Prevalence of exercise-associated hyponatremia in male ultraendurance athletes
Abstract
OBJECTIVE: The prevalence of exercise-associated hyponatremia (EAH) has mainly been investigated in marathoners and Ironman triathletes. The aim of this study was to investigate the prevalence of EAH in male ultraendurance athletes in other disciplines, such as ultraswimming, ultracycling, and ultramarathon running. DESIGN: Observational field study. SETTING: "Marathon Swim" in Lake Zurich, the "Swiss Cycling Marathon," the "Swiss Bike Masters," the "100-km Lauf Biel," and the "Swiss Jura Marathon." PARTICIPANTS: Fifteen ultraswimmers, 28 ultra-road cyclists, 37 ultra-mountain bikers, 95 ultramarathoners, and 25 mountain ultramarathoners. MAIN OUTCOME MEASURES: Changes in body mass, plasma sodium, urinary specific gravity, and hematocrit were measured. The athletes recorded their intake of fluids. RESULTS: Two swimmers (13%), 3 road cyclists (10.7%), no mountain bikers (0%), 5 ultramarathoners (5%), and 2 mountain ultramarathoners (8%) developed EAH. In the mountain bikers (r = -0.41) and the 100-km ultramarathoners (r = -0.52), fluid intake was significantly and negatively related to race time. In the mountain ultramarathoners, fluid consumption increased during the race. CONCLUSIONS: The prevalence of EAH was no higher in ultraendurance athletes compared with existing reports on marathoners and Ironman triathletes. Of the 200 investigated ultraendurance athletes, 12 finishers (6%) developed EAH.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
EAH incidence rates of 6-11.5% were reported in mountain biking events.
“6–11.5% in mountain biking events [28,43]”
From Nutrition-Related Adverse Outcomes in Endurance Sports Competitions: A Review of Incidence and Practical Recommendations (2020) · cites this paper as [43]
EAH is a disorder of fluids and electrolytes that has been widely described in marathon runners and competitors in other endurance and ultra-endurance events such as cycling races of 24 h or ≥150 km, foot races of 24 h or ≥100 km, Ironman triathlons, or open-water swimming events.
“EAH is a disorder of fluids and electrolytes that has been widely described in marathon runners [32] and competitors in other endurance and ultra-endurance events such as: cycling races of 24 h or ≥150 km [28,40,43], foot races of 24 h or ≥100 km [28,31], Ironman triathlons [13,32], or open-water swimming events [43].”
From Nutrition-Related Adverse Outcomes in Endurance Sports Competitions: A Review of Incidence and Practical Recommendations (2020) · cites this paper as [43]
Cites
1 retracted
Women Hydrate More Than Men During a Marathon Race
Hew, T. D. (2005) · Clinical Journal of Sport Medicine · doi:10.1097/01.jsm.0000157652.47572.56 · Cited by 45 · see citing works
RetractedLevey, A. S., Bosch, J. P., Lewis, J. B., Greene, T., Rogers, N., Roth, D., & for the Modification of Diet in Renal Disease Study Group* (1999) · Annals of Internal Medicine · doi:10.7326/0003-4819-130-6-199903160-00002 · Cited by 15,079 · see citing works
Lameire, N. H., Vanbiesen, W., & Vanholder, R. C. (2005) · The Lancet · doi:10.1016/s0140-6736(05)70238-5 · Cited by 948 · see citing works
Hyponatremia among runners in the Boston Marathon.
Almond, C. S. D., Shin, A. Y., Fortescue, E. B., Mannix, R. C., Wypij, D., Binstadt, B. A., Duncan, C. N., Olson, D. P., Salerno, A. E., Newburger, J. W., et al. (2005) · New England Journal of Medicine · doi:10.1056/nejmoa043901 · Cited by 553 · see citing works
Evaluation of hemoconcentration from hematocrit measurements.
