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Renal Failure During Ultras


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#1 Mister G

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Posted 01 October 2004 - 08:55 PM

Thought this was interesting. The following post was made to the ULTRA list last night in the aftermath of the Angeles Crest 100 (AC) in California.

Date: Thursday, 30 September 2004 11:00:32 -0700 (PDT)
Subject: Kidney Failure
From: Andy Jones-Wilkins
To: ultra@listserv.dartmouth.edu


Dear Ultra Running Community,

I am writing to the list to share my story of acute renal failure.  I do
not post to the list often but I feel that this story is important for the
community to know.  I would welcome any questions or comments in regard to
this report especially from any medical professionals who may be out
there.

Some people on this list know me and many do not so let me start with a
bit of background and then a brief description of what happened to me.

I am a 37 year old male ultrarunner.  I am 6 feet tall and 170 pounds.  I
have been running ultras since 1997.  I ran my first 100 miler in 2000
(Angeles Crest) and knew from that point on that I had "found" my
distance.  In five years I have run 7 100 milers (3 AC's, 2 VT's, and 2
WS's).  100 milers have become the focus of my training and the highlight
of my year.  In 2003 and 2004 I ran two each (VT and AC in 2003 and WS and
AC in 2004).  Aside from the usual aches and pains associated with
recovery from 100 mile races I have never needed medical intervention
following a race and have always felt pretty much back to normal about a
week after a race.

This year at AC my story was very different.  I had what I felt was a very
good race this year finishing in 19:53 and taking 15 minutes off my time
from last year.  After finishing I was completely wiped out but doing OK.
I spent about 4 hours in the med tent and slept pretty well. I had a
massage and was hobbling about in my usual post-100 miler daze.  The first
indication that something was not quite right came at about 9:00 AM Sunday
when I had a single episode of brown, coffee colored urine.  It was not
painful and it was only one episode.  I told my wife about it and we
essentially passed it off as a deep, yellow urine that was simply the
result of dehydration.  I continued to push fluids and felt OK.  The drive
back home was uneventful and I made it it work on Monday.

That afternoon I began to feel flu-like symptoms and decided to stay home
from work on Tuesday to recover from what I thought was the flu.  I had
low-grade fever and general body aches. I just couldn't seem to shake
these symptoms.  I continued to urinate normally but my muscle soreness
was not improving.  In addition, I felt something in my stomach and back
that felt like constipation.  By Friday the pain had not increased at all
but the general malaise I felt was still present.  The "constipation"
feeling persisted and I had no energy.  Finally, on Saturday afternoon
(one week after the race) I went to the hospital and was evaluated in the
Emergency Room.  The doctors concluded that I had a severe case of
Radbomyolysis (muscle protein in the kidneys) and that I was in acute
renal failure.  After five days in the hospital, 18 litres of fluid, one
kidney ultrasound, and many hours of contemplating my future in running
100 mile races I returned home humbler and more mortal that I have ever
been before.

Of course, I have many questions about this whole thing:  Why did this
happen in my 7th 100 miler? Can I run these things anymore?  Are there any
warning signs besides the brown urine?  Can I train to avoid this?  Is
there anybody out there with a similar story?

Today my kidneys are back to 90% of normal function and the doctors
anticipate full recovery.  In the hospital I ballooned to 203 pounds
before beginning to shed the fluid and now I continue to urinate every 30
minutes and I am feeling like I might even be able to go for a short run
this weekend.  All in all, this was a serious wake-up call for me and one
which I will not ever forget.  I hope this story can help future runners
avoid renal failure and perhaps even motivate more 100 milers to take
blood tests after races to determine myoglobin content in ailing runner's
blood.

Please do not hesitate to contact me off line with comments, questions, or
advice.

Yours,

Andy Jones-Wilkins


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#2 Mister G

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Posted 01 October 2004 - 09:01 PM

A couple of subsequent accounts were posted to, or linked to, the ULTRA list.

Date:         Mon, 4 Jan 1999 12:20:41 PST

From:         stephanie ehret
Subject:      Accross the Years

A fat woman in hospital pants isn't  much of an anomaly in a western
airport.  But, it was a unique experience for me -- a normally slight,
athletic girl --  as I was the one wearing the pants.  Six days earlier
I had driven to Phoenix with my coach, Scott Weber, and Barb Marquer, a
young mother from Wyoming who finished second at the 1997 24 hour
national championships at Olander Park.  Our objective was the AcrossThe
Years  24/48/72 hour Run, Walk, Eat, Nap.  I had planned to do the 24
hour and Barb had set her sights on the 48 hour race.  We were joined,
in a separate car, by 1998 Comrades winner Charl Mattheus and his short
distance Olympian friend, Audrey.

The first evening in Phoenix Barb and I shared a room.  I was struck by
her impeccable organization and in-depth knowledge of race preparation
and strategy.  I felt hopelessly underprepared.  I was also feeling the
early signs of a cold -- slight sore throat, congestion, headache.  We
talked late into the night, driven by our anxiety, excitement and
anticipation.

When I awoke the next morning, all I could think of was my cold.  I
tossed it out to Scott like a tennis ball and he tossed it back with
several packs of Thera-flu.  Barb took some too for good measure.  The
fact that the "cold" probably had psychological roots didn't eliminate
the symptoms.   On the positive side, the "cold" had completely
distracted me from my ongoing ankle concerns.  It's always something!

