mRNA Biomarkers in Dried Blood Spots May Improve Detection of Autologous Blood Micro‐Transfusions Using an Individualized Approach

This study shows that measuring ALAS2 mRNA expression from dried blood spots (DBS) can sensitively identify autologous blood micro-transfusions (ABMTs) ABMTs with > 95% sensitivity and specificity through individualized analysis. These results highlight ALAS2 mRNA in DBS as a promising tool to strengthen anti-doping efforts against small-volume autologous transfusions.

ABSTRACT

Autologous blood transfusions (ABTs) are prohibited by the World Anti-Doping Agency (WADA), yet detecting autologous blood micro-transfusions (ABMTs) remains a challenge. Due to smaller transfused volumes, ABMTs cause attenuated biomarker changes, limiting detection sensitivity within the Athlete Biological Passport (ABP). This study assessed whether mRNA expression of 5-aminolevulinic acid synthase (ALAS2) and carbonic anhydrase 1 (CA1), measured from dried blood spots (DBS), could serve as sensitive biomarkers of ABMT. In a randomized, placebo-controlled design, 47 trained individuals (24 ♀; mean VO₂peak 56 ± 7 mL·min⁻¹·kg⁻¹) were allocated to an ABMT group (n = 23; ♀ = 12) or placebo group (n = 24; ♀ = 12). The ABMT group donated 450 mL of blood and received a 130 mL packed red blood cell reinfusion 4 weeks later. Blood sampling occurred regularly before and after both donation and reinfusion. ALAS2 and CA1 mRNA expression from DBS, and reticulocyte percentage (RET%) from venous blood, were analyzed. Following blood donation, ALAS2, CA1, and RET% increased by 270%, 200%, and 150%, respectively. However, no consistent group-level changes were observed after ABMT. Individualized analysis identified more outliers for ALAS2 than for CA1, and blinded interpretation of individual mRNA profiles achieved > 95% sensitivity and specificity for detecting ABMT. These findings suggest that ALAS2 mRNA expression, assessed via minimally invasive DBS sampling, is a promising biomarker for identifying ABMT. This approach may enhance current anti-doping strategies by improving sensitivity to small-volume autologous transfusions that evade detection through traditional ABP biomarkers.