Potentially harmful advantage to athletes: a putative connection between UGT2B17 gene deletion polymorphism and renal disorders with prolonged use of anabolic androgenic steroids

"The purposes of the World Anti-Doping Code and the World Anti-Doping Program which supports it are: i) to protect the Athletes' fundamental right to participate in doping-free sport and thus promote health, fairness and equality for Athletes worldwide, and ii) to ensure harmonized, coordinated and effective anti-doping programs at the international and national level with regard to detection, deterrence and prevention of doping" [1]. Current doping control is primarily based on enforcement, complemented by deterrence strategies. Meticulously regulated testing protocols, including regulated analytical testing in accredited laboratories and international standards are in place to identify those who violate the anti-doping rules worldwide and to deter others from doing so [2, 3]. The use of performance-enhancing substances and methods deemed to be prohibited is an anti-doping rule violation that is established by the presence of a prohibited substance or its metabolites or markers in the athlete's sample, typically urine or blood [1].

Aside from an ongoing ethical debate on various facets of doping [4], including moral reasoning [5] and medical ethics [6–9], recent critical analyses of the current anti-doping approach have claimed that the current anti-doping is not fit for purpose [10–13]. Reasons for this criticism encompassed ethical issues around constant surveillance [14, 15], analytical difficulties and costs [16, 17], as well as marked inter-individual differences [18–20].

Anabolic androgenic steroids (AASs) are synthetic derivatives of the endogenously produced male sex hormone, testosterone, which exhibits both anabolic (protein synthesizing) and androgenic (masculinising) effects. Steroids are one of the most potent and the most widely used performance-enhancing substances both amongst Olympic athletes [21–23] and also those outside of the auspices of the World Anti-Doping Agency (WADA), such as competitive and recreational body builders, professional players or even non-athlete adolescent boys [24, 25]. The use of AASs is widespread particularly amongst athletes because such drugs can improve their performance in sports by accelerating muscle growth, increasing aggressiveness and enhancing a sense of well-being. Chronic use of AASs has been known to cause serious adverse effects such as virilization, feminization, liver disorders, neuropsychiatric disorders, adverse blood lipid profiles (increased LDL and decreased HDL), cardiovascular disorders and renal complications [26–28]. Among these, renal diseases have received less attention, most likely because renal disorders are infrequent among AAS users in comparison to other, more prevalent diseases. Throughout the last decade, the literature sporadically presented cases of severe renal disorders among AASs users, especially with elevated and prolonged use [29–34]. The number of incidents presented is well below the estimated number of AAS users, however, the user profiles described in these case studies do not differ significantly from those AASs abusers who do not develop renal complications. Thus, there may be a connection between deletion mutation in a steroid conjugating enzyme and occurrence of renal diseases with chronic use of AAS.

AASs are commonly excreted in urine mainly as glucuronide conjugates, the formation of which is catalyzed by various uridine diphosphate-glucuronosyltransferase (UGT) enzymes. The UGTs 2B7, 2B15 and 2B17 are found to be the principal enzymes involved in glucuronidation of androgens and their metabolites in humans. Glucuronidation of steroids and their phase I metabolites is an important detoxification and deactivation metabolic pathway which is catalyzed mainly by UGT2B17 and to a minor extent by UGT2B15 [35–38]. In 2008, a few months before the Beijing Olympics, Schultze and colleagues discovered that the occurrence of deletion polymorphism in the gene coding of UGT2B17 enzyme affected the urinary excretion patterns of testosterone [18]. As the current doping testing regime relies on detecting the steroid metabolites in urine, UGT2B17 deficient drug abusers are likely to test negative despite the use of the drug. Although the enzyme deficient athletes who are aware of their own genetic profile may benefit from evading doping testing, they may be vulnerable to serious health consequences due to inadequate deactivation and elimination of steroids. The potential consequences of this discovery has triggered the WADA and sport governing bodies to examine their testing regimes.

However, it is inevitable that this phenomenon has significant implications beyond the sporting arena. Juul et al. [39] observed in pubertal boys, that the homozygous deletion in the UGT2B17 gene, in line with Schulze et al. [18], affected the urinary excretion pattern of androgen metabolites, but not circulating androgen levels. A deficiency of the UGT2B17 enzyme decreases the rate of steroid deactivation and elimination, and owing to this, the bioavailability of steroids may be enhanced to a certain extent. Hence, elevated and prolonged use of AAS may predispose the enzyme deficient individuals to detrimental effects, particularly relating to kidney damage.

Therefore, in this paper we hypothesise that the observed renal disorders among AAS users is connected to the genetic profiles of these users and functional polymorphic deletion of the UGT2B17 gene significantly increases the chance of developing kidney complications.