The night before the race Barb and I had decided to take separate rooms
to limit the sharing of germs and late night stories.  I spent several
hours bumbling deleriously around the room going over my supplies and my
"game plan."  Finally I enjoyed the luxury of simply waiting for the
race to begin -- too late for last minute reparations.  I imitated
Barb's strategy of alternating bottles of Cytomax and
Metabolol,ultimately consuming about six bottles between the evening and
the beginning of the race.   I slept fitfully but deeply -- strange
dreams that had nothing to do with the race.  Then the alarm went off
and I calmly dressed, making sure that my lucky angel pin was firmly
attached to my equally lucky Fat Tire baseball cap.

The race began on Tuesday, December 29th,  9:00 a.m.  How is it that I
can't remember the start of the race?  Suddenly I was simply running.
Early on Barb and I paced each other at about 10 minute miles.   I was
comforted to be running with my friend, an experienced 24 hour runner
and excellent companion.  At about mile fifteen I began to feel very
ill. Fifteen miles!  How could this be happening?  Fifteen miles wasn't
even a training run!  For fifteen miles it was barely worth getting out
of bed.All that Cytomax and Metabolol swirled in my belly.  A few sips
of Ensure at the 2 hour mark was all it took to expell the whole mess.
I tried to puke as inconspicously as possible while several runners
passed by offering condolenses and a kind of congratulatory
encouragement "Get rid of it all Steph.  You're going to feel so much
better!"  And indeed I did.

Thus began a period of effortless, joy-filled running that would take me
through about mile 70. I began to become aware of the drama around me,
of the incredible feats of the other runners -- the ultra endurance
giant, Al Howie (who eventually ran an incredible 250 miles in 72
hours!), Andrew Lovy, whose jolly stride kept a smile on my face, John
Surdyk in his mustard yellow shorts and Charl Mattheus, averaging an
impressive 8 minute mile pace and still finding enough energy to flash
me a moon every few miles as he passed.

I watched Barb in her struggles with sickness just as she had watched
mine.  I wanted to share with her my big blue magic ball of energy, but
I knew she had to find her own.  During that time the sun set, a bright
pink-yellow, deepening to rose.  The air cooled and stars came out. The
music playing on my walkman became part of the life force,
propelling me, mingling love, sadness, joy, renewal, loss with the
simple act of running. Other runners were in good spirits and we
exchanged light banter as we passed one another.  Running was extasy.
My heart could have burst.

Sometime after mile 70, I began to slow.   I discarded my walkman
feeling the need to focus.  Running became an effort, and Scott's role
became primary.  "You just finished your 100K" says Scott "now focus on
100 miles."   I began to run three laps then walk the fourth, later
shifting to running the straights and walking the curves.  At some point
I began to cry -- not from pain, anger or pity -- but a simple sadness
that had welled up and with the release of tears, left calmness in its
wake.  At 100 miles, 2:14 a.m., Scott has a surprise for me -- Peter was
on the phone.  Under the surreal lighting of the Arizona Boys Track,I
listened to the voice of my paramour -- the voice that brought me to a
Leadville finish, the voice that has lived in my head for 20 years along
with my own, the voice that is home to me.  "Happy Anniversary,
Sweetie."  It was the emotional jolt I needed.  I began to run with
deliberation.

At mile 111 Scott had another surprise for me.  I had broken a course
record that had stood for 10 years, that had been set by his wife,
Theresa.  And, she was on the phone. I was being congratulated by one of
the all time great ultra runners, Theresa Daus-Weber!  Another emotional
jolt.  That Scott's a smart one!

But, running was getting harder.  It was all I could do to keep running
the straight-aways.  Scott's coaching was becoming very focused.  Every
lap he had a word of encouragement or something to be eaten or drunk.
"Give me three good laps" he would say "then take a rest lap."  At some
point a new person, who would become increasingly important to my well
being, entered the picture.  "Hey, I'm going to run a lap with you," he
said.  "I'm Jordan."  Jordan ran several laps with me, offering
encouragement and bits of humor.  I can't remember a single thing he
said, but I remember smiling ... smiling at mile 122.

When I still had about an hour to go, Scott asked me what my running
strategy had been.  When I told him, he said that it wasn't going to be
fast enough to come close to 130 miles.  From now to the finish, I would
have to run, and I would have to run faster than I had been.  So I ran
with big tears of anger running down my face.  "That bastard", I
thought, "how can he ask me to run now?  No one else is running.  I can
barely walk. I want to die."  But I ran.  Scott said "now give me three
more laps, then take a rest lap."  With the completion of each series of
four laps Scott would say "Okay, now you have the sixth fastest time in
the world this year" or "four more laps and you'll have the seventh all
time fastest North American 24 hour time."  And I would do as he said,
cursing and crying all the while.  With about 15 minutes to go, Scott
said "Okay, no more walking, give me a final four laps.  Run."  I let
out an infamous
Steph growl and ran and cryed and sobbed and people cheered and my legs
screamed and...  I did it.  On December 30th, 9:00 a.m., the race was
over. I had just completed 128.99 miles in 24 hours, the 4th best in the
world by a woman in 1998.

That should be the end of the story but my ordeal had really just begun.
As I lay in the tent I was overcome with nausea.  I threw up into a
bucket something resembling thick, dark, water logged mushrooms.  I had
not eaten any mushrooms.  A hot flash quaked my body.  Something was
wrong. And Jordan was back like a guardian angel -- actually an
ultrarunning, Mickey Mouse loving, Doctor.  He suspected that I had
thrown up the sloughed-off lining between my stomach and esophogus.
Meanwhile, Barb was still running -- something that seemed
incomprehensible to me in my semi-delirious state.   I could overhear
some discussion about taking me to the hospital.  I sensed that I was
becoming a distraction and it would
be best to get me out of there so that Barb could focus on the race.
Plus, I was pretty sure I was dying.