Beaumont, W. V. (1972) · Journal of Applied Physiology · doi:10.1152/jappl.1972.32.5.712 · Cited by 465 · see citing works
Carvounis, C. P., Nisar, S., & Guro‐Razuman, S. (2002) · Kidney International · doi:10.1046/j.1523-1755.2002.00683.x · Cited by 339 · see citing works
Noakes, T. D., Sharwood, K. A., Speedy, D. B., Hew, T. D., Reid, S., Dugas, J. P., Almond, C. S. D., WHARAM, P. C., & Weschler, L. B. (2005) · Proceedings of the National Academy of Sciences · doi:10.1073/pnas.0509096102 · Cited by 330 · see citing works
Kavouras, S. A. (2002) · Current Opinion in Clinical Nutrition & Metabolic Care · doi:10.1097/00075197-200209000-00010 · Cited by 323 · see citing works
Predicting Glomerular Function from Adjusted Serum Creatinine
GAULT, M. H., Longerich, L., Harnett, J. D., et al. (2008) · The Nephron journals/Nephron journals · doi:10.1159/000187054 · Cited by 297 · see citing works
Hyponatremia in ultradistance triathletes
Speedy, D. B., Noakes, T. D., Rogers, I. R., Thompson, J., Campbell, R. G., Kuttner, J. A., Boswell, D. R., Wright, S. P., & HAMLIN, M. (1999) · Medicine & Science in Sports & Exercise · doi:10.1097/00005768-199906000-00008 · Cited by 283 · see citing works
Strauss, M. B., Davis, R. K., Rosenbaum, J. D., et al. (1951) · Journal of Clinical Investigation · doi:10.1172/jci102501 · Cited by 267 · see citing works
Hew‐Butler, T., Ayus, J. C., Kipps, C., Maughan, R. J., Mettler, S., Meeuwisse, W. H., Page, A., Reid, S. A., Rehrer, N. J., Roberts, W. O., et al. (2008) · Clinical Journal of Sport Medicine · doi:10.1097/jsm.0b013e318168ff31 · Cited by 223 · see citing works
Training Principles and Issues for Ultra-endurance Athletes
Zaryski, C., & Smith, D. J. (2005) · Current Sports Medicine Reports · doi:10.1097/01.csmr.0000306201.49315.73 · Cited by 222 · see citing works
The Incidence, Risk Factors, and Clinical Manifestations of Hyponatremia in Marathon Runners
Hew, T. D., Chorley, J. N., Cianca, J. C., & Divine, J. G. (2003) · Clinical Journal of Sport Medicine · doi:10.1097/00042752-200301000-00008 · Cited by 203 · see citing works
The biochemistry of runners in a 1600 km ultramarathon.
Fallon, K. E., Sivyer, G., Sivyer, K., & Dare, A. (1999) · British Journal of Sports Medicine · doi:10.1136/bjsm.33.4.264 · Cited by 198 · see citing works
Noakes, T. D., GOODWIN, N., RAYNER, B. L., BRANKEN, T., & Taylor, R. K. N. (1985) · Medicine & Science in Sports & Exercise · doi:10.1249/00005768-198506000-00012 · Cited by 197 · see citing works
Exercise-associated hyponatremia in marathon runners: a two-year experience
Davis, D. P., Videen, J. S., Marino, A., Vilke, G. M., Dunford, J. V., Camp, S. P. V., & Maharam, L. G. (2001) · Journal of Emergency Medicine · doi:10.1016/s0736-4679(01)00320-1 · Cited by 182 · see citing works
Weight changes, medical complications, and performance during an Ironman triathlon
Sharwood, K. A., Collins, M., Goedecke, J. H., Wilson, G., & Noakes, T. D. (2004) · British Journal of Sports Medicine · doi:10.1136/bjsm.2003.007187 · Cited by 179 · see citing works
Fluid Balance During and After an Ironman Triathlon
Speedy, D. B., Noakes, T. D., Kimber, N. E., Rogers, I. R., Thompson, J., Boswell, D. R., Ross, J. J., Campbell, R. G., Gallagher, P. G., & Kuttner, J. A. (2001) · Clinical Journal of Sport Medicine · doi:10.1097/00042752-200101000-00008 · Cited by 171 · see citing works
Hormonal, electrolyte, and renal responses to exercise are intensity dependent
Freund, B. J., Shizuru, E. M., Hashiro, G. M., & Claybaugh, J. R. (1991) · Journal of Applied Physiology · doi:10.1152/jappl.1991.70.2.900 · Cited by 137 · see citing works
Exercise‐associated hyponatremia: A review
Speedy, D. B., Noakes, T. D., & Schneider, C. (2001) · Emergency Medicine · doi:10.1046/j.1442-2026.2001.00173.x · Cited by 137 · see citing works
Interpreting the fractional excretion of sodium
Steiner, R. W. (1984) · The American Journal of Medicine · doi:10.1016/0002-9343(84)90368-1 · Cited by 137 · see citing works
New clinical approach to evaluate disorders of potassium excretion.