We hypothesize that with chronic and/or excessive use of AAS, individuals with a deletion polymorphism in the UGT2B17 gene (del/del) carry an increased risk of developing renal disorders owing to an increase in body mass index and possible direct toxic effects of steroids on the kidneys. Inadequate elimination of the biologically active steroids will lead to elevated serum levels and cause surplus increase in muscle mass. An increase in body mass index may cause renal injuries due to sustained elevated glomerular pressure and flow rate.

As the hypothesis is based on the dysergistic effect of the UGT2B17 polymorphism and long term exposure to AAS, a single clinical trial approach does not present a feasible way to generate evidence to support or refute the hypothesis. Therefore an alternative, multi-component approach is proposed with three distinct components: i) delineation of single dose pharmacokinetics, ii) animal model studies, and iii) genotype testing in humans suffering from renal failure.

To delineate single dose pharmacokinetics for commonly abused AAS, a population based study can be carried out which involves the administration of a single dose of a [¹³C] labelled AASs to healthy volunteers with different UGT2B17 genotypes. Routine blood tests, biofluid analyses, urinalysis and hair analyses [50, 51] will ascertain the deviation in the pharmacokinetics of steroids owing to the prevalence of different UGT2B17 genotypes. Thus, the circulating levels of active steroids (plus phase I metabolites) and alternative metabolic pathways of steroids in individuals with impaired glucuronidation activity can be determined.

An animal study involving chronic administration of AASs to mice or rats with different UGT2B17 genotypes, accompanied with routine examination of renal function will help in scrutinizing the relationship between development of renal disorders and deletion polymorphism in the gene. In addition to affording AAS induced renal impairment investigations, animal models will facilitate controlled comparative pharmacokinetic studies of short and long term AAS exposure in mice. In addition, these data will allow comparison to the pharmacokinetics from the human single dose study.

For clinical observations, patients with renal impairment after long term use of anabolic steroids should be analysed for genotype using real time PCR with allelic discrimination to determine the prevalence of UGT2B17 deletion genotypes (del/del, ins/del and ins/ins). Studies would also involve the evaluation of other UGTs which have been reported to play a role in AAS glucuronidation to accurately estimate the impact of each phenotype [52]. Thus, prospective or retrospective genotype analysis of tissues from patients undergoing clinical treatments for renal impairment with admitted steroid abuse are recommended. In addition, depending on the pharmacokinetic results from study i), analysis of hair samples could confirm cases of self-reported chronic AAS abuse.

A system that is primarily based on detection-based deterrence and sanctioning may be easily perceived as a barrier to overcome if a competitive edge can be secured by using performance-enhancing substances or methods. Thus, the current repressive approach to anti-doping inevitably leads to finding ways in detection evasion, with health concerns being secondary. In this 'nothing or all' system, the harm reduction approach that characterizes many drug prevention programmes, cannot be accommodated.

Following the paper by Schulze and colleagues [18] on the effect of UGT2B17 gene deletion polymorphism on doping tests, it is likely that this discovery is turned into practice and abused by athletes determined to use AAS. In this scenario, athletes believe that they take the known risk associated with AAS use, but not the risk of being caught. However, if the hypothesis is correct, these athletes expose themselves to an increased risk in developing renal disorders as a consequence of their UGT2B17 gene deletion polymorphism.

The harm reduction approach to doping, not yet official but increasingly advocated among doping researchers [13, 53], would benefit greatly from an empirical verification of the assumption presented in this paper. The potential danger present in this connection, a controlled clinical trial with volunteers is not feasible but primary care physicians and nephrologists are in a favourable position to advance our knowledge in this area.

Although it has been recognized by now that education based anti-doping prevention is a challenging task [54], having objective information is the sine qua non of all efforts relying on informed choice. This is not to advocate the less effective loss-framed messages [55] or fear appeals [56] in preventing AAS use, but rather to draw attention to the fact that inter-individual variations in metabolizing steroids could lead to serious health detriments in individuals even at doses below the problematic supraphysiological doses.

Groups that may benefit from this research are not only AAS users who deliberately take advantage of their unique genetic make-up to evade doping testing, hence will face increased risk of developing renal complications, but include other AAS users, such as recreational users and bodybuilders unaware of the risk, who may inadvertently subject themselves to risks of developing kidney disease. Beyond the athletic arena, administration of AAS should be avoided for patients with nephritic symptoms as it may worsen renal conditions. AAS have been found to be beneficial in improving conditions of individuals with muscle wasting disorders. Researchers have observed improvement in lean body mass of individuals with HIV and chronic obstructive pulmonary disease (COPD) after administration of AAS [27]. Thus, AAS, if not misused, can have therapeutic applications. However, patients that are devoid of the gene will be more vulnerable to serious health consequences. As pharmacokinetic investigations are a key part of the proposed hypothesis testing studies, additional information will be generated on inter-individual differences which may have implications beyond the hypothesis. In such situations, alternative treatment should be employed or a genotype based safe dose should be identified.