Scott accompanied me to the hospital, leaving Barb in the capable hands
of race Director, Paul Bonnet-Castillo.  Scott and I waited in the
emergency room for countless hours.   I felt very hot and nauseated and
all my muscles had frozen up.   I practiced my best ultra technique --
counting to eight over and over, making it through one hour at a time.
When the nurse finally arrived she shoved a tube up my nose to pump my
stomach. "I think I still have my camera," said Scott.  More tubes were
inserted to collect urine, to deliver an IV and medication, to take
blood.  The doctors detected very high CPK, an enzyme that breaks down
skeletal muscle.  A normal count is under 100, mine was 35,000.  While
this figure was very distressing to Dr. Tans, my Phoenix physician,
Jordan explained to me, and eventually, to Dr. Tans, that it is not
uncommon for an ultrarunner after a big race.

The CPK figures led Dr. Tans to diagnose my condition as Rhabdomyolysis,
"an acute, sometimes fatal disease characterized by destruction of
skeletal muscle."  The photocopied explanation given to me by the nurse
continues "Rarely, this (disease) may occur following strenuous
excercise... renal damage manifested by acute tubular necrosis may
result if myoglobinuria is accompanied with acute dehydration or
anoxia."  As if that weren't enough, they didn't tell me that it was
going to make me fat!

Treatment consisted of pumping several gallons of water into my
tissues-- water that my kidneys were not able to process
effectively.  The result was about 25 extra water pounds on my small
5'1", 100 lb, frame. When I got home, I would tell Peter that I had
actually skipped the race and spent several days hanging out at an all
night buffet.

In the meantime, Barb had dropped from her race.  Her concern for me,
the absense of her coach, the incredible mileage of the day before had
taken their toll.  She packed up the tent, organized all my belongings
and came to the hospital for a visit.  She was still smiling and joking
and being the consumate caretaker.  She had a card for me signed by
everyone at the race.  I was overwhelmed.  I hugged Barb goodbye and she
drove back home to be with her son, Madison and her husband, Constant.

People everywhere were rallying to get information and to ensure my best
possible care and comfort.   Back in Boulder, Peter became a full time
phone receptionist, communicating with Barb, Scott, my very concerned
parents and family.  Scott Weber had stayed in town to ensure my safe
departure.  Jordan Ross had called every few hours (in the middle of his
48 hour race!) to check on my status, to confer with my doctors, to
answer my questions, and to facilitate my release.

On Friday afternoon, at 1:00 p.m., I was released from Valley Lutheran
Hospital in Phoenix.  I was picked up by a cheerful entourage of Jordan,
Andy Lovy and John Surdyk.   They took me to Jordan's Mickey Mansion to
decompress and then to the airport where I waddled onto my flight back
to Colorado.

So, now I'm back in Boulder, slimming down -- losing about 5 pounds/day.
I've been on the web researching rhabdomyolosis in order to gain a
better understanding of what happened to me.  I have learned that this
disease is normally seen in patients with multiple systems failure, such
as heart conditions resulting from poorly controlled diabetes,
emphysema, etc. It's clear to me now why Jordan made such an effort to
educate the doctors in Phoenix about "exercise induced rhabdo."  While
the condition is serious,it is also somewhat common and a healthy
athlete is expected to recover fully and rapidly with proper treatment.
As part of that treatment, I sent in my Leadville application today.  I
would be interested in hearing from other athletes who have been
diagnosed with "rhabdo."

What's left to say?  Thank you.  Thank you Jordan for your medical
intervention and caretaking.  Thank you Barb for serving as an
incredible inspiration and teaching me the secrets of the 24 hour run.
Scott, I could never have gone the distance without you!  Andy, just
thinking of you makes me smile.  Thanks for hauling all my luggage and
withholding the fat jokes, John.  Thank you Paul for a well organized
race in a beautiful setting.   Thank you Audrey for your masterful
crewing (Scott had to sleep sometime!).  Thanks to everyone on the track
for their support and the great card.  Hey Charl... nice ass!

Ultrarunning is a microcosm of our lives -- it contains the drama, the
struggle, the joy and the redemption that makes life worth living.   It
brings about the best in the human spirit.   It contains all of life's
lessons.  It brings us closer to the essential meaning of our lives.
AtAcross the Years I learned that it sure as hell isn't a good way to
lose
weight!


#3 Mister G

    Kosciuszko Deprivation Syndrome since 2005

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Posted 01 October 2004 - 09:14 PM

One more. Apologies for the length, I might clean them up later when I have some time. You can skim them in a few minutes and digest (no pun intended) the important stuff.

Kidney Failure and Ultramarathoning
by Don Davis
Four days after winning the Seagate 100 km Ultramarathon in Toledo,
Ohio, I was hospitalized for 11 days with Acute Kidney Failure, a
direct consequence of the race, possibly exacerbated by the 2400 mg of
ibuprofen that I took during the race. In this article, I will
describe my race and my hospitalization, discuss similar experiences
of two runners after the 1994 Western States (WS) 100 Mile Endurance
Run, and tell what I have learned that might be of general interest.

