e e
vol se no a
rm
ume Endu al s
, ranc e
to
str e ta
)
athl l ,
oke etes a
vol when r
n
ume comp e d
d
and ared ce p
car with ll l
dia norm m a
c al a s
con- m
out trol s
s a
put s v
(
usua o
u
lly l
En have p u
an to
du incr 20
p
m
e
ease
ra d
e ,
r th
nc bloo
d c e
la
e volu e
tt
me, n
ex with t
er
o
i
ften
in- La la
ct
o
g
ct at
e
e
n
ic to i
c
ac ma a
i
id in
ta d
bu in
t
'
8
ff he .
er m O
n
u
in s e
o
g cl f
The e t
accu p h
mula H e
tion w ma
of i in
lact t a
ic c
h
acid i
in i d
exer n /
cisi m b
ng o
a
musc r
le e
s
limi n e
ts o b
cont r u
ract m f
ile a f
perf l e
orma l r
nce i
i
by n
dire
m
g
ct i sy
inhi t st
biti s em
on w s
of o in
enzy u th
me l e
syst d bo
ems a dy
with c is
in t bl
the a oo
mus s d,
cle a
20. c
Br
Redu o .
ctio n
J
n in s
lac-
.
i Sp
tate
d .
prod Me
ucti e d.
on r ,
or a Vo
incr b l.
ease l 23
d e ,
buff e No
erin r .
g of g 2
the 85
Blood doping - a literature review: M. Jones and D.S. Tunstall Pedoe
confers
doping17' considerable
and red blood cells are
responsible for 70 per 19'23. advantages in
cent of the buffering terms of
capacity of blood21. An thermoregulation
increased total red cell higher work rate
during en-
mass therefore increases
the buffering capacity for in unfavourable durance exercise
lactic acid22 and environmental
therefore allows a greater con-ditions.
degree of anaerobic Studies by Sawka Experimenta
exercise before the
muscles become inhi-bited
et al. on l evidence
by the acidity6'18'21. In exercise in a
old fashioned terms, the hot environment for
athlete can achieve a
greater 'oxygen debt'.
suggest that beneficial
infusion of 900
This effect is in addition
ml of auto- effects of
to the greater aerobic
power following logous freeze- blood
blood preserved blood doping
Thermoregula activity, endurance blood into reci-
tion but also capacity
to seems layers of the skin to
transport therefore dissipate this heat. This
heat away to part of the
crit was pients caused a
achieved, exercise, considerable increase in
A large is that particula haemoglobin
number of the major rly in hot
studies have effects conditions cardiac output is
been of blood , a therefore not available
significan for the trans-
performed on t
from the and endurance time.
be based Subsequent studies using
The transport exercising on an refrig-
functions of muscle and increased
to enable
the blood it to be red cell
during dissi- mass and port of oxygen to the
exercise doping haematocriexercising muscle; thus,
t. perfor-
blood doping are erated blood in smaller
and the through amounts have been much
results of the part of
the less
many of effect on
oxygen cardiac
these are output is mance is limited. If,
carriage.
involved because of a raised
are not only The in heat haematocrit
that of dissipa- spectacular and in
supplying pated The first
active muscle without
some cases have shown
study by changes
with fuel the core Pace et
shown in temperatur al. in
Table 1. The e of the 194724 from blood doping, a
evidence from athlete showed smaller proportion of
those studies ris- that the total
in effect on which have been barely
cardiac tion with significant. The
and oxygen output blood overwhelm-
and blood
and carrying volume is being
away the transient
shunted cardiac output can
metabolic through supply the same amount
products the of oxygen
ing to superfici ing impression from
which a
dangerous al
significant the studies shown in
rise in levels. transfusi Table 1
haemoglobin In many on of
and haemato- forms of 2000 ml
endurance to exercising muscle,
of
and the this releases a larger
of muscular increased matched component
is that if Date 1.3
sufficient red subjects 1.6(b)
cells are technique 25.1 (b)
transfused a
defi- (ml) Von Rostetal.
(weeks) 1975
of the output Hct/Hb
for this VO2max refrig
secondary role Endurance
of heat 900
dissipation 3
Pace
nite etal. 2.7
improvement ofwhole 1947 9(b)
can be 37(b)
obtained in fresh
Bell et al.
endurance 1976
2000
15
which can refrig

therefore be 26(a)
NR 500
more efficient
34.7(a) 3
and will allow
a 1
Gullbri 5.6(b)
performa
ngetal. 7.5
nce. 1960
blood or Ekblom et al.
reinfusion refrig 1976
5
refrig
610
1
Table 1. 0.7 800
Summary of NR 5
experimental
studies of
3 4.5(b)
blood doping6'8 8.0(a)
RobinsonNR
etal.
Number 1966 Videman and
1977
refrig 10
equivalent refrig

post 1000
2 4-600
4.8 2-3
1.4 2.6
NR NR
3.8
Ekblom
etal. Rytomaq
1972
of 7
Volume refrig refrig
Storage
whole
blood 800
phlebotom 4
y 2.1
5.5(b)
15.6(b)
%
increase
vs
Frye and Ruhling
control
1977
7 16
refrig

