Comment on “Sub-anesthetic Xenon Increases Erythropoietin Levels in Humans: A Randomized Controlled Trial”

Effect of xenon and argon inhalation on erythropoiesis and steroidogenesis: A systematic review

Background

Xenon and argon inhalation were included on the WADA Prohibited List in 2014 due to the reported positive effects on erythropoiesis and steroidogenesis that occur as a result of their application. Thus, the systematic review of studies supporting these notions is of interest.

Methods

A thorough search on the effects of xenon and argon inhalation on erythropoiesis and steroidogenesis, as well as their negative effects on human health and method detection was conducted. Pubmed and Google Scholar databases and the Cochrane Library were researched, as well as the WADA research section. The search was conducted in accordance with the PRISMA guidelines. All articles written in English and published between 2000 and 2021 were analyzed, as well as reference studies meeting the search criteria.

Results

At present, there are only two publications in healthy human subjects evaluating the effects of xenon inhalation on erythropoiesis that found no conclusive evidence of a positive effect on erythropoiesis. This research was published following the inclusion of this gas on the WADA Prohibited List in 2014 and had a high risk of bias. There were no studies available on the effect of argon inhalation on erythropoiesis. Furthermore, no studies were found on the effect of xenon or argon inhalation on steroidogenesis in healthy subjects and no studies relating to the effects of xenon or argon inhalation on erythropoiesis and steroidogenesis were found on the WADA website.

Conclusion

There is still inconclusive evidence to support the administration of xenon and argon inhalations on erythropoiesis and steroidogenesis and their positive effects on health. Further research is warranted to establish the effects of these gases. Additionally, improved communication between anti-doping authorities and all key stakeholders is required to support the inclusion of various substances on recognized prohibited lists.

The Inclusion in WADA Prohibited List Is Not Always Supported by Scientific Evidence: A Narrative Review

Context: Our goal was to review the current literature regarding the ability of substances that have recently been included in the WADA prohibited list (i.e., meldonium, trimetazidine, xenon, and cobalt) or in the monitoring program (i.e., ecdysterone and bemethyl) to enhance performance in athletes or cause adverse effects. Evidence Acquisition: To find out which studies led to the prohibition of the substances mentioned, we searched the PubMed database using keywords including the substances’ or methods’ names, as well as phrases related to various aspects of sports activities and health assessments of athletes. Results: The results obtained during our systematic literature search clearly indicate that there is a lack of scientific evidence supporting the impact of several substances prohibited by WADA (i.e., meldonium, trimetazidine, xenon, and cobalt) on athletic performance or on health in athletes. Conclusions: There is insufficient evidence that the previously mentioned substances have any performance enhancing potential. If left on the list, meldonium may be classified as a “specified substance” because of its wide availability and due to the fact that this drug that can be easily bought over the counter without a prescription.

Review of WADA Prohibited Substances: Limited Evidence for Performance-Enhancing Effects

The World Anti-Doping Agency is responsible for maintaining a Prohibited List that describes the use of substances and methods that are prohibited for athletes. The list currently contains 23 substance classes, and an important reason for the existence of this list is to prevent unfair competition due to pharmacologically enhanced performance. The aim of this review was to give an overview of the available evidence for performance enhancement of these substance classes. We searched the scientific literature through PubMed for studies and reviews evaluating the effects of substance classes on performance. Findings from double-blind, randomized controlled trials were considered as evidence for (the absence of) effects if they were performed in trained subjects measuring relevant performance outcomes. Only 5 of 23 substance classes show evidence of having the ability to enhance actual sports performance, i.e. anabolic agents, β2-agonists, stimulants, glucocorticoids and β-blockers. One additional class, growth hormone, has similar evidence but only in untrained subjects. The observed effects all relate to strength or sprint performance (and accuracy for β-blockers); there are no studies showing positive effects on reliable markers of endurance performance. For 11 classes, no well-designed studies are available, and, for the remaining six classes, there is evidence of an absence of a positive effect. In conclusion, for the majority of substance classes, no convincing evidence for performance enhancement is available, while, for the remaining classes, the evidence is based on a total of only 266 subjects from 11 studies.

Postconditioning effects of argon or xenon on early graft function in a porcine model of kidney autotransplantation

BACKGROUND

Ischaemia-reperfusion injury is inevitable during renal transplantation and can lead to delayed graft function and primary non-function. Preconditioning, reconditioning and postconditioning with argon and xenon protects against renal ischaemia-reperfusion injury in rodent models. The hypothesis that postconditioning with argon or xenon inhalation would improve graft function in a porcine renal autotransplant model was tested.

METHODS

Pigs (n = 6 per group) underwent left nephrectomy after 60 min of warm ischaemia (renal artery and vein clamping). The procured kidney was autotransplanted in a separate procedure after 18 h of cold storage, immediately after a right nephrectomy. Upon reperfusion, pigs were randomized to inhalation of control gas (70 per cent nitrogen and 30 per cent oxygen), argon (70 per cent and 30 per cent oxygen) or xenon (70 per cent and 30 per cent oxygen) for 2 h. The primary outcome parameter was peak plasma creatinine; secondary outcome parameters included further markers of graft function (creatinine course, urine output), graft injury (aspartate aminotransferase, heart-type fatty acid-binding protein, histology), apoptosis and autophagy (western blot, terminal deoxynucleotidyl transferase dUTP nick-end labelling (TUNEL) staining), inflammatory mediators and markers of cell survival/growth (mRNA and tissue protein quantification), and animal survival. Results are presented as median (i.q.r.). ANOVA and Kruskal-Wallis tests were used where indicated.

RESULTS

Peak plasma creatinine levels were similar between the groups: control 20·8 (16·4-23·1) mg/dl, argon 21·4 (17·1-24·9) mg/dl and xenon 19·4 (17·5-21·0) mg/dl (P = 0·607). Xenon was associated with an increase in autophagy and proapoptotic markers. Creatinine course, urine output, injury markers, histology, survival and inflammatory mediators were not affected by the intervention.

CONCLUSION

Postconditioning with argon or xenon did not improve kidney graft function in this experimental model. Surgical relevance Ischaemia-reperfusion injury is inevitable during renal transplantation and can lead to delayed graft function and primary non-function. Based on mainly small animal experiments, noble gases (argon and xenon) have been proposed to minimize this ischaemia-reperfusion injury and improve outcomes after transplantation. The hypothesis that postconditioning with argon or xenon inhalation would improve graft function was tested in a porcine kidney autotransplantation model. The peak plasma creatinine concentration was similar in the control, argon and xenon groups. No other secondary outcome parameters, including animal survival, were affected by the intervention. Xenon was associated with an increase in autophagy and proapoptotic markers. Despite promising results in small animal models, postconditioning with argon or xenon in a translational model of kidney autotransplantation was not beneficial. Clinical trials would require better results.