I am 49 years old and have been running ultras regularly since 1979.
My most memorable performances have included

winning the first ultra I ran, a 6:10 50 miler in my hometown of
Bethlehem, Pennsylvania,
winning a Sri Chinmoy 12-hour race near San Francisco in 1989,
covering almost 78 miles,
second in 45-49 age group in national championship 100 km in 8:51 in
New York City in 1993, and
representing the US in the 1994 Italian Del Passatore 100 km, where I
finished 54th of 3500 participants in 9:39.
The Seagate Ultras on November 26, 1994, included races of 60 km, 50
miles, and 100 km, each run on the same 1.1 mile loop. There were
approximately 10, 10, and 6 runners, respectively, in these races,
which were judged separately. My 9:29 time for 100 km was not very
fast, but it won that race easily, and I also went through 60 km and
50 miles faster than anyone in those races. So I am not a novice.
The weather for the race was ideal by my standards, with temperatures
in the 30s, light wind, and no precipitation. I was drinking water
and/or Gatorade almost every lap, so I don't think dehydration was a
cause of my problem. One unusual feature of the race is that I stopped
to urinate at least 25 times, whereas usually I stop about 6 times in
a race of that duration. I attributed that to the cool weather keeping
me from sweating.

One factor which is probably significant is that three weeks before
the race, during an easy run the day after an excellent 41-mile
training run, I injured a calf muscle. I used electronic stimulation
to promote healing, and ran very little during the three weeks
preceding the race. This area bothered me frequently during the race,
feeling as if it wanted to cramp. Whenever this happened, I would take
two 200 mg ibuprofen and some salt (from pretzels). Six times during
the race I took two of these pills. I had taken at least eight
ibuprofen during some previous races, so I don't feel that the
ibuprofen was the main thing that made this race different.

The race was on Saturday. On Sunday, I felt typical day-after soreness
and disinterest in food. It was on Monday that my stomach really
rebelled, and I vomited for the first time. On Tuesday, I could hold
nothing down, and vomited three times, while still carrying on my
normal professorial routine. I don't remember whether I was urinating
on Monday and Tuesday. I know that on Saturday and Sunday my urine was
discolored, but this has happened to me before. On Wednesday, I went
to the doctor, and blood work indicated kidney failure, for which I
was told to get to the hospital immediately.

Continuous intravenous saline solution and drugs to stimulate kidney
function were administered. I was catheterized to facilitate urine
collection. Friday night the doctors said that if I wasn't producing
more urine by morning, I would have to undergo dialysis, in order to
moderate the levels of toxicity in my blood. This threat must have
jarred my kidneys into action, for the urine really started to flow
that night, averting the dialysis. My weight peaked at 178, thirty
pounds above its normal level, due to all the fluid being pumped into
me. Some of this fluid went to my lungs, causing a temporary condition
of congestive heart failure. My wife said I had the cheeks of a
chipmunk and the neck of a football lineman. Once the urine was
flowing at nearly 1 liter per hour, my weight dropped back to nearly
its normal level. It was then a matter of adjusting the rate of
intravenous intake so that my kidneys would produce urine at an
appropriate rate.

In the meantime, I suffered continual nausea. The toxins in my blood
upset my stomach's functioning. Various drugs, some given
intravenously, some orally, and some by injections, eventually
regulated this. I went nine days without really eating.

The explanation for how such a healthy sport can cause such a serious
problem is quite well understood. It is explained in Noakes' "Lore of
Running," as well as in many medical books which I consulted after
leaving the hospital. Your muscles contain myoglobin, a protein which
causes the red color of the muscles and helps the muscle use oxygen.
Myoglobin is primarily contained in the slow-twitch muscles which are
used in low-intensity exercise of long duration, and is particularly
prevalent in trained athletes. When a muscle breaks down or is
injured, some of this myoglobin is leaked into the bloodstream, which
carries it to the kidney. There is not general agreement as to exactly
how the myoglobin causes kidney failure. Probable factors are (1)
tubular obstruction, (2) toxic reaction, and (3) decreased oxygen
supply to the kidneys.

There is much evidence that kidney failure is exacerbated by
ibuprofens and other nonsteroidal anti-inflammatory drugs (NSAIDs).
There are substances in your body called prostaglandins which cause
the blood vessels flowing into the kidney to dilate when necessary,
increasing the blood flow to the kidney. The prostaglandins will
ordinarily do this when the kidney is under attack from myoglobins.
However, it is known that NSAIDs inhibit the action of the
prostaglandins, thus allowing the myoglobins to do their nasty
business unimpeded. Recent articles in medical journals have debated
what constitutes a dangerous level of ibuprofen usage. My
nephrologists agree that 2400 mg was too much for me, and was a
definite contributor to my kidney failure. On the other hand, David
Warady, in winning the 1992 Trans-America Footrace, took 7000 mg per
day for 50 days with no problem.

Dr. Bob Lind, WS medical director, is skeptical about the role of
NSAIDs in kidney failure. He has done some studies during recent WS
races, and reported some preliminary findings in a November 1986
article in Ultrarunning. He has found no correlation between NSAID use
and CPK (creatine phosphokinase) readings in the blood of runners
immediately after the race. CPK is an enzyme leaked from the muscles
into the blood along with myoglobin, and so it is an excellent
indicator of rhabdomyolysis, which is injury of the muscle cell
allowing its contents to escape. But the role of NSAIDs in promoting
kidney failure is separate from the myoglobin and CPK leakage, and so
this lack of correlation is not surprising.