West, M. L., Marsden, P. A., Richardson, R., Zettle, R. M., & Halperin, M. L. (1986) · PubMed · Cited by 126 · see citing works
The Utility of the Transtubular Potassium Gradient in the Evaluation of Hyperkalemia
Choi, M. J., & Ziyadeh, F. N. (2008) · Journal of the American Society of Nephrology · doi:10.1681/asn.2007091017 · Cited by 112 · see citing works
Osmotic and Nonosmotic Regulation of Arginine Vasopressin during Prolonged Endurance Exercise
Hew‐Butler, T., Jordaan, E., Stuempfle, K. J., Speedy, D. B., Siegel, A. J., Noakes, T. D., Soldin, S. J., & Verbalis, J. G. (2008) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/jc.2007-2336 · Cited by 109 · see citing works
Study of Hematological and Biochemical Parameters in Runners Completing a Standard Marathon
Reid, S. A., Speedy, D. B., Thompson, J., Noakes, T. D., Mulligan, G., Page, T., Campbell, R. G., & Milne, C. (2004) · Clinical Journal of Sport Medicine · doi:10.1097/00042752-200411000-00004 · Cited by 107 · see citing works
Speedy, D. B., Rogers, I. R., Noakes, T. D., Wright, S. J., Thompson, J., Campbell, R. G., Hellemans, I. J., Kimber, N. E., Boswell, D. R., Kuttner, J. A., et al. (2000) · Clinical Journal of Sport Medicine · doi:10.1097/00042752-200010000-00009 · Cited by 104 · see citing works
Page, A. J., Reid, S. A., Speedy, D. B., Mulligan, G., & Thompson, J. (2007) · Clinical Journal of Sport Medicine · doi:10.1097/jsm.0b013e31802b5be9 · Cited by 98 · see citing works
Food Intake and Electrolyte Status of Ultramarathoners Competing in Extreme Heat
Glace, B. W., Murphy, C. A., & McHugh, M. P. (2002) · Journal of the American College of Nutrition · doi:10.1080/07315724.2002.10719254 · Cited by 97 · see citing works
The incidence of exercise-associated hyponatraemia in the London marathon
Kipps, C., Sharma, S., & Pedoe, D. T. (2009) · British Journal of Sports Medicine · doi:10.1136/bjsm.2009.059535 · Cited by 94 · see citing works
Hyponatremia and Weight Changes in an Ultradistance Triathlon
Speedy, D. B., Faris, J. G., Hamlin, M., Gallagher, P. G., & Campbell, R. G. (1997) · Clinical Journal of Sport Medicine · doi:10.1097/00042752-199707000-00005 · Cited by 93 · see citing works
Risk Factors for Exercise-associated Hyponatremia in Non-elite Marathon Runners
Chorley, J. N., Cianca, J. C., & Divine, J. G. (2007) · Clinical Journal of Sport Medicine · doi:10.1097/jsm.0b013e3181588790 · Cited by 92 · see citing works
Fluid and Electrolyte Status in Athletes Receiving Medical Care at an Ultradistance Triathlon
OʼToole, M. L., Douglas, P. S., Laird, R. H., & Hiller, W. D. B. (1995) · Clinical Journal of Sport Medicine · doi:10.1097/00042752-199504000-00008 · Cited by 71 · see citing works
Hyponatremia in runners requiring on-site medical treatment at a single marathon