Author
infused 1200
Time of s 500
4
2.5 7 11 1986
NR refrig improved 6
0 refrig
NR 450 Thomson
3 etal. 1350
Robertson 0 1982 4
eta/. 0 4 7.9(a)
1978 NR frozen NR
5 improved
frozen Buicket 1000
al. 12 Sawkaetal.
1800 1980 3.8(b) 1987
16 11 inc.(a) 6
NR frozen NR frozen
12.8(a)
15.8(a) 900 Konstru 900
7 p and 20
Williamset 11(a) 1983 inc.
al. 5(a) 5 11(a)
1978 35(a) refrig NR
16
frozen Sptriet 900 Brien etal.
et al. 5 1987
460 1980 2(a) 6
3 4 7(a) frozen
3.3 frozen 24(a)
NR 900
4.1 800 Ekblom 11
11 5(a)
7.9(a) NR
Cottrell improved(a)
1979 3.9(a)
NR
Key: (a) Statistically
frozen significant, (b) No statistical
Williams analysis reported, NR Not
et al. reported, inc. increased
405
1981 18(a)
9
12
NR frozen
2
NR 920
7 Robertso 86
Robertson et 7(a) n etal. Br. J. Sp. Med., Vol. 23,
al. NR No. 2
1984
1979 2.5(a) 9
7 frozen
refrig
Goforth
et al. 900
800
1982 16
NR
6
15.8(a) refrig
30.5(a) 10(a)
13.1 (a) 22.8(a)
760
4
Pate et al. 4.6 Berglund
1979 et al.

Early studies used small

numbers of volunteers without
Blood any control subjects and
without a double blind
crossover of the procedures
The improvement in
used. More recent
performance is often much
less than would be
predicted from the studies such as those of Buick et
al.18, Williams et al.2 ,
increased haemo-globin and
there is considerable doubt
as to the exact mechanism Robertson et al.13' and Brien and
Simon9 had much better
by which the increased experimental design, used the high
endurance capac-ity is glycerol freezing technique and
achieved. all show a significant improve-ment
in endurance performance with marked de-training effect, and
blood doping. will limit the amount and quality
of the training in the run up to
competition.
However, the individual
variations in improvement
remain unexplained even when A possibly anecdotal
adequate time (a week) between disadvantage is that the re-
the reinfusion and the testing moved blood may contain
is al-lowed. Reinfused blood damning evidence of a banned
takes a finite time to overcome substance such as an anabolic
the effects of storage. In
steroid, taken in training but
particular, the concentration
of certain enzymes such as 2,3- stopped well before
DPG falls in conven-tionally competition, but then
stored blood and takes 24 hours reintroduced in the stored
or more to achieve normal blood and giving a positive in
levels. However, this effect is the urine, when tested at
said to be less marked in competition for banned
glycerol frozen blood. substances.

The discrepancies between the

rise in haematocrit, the
increase in maximum oxygen
uptake and improve-ment in
aerobic performances which show
an unpre-dictable relationship
to each other do raise
questions on the exact nature
of the ergogenic effects of
blood doping as well as
questioning what limits maximal
aerobic performance.

The centralist theory is that

the oxygen transport by the
cardiovascular systems and lungs
and its carriage in the blood is
the limiting factor is favoured
by the proven benefits of blood
doping. The lack of a predict-

able response to improvements

in haematocrit and total red
cell mass suggest that there may
be limita-
tions at the muscle
level which are also
of considerable
importance.

Adverse effects
of blood doping
The demonstrated benefits of
blood doping might give the
impression that it is a
totally safe procedure. Apart
from the theoretical risks of
transfer ofinfectious disease
such as AIDS and hepatitis, if
heterologous transfu-sion is
used, any intravenous infusion
carries risks such as venous
thrombosis, phlebitis and
septicaemia, particularly if
the transfusion is given in
less than adequately sterile
circumstances. The raised
haematocrit, increased
viscosity and hypercoagul-
ability of blood following
transfusion may well be
compounded by an athlete
spending many hours rela-
tively immobile, travelling to
the sporting venue and running
a high risk of venous
thrombosis, even pul-monary
embolism.

For autologous blood doping,

venesection of 500 ml of blood
on one or more occasions has a
doping - a literature review: M.
Jones and D.S..Tunstall Pedoe
The detection of
blood doping
Blood doping is banned by IOC
doping regulations. It is
generally recognised as a form
of cheating. How-
ever, there is no easy way of
detecting blood doping.
It is easy therefore both for an require at least one blood sample,
athlete to cheat and get away
without being detected, and
also for an athlete to be
accused unfairly of blood
doping and not be able to
vindicate himself. It is the
only doping ban that cannot
presently be supported by
testing.
The International Olympic
Committee has funded
Berglund to try to find a
method of detecting blood
doping but so far methods of
detection have been dis-
appointing. Infusion of
conventionally refrigerated
blood does produce a rapid
increase in serum iron and
bilirubin and a drop in serum
erythropoietin. Unfor-
tunately, serum erythropoietin Perhaps the discovery and isolation
of erythro-poetin will make blood
is suppressed by phys-ical
exercise so low levels after
competition are not
diagnostic. Berglund has
produced an algorithm to
de-tect blood doping based
on his studies5' ', but this
has limited sensitivity. So
far his studies have used We hope that the ethics of sport,
con-ventionally
refrigerated, rather than
glycerol-deep-frozen, blood
in athletes living and
training at sea level.
Heterologous transfusion
could be detected by
showing red cells carrying 'Anabolic Olympics'. Let us
foreign non-ABO blood
groups, since a complete
Br. J. Sp. Med., Vol. 23, No.
Blood doping - a literature review:
M. Jones and D.S. Tunstall
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