My theory about what made this race different for me is that the pre-
existing calf injury caused an unusually large amount of myoglobin to
be leaked into the blood. Both Dr. Lind and one of my nephrologists
speculate that racing after a 3-week near-layoff could have caused all
the myoglobin leakage. There is ample evidence that tremendous
exertion by an untrained person can cause myoglobin leakage; I
wouldn't have thought that I would lose that much of my training edge
in three weeks of relative inactivity.

To check whether you are a candidate for kidney failure, you might
have blood work done after a race. An elevated CPK reading shortly
after the race indicates a likelihood of kidney failure. An average
CPK reading is 10 to 150. Dr. Lind reports that an average reading for
a runner after WS is 17,000, that a reading of 25,000 to 50,000 is
indicative of possible kidney failure, while a reading of 100,000 is a
very dangerous signal. He has seen one or two kidney failures (out of
400 runners) after several WS races when the weather was hot.

I did not get a CPK reading until the fourth day after my race, and
CPK readings generally drop after 24 to 48 hours. My doctors were most
concerned about the creatinine in my blood. Creatinine is a waste
product which the kidney is supposed to remove from your blood. It is
an indicator that the kidney has already ceased to function. It does
not achieve an elevated value as quickly as the CPK, but it stays
elevated as long as your kidneys are not functioning properly. The
normal range for creatinine is 0.7 to 1.5 mg/dL. My reading four days
after the race was 6, and it increased to almost 8 after a few days in
the hospital. A reading of 8 says that your kidneys are functioning at
somewhat less than 1/8 of their capacity. I was released from the
hospital when it got down to 1.7, and a week later it was down to 1.1.
Several studies of runners after races of 26 or 62 miles have shown
slight increases of creatinine shortly after the race, but nothing
nearly comparable to the huge increases in CPK that Dr. Lind sees
after WS.

CPK measures rhabdomyolysis, whereas creatinine is a direct measure of
kidney malfunction. Although rhabdomyolysis and kidney failure are
frequently linked, due to myoglobins, it is possible to have either
one without the other. My nephrologists warn that heavy ibuprofen use
during a race could cause kidney failure even without extremely high
CPK readings if the prostaglandin- inhibiting effect were significant.
A highly-publicized very recent study has also implicated
acetaminophens such as Tylenol in kidney failure.

Subsequent to distributing preliminary versions of this article, I
have talked to two runners who suffered Acute Kidney Failure as a
consequence of the 1994 WS race. One of them, Greg Miller, 34, from
California, fractured his ankle 5 miles into the race, but kept going
until the 80-mile mark, using ibuprofen to reduce the pain. He started
vomiting at the emergency room of the nearby hospital to which he was
taken. His hospital stay was very similar to mine, lasting 10 days
with a 25-pound weight gain due to fluid, a creatinine level of 9
which put him on the verge of dialysis, and much vomiting.

The other, Bill Fornoff, 51, from Maryland, had a more severe case of
Acute Kidney Failure. He was in the hospital for 17 days, and had to
undergo dialysis for five of those days. During each of those days, he
was connected for four hours to a machine which performed the function
of his kidneys, removing toxins from his blood. His peak creatinine
level was 10, and he also gained 30 pounds of fluid temporarily. Like
Greg and me, his main symptom was vomiting, which began the day after
the race. After flying home the next day, he was told by two doctors
that his vomiting was probably due to a bacterial infection that he
had picked up during the race, and so it took several days for his
kidney failure to be diagnosed. He finished the race six minutes
before the 30-hour cutoff, and felt no particular injury that might
have contributed to unusually large myoglobin leakage, except for an
unprecedented amount of pain in his quadriceps, which he attributes to
all the downhill running. He took one 500 mg Naprosyn during the race.
His one lasting effect of this incident is high blood pressure, for
which he still takes medication.

Both Miller and Fornoff ran respectable marathons six months after
their bouts with kidney failure. My nephrologists have said that it is
probably safe for me to race, provided I am well-trained and not
injured, stay away from NSAIDs, hydrate adequately, and ingest plenty
of potassium. They will also monitor my CPK after some long training
runs. Dr. Lind adds that it is important to check that one is not
losing weight during the race. Hot weather has also been implicated in
many cases of kidney failure after long races, and I would try to
avoid that. It is also known that kidney failure becomes more likely
with increasing age, and so I will try to become younger. All
ultramarathoners should consider these precautions, and if they start
vomiting a day or two after a race, they should immediately have their
blood tested for elevated CPK and creatinine levels. Be aware that
this sport is capable of inflicting damage much more serious than the
temporary injury to the musculo- skeletal system which occurs commonly
to virtually all ultramarathoners.


#4 plu

    1000-club gold-rated CoolRunner

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Posted 02 October 2004 - 12:35 PM

Mr G,

Thanks for providing these for us to read.  

I asked a few months ago in a thread or in an email list about some of the move severe effects of ultra running.  I received some very useful emails in reply. This has been most informative

It seems these were a product of not only the running but also the management of one's body prior to, during and after the run. Including the taking of anti inflams.

Although it is sobering and I felt a bit scared reading it I would rather know about what could happen than be in the dark.  I am sure there are a lot of other ways to get acute renal failure.


Thanks for putting it out there us.  I for one prefer to be informed.