Hsieh, M., Roth, R., DAVIS, D. L., Larrabee, H., & Callaway, C. W. (2002) · Medicine & Science in Sports & Exercise · doi:10.1097/00005768-200202000-00001 · Cited by 63 · see citing works
Change in Serum Sodium Concentration During a Cold Weather Ultradistance Race
Stuempfle, K. J., Lehmann, D. R., Case, H. S., Hughes, S. L., & Evans, D. (2003) · Clinical Journal of Sport Medicine · doi:10.1097/00042752-200305000-00008 · Cited by 61 · see citing works
Hyponatremia Among Runners in the Zurich Marathon
Mettler, S., Rusch, C., Frey, W. O., Bestmann, L., Wenk, C., & Colombani, P. C. (2008) · Clinical Journal of Sport Medicine · doi:10.1097/jsm.0b013e31817e3515 · Cited by 56 · see citing works
Gerth, J., Ott, U., Fünfstück, R., et al. (2002) · Clinical Nephrology · doi:10.5414/cnp57425 · Cited by 54 · see citing works
The Immediate and Delayed Effects of Marathon Running on Renal function
Irving, R. A., Noakes, T. D., Irving, G. A., & van Zyl-Smit, R. N. (1986) · The Journal of Urology · doi:10.1016/s0022-5347(17)45275-x · Cited by 50 · see citing works
Increased renal tubular sodium reabsorption during exercise-induced hypervolemia in humans
Nagashima, K., Wu, J., Kavouras, S. A., & Mack, G. W. (2001) · Journal of Applied Physiology · doi:10.1152/jappl.2001.91.3.1229 · Cited by 49 · see citing works
Male ironman triathletes lose skeletal muscle mass
Knechtle, B., Baumann, B., Wirth, A., Knechtle, P., & Rosemann, T. J. (2010) · PubMed · doi:10.5167/uzh-33316 · Cited by 48 · see citing works
Self-citationBACK-DIFFUSION OF UREA IN THE MAMMALIAN KIDNEY
Dole, V. P. (1943) · American Journal of Physiology-Legacy Content · doi:10.1152/ajplegacy.1943.139.4.504 · Cited by 42 · see citing works
Reid, S. A., & King, M. (2007) · Clinical Journal of Sport Medicine · doi:10.1097/jsm.0b013e31804c77da · Cited by 41 · see citing works
An Ultra-cycling Race Leads to no Decrease in Skeletal Muscle Mass
Knechtle, B., Wirth, A., Knechtle, P., & Rosemann, T. J. (2009) · International Journal of Sports Medicine · doi:10.1055/s-0028-1104585 · Cited by 40 · see citing works
Self-citationKnechtle, B., Duff, B., Amtmann, G., & Kohler, G. (2008) · Research in Sports Medicine · doi:10.1080/15438620701878881 · Cited by 37 · see citing works
Self-citationExercise-Associated Hyponatraemia after a Marathon: Case Series
Goudie, A., Tunstall-Pedoe, D. S., Kerins, M., & Terris, J. (2006) · Journal of the Royal Society of Medicine · doi:10.1258/jrsm.99.7.363 · Cited by 37 · see citing works
Schenk, K., Gatterer, H., Ferrari, M., Ferrari, P., Cascio, V. L., & Burtscher, M. (2010) · Clinical Journal of Sport Medicine · doi:10.1097/jsm.0b013e3181c9673f · Cited by 34 · see citing works
Do ultra-runners in a 24-h run really dehydrate?
