Abstract
Zusammenfassung. Die belastungsassoziierte Hyponatriämie ist definiert als eine Plasmakonzentration von <135 mmol/l für Natrium und wurde erstmals Mitte der Achtzigerjahre von Timothy Noakes am Comrades Marathon in Südafrika beschrieben. Ein Absinken des Plasmanatriums unter diesen Grenzwert tritt bei übermässiger Flüssigkeitszufuhr auf. Risikofaktoren sind lange bis sehr lange Ausdauerbelastungen, extreme klimatische Bedingungen, weibliches Geschlecht sowie Wettkämpfe in den USA. Bezüglich Sportarten tritt die Hyponatriämie eher beim Schwimmen und beim Laufen auf, aber ganz selten beim Radfahren. Während eine leichte Hyponatriämie keine klinischen Symptome macht, kann eine ausgeprägte Hyponatriämie aufgrund eines Hirnödems zu neurologischen Ausfällen bis hin zum Tod führen. Die beste Prävention der belastungsassoziierten Hyponatriämie ist die Reduktion der Flüssigkeitszufuhr unter Belastung.
Abstract. Exercise-associated hyponatremia is defined as a plasma sodium concentration of <135 mmol/l and was first described by Timothy Noakes at the Comrades Marathon in South Africa in the mid-1980s. A decrease in plasma sodium <135 mmol/l occurs with excessive fluid intake. Risk factors include long to very long endurance performance, extreme climatic conditions, female gender and competitions in the USA. Regarding its prevalence by sport, exercise-associated hyponatraemia tends to occur while swimming and running, but rarely when cycling. While mild exercise-associated hyponatremia does not lead to clinical symptoms, severe hyponatremia due to cerebral edema can lead to neurological deficits and even death. The best prevention of exercise-associated hyponatremia is the reduction of fluid intake during exercise.
Résumé. L’hyponatrémie associée au stress est définie comme une concentration plasmatique <135 mmol/l pour le sodium. Elle a été décrite pour la première fois par Timothy Noakes lors du marathon Camarades en Afrique du Sud au milieu des années 1980. Une diminution du sodium plasmatique en-dessous de cette limite se produit par un apport excessif de liquide. Les facteurs de risque comprennent les efforts d’endurance longue à très longue, les conditions climatiques extrêmes, le sexe féminin et les compétitions aux États-Unis. En ce qui concerne le type de sport, l’hyponatrémie a tendance à se produire en nageant et en courant, mais rarement en cyclisme. Bien que l’hyponatrémie légère ne produise pas de symptômes cliniques, une hyponatrémie sévère due à un œdème cérébral peut entraîner des déficits neurologiques et même la mort. La meilleure prévention de l’hyponatrémie liée à l’exercice consiste à réduire l’apport hydrique au cours de l’exercice.
Bibliografie
: Men’s Participation and Performance in the Boston Marathon from 1897 to 2017. Int J Sports Med 2018; 39: 1018–1027.
: Russians are the fastest 100-km ultra-marathoners in the world. PLoS One 2018; 13: e0199701.
: The age-related performance decline in marathon cross-country skiing – the Engadin Ski Marathon. J Sports Sci 2018; 36: 599–604.
: Older recreational cross-country skiers adopt more even pacing strategies than their younger counterparts of similar performance level. Res Sports Med 2018; 10: 1–9.
: The age-related performance decline in ironman triathlon starts earlier in swimming than in cycling and Running. J Strength Cond Res 2018; 32: 379–395.
: Participation and performance trends in ultra-triathlons from 1985 to 2009. Scand J Med Sci Sports 2011; 21: e82–90.
: Participation trends of ultra endurance events. Sports Med Arthrosc Rev 2019; 27: 3–7.
: Physiology and pathophysiology in ultra-marathon running. Front Physiol 2018; 9.
: Sudden dardiac arrest during participation in competitive sports. N Engl J Med 2017; 377: 1943–1953.
, : Sports-related sudden cardiac death in a competitive and a noncompetitive athlete population aged 12 to 49 years: data from an unselected nationwide study in Denmark. Heart Rhythm 2014; 11: 1673–1681.
: Fatal water intoxication and cardiac arrest in runners during marathons: prevention and treatment based on validated clinical paradigms. Am J Med 2015; 128: 1070–1075.
: Exercise-associated hyponatremia. Semin Nephrol 2009; 29: 271–281.
: Exercise-associated hyponatremia. Clin J Am Soc Nephrol 2007; 2: 151–161.
: Exercise-associated hyponatremia. Phys Sportsmed 2008; 36: 55–61
: Therapeutic recommendations for management of severe hyponatremia: current concepts on pathogenesis and prevention of neurologic complications: Clin Nephrol 1996; 46: 149–169
: Death by water intoxication. Mil Med 2002; 167: 432–434.