Plu

#5 Gem

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Posted 02 October 2004 - 12:55 PM

Three years ago I ran the Oxfam 100km Trailwalker.  Things were going well, I was in a team of 3 boys.  We ran the first 40-50km and were doing well.  We chose not to rest or sleep, I did not run with a camelbak and just filled up my water bottle at the checkstations.  At about 60km one of my team members dropped out with an ITB problem.
We were heading down some steep hills and I felt my knee go.  Being as stubborn as I was I ignored the pain and at the next checkstation popped some Panodeine Forte.  Kept going, no sleep, walked through the night and lumbered on.  No more running as the pain in my knee was significant - so we walked.  We lost our second team member who rolled his ankle quite badly.
And then there were two.....
I kept popping pain killers and filling up my water bottle every now and then. I ate little and just kept plugging on.
By this time I was hobbling, but being so stubborn I just kept going.  After the last check point things started to go wrong.  I was vomitting and had bad diarrohea.  It was constant, walk 100 metres and either vomit or the other end...With about 10km to go I couldn't remember the first name of my team mate.  I remembered his last name, but couldn't for the life of me remember his first name, I also didn't really understand what I was doing, I just knew that I had to keep going (there were no more checkstations - it was all bush track so we had to keep going).  It was getting dark (by this time we were into the second night) and every step felt like a knife was going through my leg.
We made it to the finish and we were met by my folks.  Dad put me in the back of our little hatchback and I lay down.  Mum and Dad said that they knew something was wrong when I began to ramble.  I was talking about inexplicable things and raising strange issues.  Dad took me to Hornsby Hospital.  I couldn't move, a hospital warden carried me out of the car and I went straight to emergency.
The doctor asked me where I was.  I told him I was in Artarmon (for those not from Sydney, Artarmon is at the other end of the city from Hornsby).  He asked me when I was born, I said "back then" as I couldn't remember when I was born.  A series of other questions were asked all of which I gave incoherent answers (these are all accounts from mum).  Blood was taken and other tests conducted.  I was diagnosed with Radbomyolysis and I also had a dislocated knee (right out of the socket).
What resulted was 2 days in the Critical Care Unit.  Another 5 or so days in the normal ward.  Then time in a knee brace with extensive hydrotherapy and learning to walk then run again.
The moral of this tale is - make sure that you drink plenty of water.  Do NOT take painkillers prior or during a race (unless it is 1 or two) and don't be a stubborn idiot.
I was told by the specialist that if Mum and Dad had taken me home that night I would have died.  So I owe them one.
I guess I finished the 100km.
Gems
xo

#6 Mister G

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Posted 02 October 2004 - 01:27 AM

Several ULTRA listers put some questions to Andy Jones-Wilkins about his intake of fluid, food and drugs during Angeles Crest. It'll be interesting to read his reply.

I think the only time I've taken painkillers in a race was in the last 10 miles at Western States, when, at the suggestion of my pacer Carol LaPlant, I took several ibuprofen between the Brown's Ravine and Highway 49 aid stations. It certainly helped, but I've never done it again. I got the impression from Carol that she took painkillers in 100s as a matter of course, and she's done a lot of 100 milers.

After every one of my four 100 mile finishes, I've come down with a respiratory infection which has cleared up by the end of the week. I expect it to happen again after Coast- Kosci.

Training for ultras is probably healthy. Is racing ultras (the big ones,not the 50Ks) healthy? Probably not. Is it going to stop me running 100s? No.

#7 Gem

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Posted 02 October 2004 - 01:59 AM

Having said all that - would I do it again?  Absolutely - with the correct training, a full camelbak and zero painkillers.

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Posted 02 October 2004 - 02:09 AM

Thanks very much for these great posts relating to the kidneys. Certainly gives me a lot to think about.

On hot days, we need to be careful about encouraging other runners to "soldier on" just for the sake of finishing.

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Posted 02 October 2004 - 02:41 AM

I was wondering about mr g's motives in posting these articles - maybe as a reminder that running ultras (particualry 100km, 100 miles and further) can be quite dangerous - just plonking them out there fore people to read is quite a sensationalist tactic ?

In the case of stephanie ehret, I seem to remember that some people thought she raced recklessly by chasing a record, and not eating and drinking enough.

It is clear that people need to learn about their bodies and look after themselves even when they are very very stuffed in a race.

Anyone who thought Ultras couldn't be dangerous is deluding themselves. They have been a spate of deaths and near-death experiences recently (mainly in the USA) where the numbers of runners competing are quite high and where proprotionally higher numbers are running 100 mile trail races than elsewhere.

#10 Jogger

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Posted 02 October 2004 - 03:06 AM

Thinking about it some more, these articles should indicate that looking after yourself and knowing yourself and its needs is good. ALL THREE articles were about people who won a race or ran a pb (still sub-20 for 100 miles) so these could be classed as "top runners" certainly not joe plodder ie not common occurrences.

For Stephanie's race:
* Stephanie Ehret won the 24 hour track event - outright - by almost 28 miles.
* Her 129 miles was the 4th longest distance done that year, and puts her 7th for an American woman (206km).
* This was her first 24 hour track race.
* She hit 100 miles in only 17:14.

Here is an article for the biological scientists

#11 Mister G

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Posted 02 October 2004 - 03:41 AM

quote:


Originally posted by KevinTiller:
I was wondering about mr g's motives in posting these articles [...] just plonking them out there fore people to read is quite a sensationalist tactic ?

