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Wilderness Environ Med. 2017 Dec;28(4):291-298. doi: 10.1016/j.wem.2017.05.008. Epub 2017 Aug 7.

Exercise-Associated Hyponatremia, Hypernatremia, and Hydration Status in Multistage Ultramarathons.

Author information

Department of Rehabilitation, Orthopedics and Sports Medicine, University of Washington and Seattle Children's Sports Medicine, Seattle, WA (Dr Krabak). Electronic address:
Department of Emergency Medicine, Stanford University School of Medicine, Stanford, CA (Dr Lipman).
Department of Physical Medicine and Rehabilitation, University of California, Davis Sports Medicine, Sacramento, CA (Dr Waite).
Department of Rehabilitation Medicine, University of Washington, Seattle, WA (Dr Rundell).



Dysnatremia and altered hydration status are potentially serious conditions that have not been well studied in multistage ultramarathons. The purpose of this study was to assess the incidence and prevalence of exercise-associated hyponatremia (EAH) (Na+ <135 mmol·L-1) and hypernatremia (Na+ >145 mmol·L-1) and hydration status during a multistage ultramarathon.


This study involved a prospective observational cohort study of runners competing in a 250-km (155-mile) multistage ultramarathon (in the Jordan, Atacama, or Gobi Desert). Prerace body weight and poststage (stage [S] 1 [42 km], S3 [126 km], and S5 [250 km]) body weight and serum sodium concentration levels were obtained from 128 runners.


The prevalence of EAH per stage was 1.6% (S1), 4.8% (S3), and 10.1% (S5) with a cumulative incidence of 14.8%. Per-stage prevalence of hypernatremia was 35.2% (S1), 20.2% (S3), and 19.3% (S5) with a cumulative incidence of 52.3%. Runners became more dehydrated (weight change <-3%) throughout the race (S1=22.1%; S3=51.2%; S5=53.5%). Body weight gain correlated with EAH (r=-0.21, P = .02). Nonfinishers of S3 were significantly more likely to have EAH compared with finishers (75% vs 5%, P = .001), but there was no difference in either EAH or hypernatremia between nonfinishers and finishers of S5.


The incidence of EAH in multistage ultramarathons was similar to marathons and single-stage ultramarathons, but the cumulative incidence of hypernatremia was 3 times greater than that of EAH. EAH was associated with increased weight gain (overhydration) in early stage nonfinishers and postrace finishers.


hydration; hypernatremia; hyponatremia; ultramarathon running

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