Reply

To discourage the use of rhEPO, the world cycling union (UCI) excludes subjects with a packed cell volume (PCV) of over 50 % and 47 %, respectively for men and women. The world ski federation (FIS) excludes athletes with haemoglobin values (Hb) above 185 g/L (11.5 mmol/L) for men and 165 g/L (10.2 mmol/L) for women. As blood tests are not yet allowed for doping control, such investigations are called 'health tests', and the consequences of finding 'unhealthy' values are relatively mild. One problem with the arbitrary limits used is that athletes who have a physiologically high PCV or Hb may be identified as 'unhealthy', in particular those living at high altitude [1] [2]. Kujala and coworkers added some important information to our paper in which we demonstrated that many high altitude athletes would be taken out of competition using the PCV criteria used by the UCI [2]. They showed, using data from a period before introduction of rhEPO, that several elite athletes (1.3 %) would be excluded by using PCV limits (set by UCI) but none based on Hb limits (set by FIS).

We have now expanded our PCV data with Hb concentration values and compared the results with those from Kujala et al. The results are summarised in Table [1]. Hb values were obtained at the same moment as PCV under conditions described before in this journal [2]. In our study one test (0.8 %) of all 126 PCV tests in lowlanders exceeded 50 %, which would result in exclusion of one athlete from the 36 lowlanders (2.8 %). However, in highland athletes 9 PCV tests of 44 were 'positive' (20.5 %) which means that 4 out of 14 highlanders (28.6 %) were not 'healthy' in terms of the UCI. It is remarkable that none of these athletes, neither lowlanders nor highlanders would be excluded using the FIS standard for Hb concentration. This does not mean, however, that Hb concentration is the ideal parameter as it is, like PCV, influenced by changes in plasma volume. Probably the only way to avoid bias by sometimes considerable fluctuations in plasma volume (expansion and contraction) is to estimate the total amount of circulating Hb, which is not practically conceivable. Another indirect estimation, also free from fluctuations in plasma volume, would be measurement of total red cell volume, which is used as the golden standard to identify patients with polycythaemia vera.

Although athletes with a high PCV or Hb concentration are excluded from competition for health reasons, little is known about the health risk. There may even be a risk at lower values than set by UCI and FIS.

More research is needed to examine physical health of elite athletes, in particular during long-lasting endurance competitions, e.g. the Tour de France, or competitions under extreme climatological conditions, such as the World Athletics Championships in Sevilla in 1999 with temperatures up to 48 °C. During these competitions a careful investigation of daily changes in body function and of haematological, biochemical. and endocrinological values is needed. Perhaps then we could obtain a more critical view on the health risks of elite athletes and provide advice for protection.

References

• 1 Marx J JM, Vergouwen P CJ. Packed-cell volume in elite athletes.  The Lancet. 1998;  352 451
• 2 Vergouwen P, Collée T, Marx J. Haematocrit in elite athletes.  Int J Sports Med. 1999;  20 538-541