Not really. It's pretty obvious that for every hospitalised ultrarunner, there are hundreds of runners who have no sigificant aftereffects, so not that sensational. Like I said in my first post, I thought it was "interesting" reading.  ;)  

I probably had the Vioxx thread in the back of my head- knowing that people take these sorts of things on a regular basis- although one of those articles is skeptical of the theory that NSAIDs are responsible for this sort of damage.

quote:


Originally posted by KevinTiller:
ALL THREE articles were about people who won a race or ran a pb (still sub-20 for 100 miles) so these could be classed as "top runners" certainly not joe plodder ie not common occurrences.

Yeah, it does seem to affect frontrunners more often, but then the third article I posted mentions the guy who finished WS in 29.54...

#12 Jogger

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Posted 02 October 2004 - 04:26 AM

Four days after winning the Seagate 100 km Ultramarathon in Toledo, Ohio, I was hospitalized for 11 days with Acute Kidney Failure, a
direct consequence of the race, possibly exacerbated by the 2400 mg of ibuprofen that I took during the race.


let that be a lesson to us!

I don't know any australian ultrarunners that take anti-inflamms as a regular course during ultras (although assume there are some) but it seems quite prevalent in the USA and South Africa so much so they call it vitamin-I for ibuprofin. I don't think the poms have a culture of it either.

of course thats a helpful simplification and not a dangerous generalisation   ;)

#13 lebusqp

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Posted 02 October 2004 - 05:10 AM

I would have thought taking 2400mg of Ibuprofin in a 10hr period was dangerous regardless of running a 100k at the same time.

#14 undercover brother

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Posted 02 October 2004 - 05:49 AM

mr g,

thanks for the info - those americans certainly know a lot about their health!
a few thoughts as a supposed medically qualified person.
renal failure was certainly my biggest fear when starting ultras.

the renal failure we see is obviously multifactorial...(in no particular order)
1. dehydration
2. rhabdomyolysis - breakdown of muscle/protien (reflected by CK/CPK levels as described above) that basically 'clagg' the kidneys.
have never seen a correlation between CK levels and the 'speed' of the runner.
3. drugs - NSAIDS are a definate NONO to me.
i personally would NEVER, i repeat NEVER take them in an ultra even if my whole damn leg was going to fall off.  there is some evidence that in overdose paracetamol can harm the kidneys but its ok in moderation and i would however take this.
4. heat - worsens muscle breakdown and dehydration
5. other issues - age, other medications the person may be taking etc...

the distinct absence of symptoms with this problem is the thing that should frighten us all.
by the time u feel 'crappy' and start pissing treakle you're already in big trouble.
the only other way of knowing would be to take CK (CPK in the US) levels on everyone!

i guess the main message for everyone would be to be educated about the problem so you can prevent it from happening (by keeping hydrated and not taking NSAIDS) or if not then pick up the 'late' warning signs - not much urine, treakle colored urine.

as a doctor i just wonder how many of these people we blow off with 'average' CK levels in the 10's of thousands end up with some degree of renal 'impairment' over the years because of it.
(you need to lose about half of your renal function before it reflects in your blood creatinine test/level.)
and as a runner i just shrug my shoulders grab my pack and go for another 100mile run in 30+ degree heat.

think i may take some blood from myself tomorrow.

#15 plu

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Posted 02 October 2004 - 07:45 PM

Hi All,

I actually waited  before I first commented and I was the first, which seems to be three hours later - so I guess people were not  sure how to respond.

I have slept on what I want to add to this thread.

I said before that a few months ago I sent out a request for information on the longer term or more serious effects of ultra running. I received some emails mainly of a supportive nature to give it a go which I appreciated.

I acknowledge that it is important to experience things yourself, however, I think it is equally important to know what you might be in for if you move to another level .  Reading Gems story was very informative and frightening and I needed to read it.  Also it slipped by me that the people in what Mr G put up were elite ultra runners.  So now I understand that ultra runners that are sensible in pill taking, well hydrated …. can help reduce the risk of some of these things happening

This thread is important because it has given some more information and now shows me how close I have been to similar situations.  This is the sort of information I could have used to great effect in the era of my PBs.  

Some of the stomach disorders, black stools, fainting,  coloured urine (I did not realize that there could be blood in urine before you saw it)…. after longer and fast triathlons were more potentially serious. Some of these things happened a few days later and I did not draw the connection.  In most cases they were associated with big efforts, dehydration, not training and eating properly not recovering properly (drinking beer after a race)….

I do not see a thread like this as a form sensationalism especially when it is read taking into account all the perspectives and experiences.

So to those who have shared so far and are prepared to share their experiences in the future I thank you.


Plu

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Posted 03 October 2004 - 02:43 PM

A great thread. Well done to Mr G for posting the information in the first place. I think for too long there hasnt been enough discussion in the Aust ultra scene about training, effects and the possible probs that can occur.

I was discussing this issue with a friend of mine in the States. He is an Ultra runner and very learned in the medical profession. This was his conclusion. "Hopefully, people who =go really long have not only trained body and mind, but have really seriously looked at all the physical variabilities thaaaat they could and have a prepared response to them". Very good thoughts I think!

I think Ultras can be dangerous if you dont prepare and if you dont listen to your body when something does happen in a race. I went into the 24hr at the beginning of the year only having done the basics in training! It wasnt my first - but my first in about 4/5 years.  About half way through my left side started playing up and I knew it was going to get worse. I could have solidered on - finished the race and got another 100km plus total! BUT - I would have been absolutely injured at the end of it and would have taken months to get the body back to normal! Moral of the story - I listened to the body, declared myself finished for that day and know that I'll be coming back stronger another day!

Keep the discussion coming on this. It's great.