Knechtle, B., Wirth, A., Knechtle, P., Rosemann, T. J., & Senn, O. (2010) · Irish Journal of Medical Science (1971 -) · doi:10.1007/s11845-010-0500-8 · Cited by 30 · see citing works
Self-citationNo Dehydration in Mountain Bike Ultra-Marathoners
Knechtle, B., Knechtle, P., Rosemann, T. J., & Senn, O. (2009) · Clinical Journal of Sport Medicine · doi:10.1097/jsm.0b013e3181b47c93 · Cited by 25 · see citing works
Self-citationRose, S., & Peters, E. M. (2008) · British Journal of Sports Medicine · doi:10.1136/bjsm.2008.049551 · Cited by 24 · see citing works
Knechtle, B., Knechtle, P., Kaul, R., & Kohler, G. (2009) · Research Quarterly for Exercise and Sport · doi:10.1080/02701367.2009.10599530 · Cited by 20 · see citing works
Self-citationTHE EFFECTS OF DIFFERENT ENDURANCE SWIMMING INTENSITIES ON BONE DEVELOPMENT IN RATS
Hsieh, S. S., Huang, T. H., Chang, F. L., & Yang, R. (2002) · Medicine & Science in Sports & Exercise · doi:10.1097/00005768-200205001-00460 · Cited by 9 · see citing works
Flagged first, then by citations
Cited by
Sorted by citations
Exercise-Associated Hyponatremia: 2017 Update
Hew-Butler, T., Loi, V., Pani, A., & Rosner, M. H. (2017) · Frontiers in Medicine · doi:10.3389/fmed.2017.00021 · Cited by 112 · see citing works
Nutrition in Ultra-Endurance: State of the Art
Nikolaidis, P. T., Veniamakis, E., Rosemann, T., & Knechtle, B. (2018) · Nutrients · doi:10.3390/nu10121995 · Cited by 70 · see citing works
“Nonetheless, the occurrence of EAH in ultra-marathoners [84] is similar as in marathoners [85].”
BackgroundSelf-citationWinger, J. M., Hoffman, M. D., Hew-Butler, T. D., Stuempfle, K. J., Dugas, J. P., Fogard, K., & Dugas, L. R. (2013) · International Journal of Sports Physiology and Performance · doi:10.1123/ijspp.8.5.536 · Cited by 36 · see citing works
Martínez-Sanz, J. M., Fernández Nuñez, A., Sospedra, I., Martínez-Rodríguez, A., Domínguez, R., González-Jurado, J. A., & Sánchez-Oliver, A. J. (2020) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph17114082 · Cited by 25 · see citing works
- Authors
- Knechtle, B., Gnädinger, M., Knechtle, P., Imoberdorf, R., Kohler, G., Ballmer, P., Rosemann, T., & Senn, O.
- Affiliations
- University of Zurich (CH)
- Kantonsspital Winterthur (CH)
- University Hospital of Basel (CH)
- Corresponding author
- Knechtle, Beat
- Knechtle, Patrizia
- Venue
- Clinical Journal of Sport Medicine
- Published
- 2011-05
- Volume
- 21
- Issue
- 3
- Pages
- 226-232
- ISSN
- 1050-642X (ISSN-L)
- OpenAlex
- W2313002491
- Cited by
- 48
- References
- 51
- Citations by year
- 2025: 2 · 2024: 2 · 2022: 2 · 2021: 2 · 2020: 3 · 2019: 4 · 2018: 4 · 2017: 1 · 2016: 1 · 2015: 4 · 2014: 7 · 2013: 8 · 2012: 5
- FWCI
- 6.26
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Clinical Journal of Sport Medicine (publishedVersion)
- PubMed (publishedVersion)
- Zurich Open Repository and Archive (University of Zurich) (submittedVersion)
- Topics
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Electrolyte and hormonal disorders
- Health Sciences › Medicine › Physiology › Thermoregulation and physiological responses
- Health Sciences › Medicine › Rehabilitation › Exercise and Physiological Responses
- Keywords
- exercise-associated hyponatremia, prevalence, plasma sodium, fluid intake, ultramarathon, mountain biking, electrolyte balance, hematocrit, urine specific gravity
- MeSH terms
- Adult, Bicycling, Humans, Hyponatremia, Male, Middle Aged, Physical Endurance, Running, Swimming, Body Mass Index, Prevalence, Athletes
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