Phil

#17 Mister G

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Posted 03 October 2004 - 04:36 PM

By sheer coincidence, at this morning's Star I ran for a while with a Strider who has done quite a few Trailwalkers (100km), including an excellent 18 hour finish last year. However, he was describing to me his problems at this year's event, which culminated in him lying down and sleeping on the side of the road in Mt Kuringai, followed by a trip to hospital, where he was on a drip for 2 days.

His original problem was dehydration (a bit startling in itself, given his experience, the fact that it was a winter day, and he was only 50-odd km into the event) but from his description this became rhabdomyolysis- muscle proteins in his bloodstream, high CK count, etc. He was off running for several weeks- was only getting back into it just recently.

Very unlikely event, but just shows you never know, eh?

#18 Colac

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Posted 03 October 2004 - 04:43 PM

NEVER EVER EXCEED THE RECOMMENDED DOSAGE OF ANY MEDICINE unless you consult very closely with a Medical Doctor.  

You would be shocked if you knew HOW OFTEN Doctors have to tell parents "we can't do any more to save your child, as you damaged it's brain by giving it more than the recommended dose rate per day of the pain killer".
  
Doctors base their research on people who are sick.  Wouldn't it be better to study people who
are well, and work out why they are healthy, then prescribe that.

One of the quickest ways to cause dehydration is to run low on carbs in the bloodstream.  

1 gram of glycogen retains 1.8 grams of water.  When you carbo-load, you can gain 3 kgs because of the extra water stored with the extra carbs.

If you run very low on energy stored in the bloodstream, liver and muscles, then water is rapidly lost out of the body, as carbo-loading is reversed.  

Tired muscles can't protect themselves, and become easily damaged if we soldier on with the fuel tank almost empty.

On hot days, I drink a lot more carbo to lessen the chances of dehydration. I drink it at 100% concentration, so even a teaspoon full is easy to drink.   Tiny, frequent doses won't overload your stomach and cause nausea.

Cold water is drunk seperately, because the quantity needed varies from race to race.

Warm water on a hot day, can taste funny, and you can feel nausea if you try to drink enough to stop your core temperature rising too high.

#19 Mister G

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Posted 06 October 2004 - 01:40 AM

Here's Andy Jones-Wilkins' follow up post to the ULTRA list- it was his collapse that started this....

First of all, thank you all for the kind words of support following my
report on kidney failure. I truly appreciated all of your well wishes and
please know that I am improving every day. I even went for a slow six miler
this morning and felt OK.

I want to follow up on a few questions and comments that emerged from my
report:

1. I took two 200mg ibuprofen tablets at mile 90. They were my first
NSAID's in two weeks since I had essentially "detoxed" in the weeks leading
up to the race.
2. I consistently drank between 40-70 ounces of fluids per hour throughout
the day and into the night. I split between cytomax and plain water and
added carboplex during the last 35 miles of the race.
3. I ate solid food through mile 83 (peanut butter and jelly sandwiches,
turkey sandwiches, yogurt and granola, chicken soup, Gu) and kept taking Gu
every 45 minutes through the last half hour of the race.
4. I took one Succeed cap every 45 minutes during the warm part of the day
and one an hour in the evening (this is approximate)
5. I did push the pace very hard especially during the last 20 miles. Many
of you have suggested that this may have been where I was most aggressively
"pushing the envelope" and may, quite frankly, be where the most severe
muscle damage occurred.

Finally, I want to publicly state that the race management of the AC 100
and all involved with the race are in no way responsible for my renal
failure. I had no noticeable symptoms during the race and the medical staff
was incredibly helpful with post race assistance and intervention. I
acknowledge the fact that my brown urine freaked me out and I made the
individual choice not to tell anyone but my wife about it. That was my
mistake and one which I will not make again. I guess my only advice to
others (especially those who might be redlining on the edge of total
meltdown) would be to report any brown urine to a medical official and hope
for the best. Renal failure is not fun.

Please keep the comments and questions coming as I am hoping to avoid this
happening again in the future.

Yours,

Andy Jones-Wilkins


#20 FlashDuck

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Posted 12 December 2004 - 12:53 PM

I remebered this thread, and thought that I should share my experience here rather than start a new topic.

I had an excellent return to running after some abdominal surgery two months ago.  This culmninated in joining other CR runners at the Central Coast Half, with the realistic expectation of another good run.  On a 'special' (read boring as hell, but it works) diet leading up to races of medical fluid supplementation with no fibre, however a balance of carbs & protein, I was very well hydrated.

However, as I was experiencing some gastoinstestinal ditress into the run, I did not take water at the drink stations, as the ingestation of food/fluid usually aggrevates this for me.  Bad mistake!  It was uncommonly humid at the start for a Canberran (78%) and my performance died completely about 9km into the run.  Towards the end, I struggled even further, with sharp pains over the last few hundred metres.

Over the following days I 'blew up' like a stuffed sausage - and began to feel very ordinary.  A visit to my (running) GP yesterday confirmed that my kidneys had shut down at the time.

Drink Drink Drink!!!  

It was a salutory reminder that despite all the hydatration at the start, and being used to not drinking during runs of this time, one can't be too complacent.  It is easy to compromise renal function at this time of year runs far shorter than an Ultra.

How foolish do I feel . . .    :o

#21 plu

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Posted 12 December 2004 - 03:58 PM

Flashduck,

I hope you are okay.  You held on for a while after 9km.  We did not pass you till 12 or so.  I did not see you at the end.  I wondered what had happened to you.

All the best for your recovery.

Plu