Die Welt : Triathlet (30) stirbt weil er zu viel Wasser trank [18/1/2019]. Available from: www.welt.de/sport/fitness/article143731940/Triathlet-30-stirbt-weil-er-zu-viel-Wasser-trank.html; letzter Zugriff 23.04.2019.: Water intoxication: a possible complication during endurance exercise. Med Sci Sports Exerc 1985; 17: 370–375.
Comrades Marathon [19/1/2019]. Available from: www.comrades.com/.
: Water intoxication – Considerations for patients, athletes and physicians. Practl Gastroenterol 2008; 32: 46–53.
: Is drinking to thirst optimum? Ann Nutr Metab 2011; 57: 9–17.
: The danger of an inadequate water intake during marathon running. S Afr Med J 1969; 43: 893–896.
: Drinking guidelines for exercise: what evidence is there that athletes should drink “as much as tolerable”, “to replace the weight lost during exercise” or “ad libitum”? J Sports Sci 2007; 25: 781–796.
: Drinking policies and exercise-associated hyponatraemia: is anyone still promoting overdrinking? Br J Sports Med 2008; 42: 796–501.
: Sports drinks: Prevention of “voluntary dehydration” and development of exercise-associated hyponatremia. Med Sci Sports Exerc 2006; 38: 193.
: Physiopathological, Epidemiological, Clinical and Therapeutic Aspects of Exercise-Associated Hyponatremia. J Clin Med 2014; 3: 1258–1275.
, : Consensus statement of the 1st International Exercise-Associated Hyponatremia Consensus Development Conference, Cape Town, South Africa 2005. Clin J Sport Med 2005; 15: 206–211.
, : Statement of the Third International Exercise-Associated Hyponatremia Consensus Development Conference, Carlsbad, California, 2015. Clin J Sport Med 2015; 25: 303–320.
: Exercise-associated hyponatremia during winter sports. Phys Sportsmed 2010; 38: 101–106.
: Disorders of water- and electrolyte balance in a triathlon. 2 case reports and review of the literature. Praxis (Bern 1994) 1997; 86: 937–942.
: Acute hyponatremia in ultra-endurance athletes. Am J Emerg Med 1994; 12: 441–444.
: Special communication of a case of hypovolemic-associated EAH: lessons learned during recovery. Curr Sports Med Rep 2017; 16: 289–293.
: Exercise-associated hyponatremia: 2017 Update. Front Med (Lausanne) 2017; 4: 21.
: Fluid and electrolyte balance during the comrades marathon. S Afr Med J 1971; 45: 147–150.
: The immediate and delayed effects of marathon running on renal function. J Urol 1986; 136: 1176–1180.
: Plasma volume and renal function during and after ultramarathon running. Med Sci Sports Exerc 1990; 22: 581–587.
: Weight changes, medical complications, and performance during an Ironman triathlon. Br J Sports Med 2004; 38: 718–724.
: Muscle water and electrolytes following varied levels of dehydration in man. J Appl Physiol 1976; 40: 6–11.
,: Three independent biological mechanisms cause exercise-associated hyponatremia: Evidence from 2,135 weighed competitive athletic performances. Proc Natl Acad Sci USA 2005; 102: 18550–18555.
, : Exercise-induced hyponatremia in ultradistance triathletes is caused by inappropriate fluid retention. Clin J Sport Med 2000; 10: 272–278.
, : A prospective study of exercise-associated hyponatremia in two ultradistance triathletes. Clin J Sport Med 2000; 10: 136–141.
: Dehydration and hyponatremia during triathlons. Med Sci Sports Exerc 1989; 21: S219-S221.
, : Sweat sodium loss influences serum sodium concentration in a marathon. Scand J Med Sci Sports 2017; 27: 152–160.
, : Effects of dietary sodium on body and muscle potassium content during heat acclimation. Eur J Appl Physiol 1985; 54: 391–397.
: Dehydration in soldiers during walking/running exercise in the heat and the effects of fluid ingestion during and after exercise. Eur J Appl Physiol 1997; 76: 517–524.
: Sodium-free fluid ingestion decreases plasma sodium during exercise in the heat. J Appl Physiol (1985) 1999; 86: 1847–1851.
: Role of osmolality and plasma volume during rehydration in humans. J Appl Physiol (1985) 1988; 65: 325–331.
. Shift in body fluid compartments after dehydration in humans. J Appl Physiol (1985) 1988; 65: 318–324.
: The incidence of hyponatremia during prolonged ultraendurance exercise. Med Sci Sports Exerc 1990; 22: 165–170.
: The hyponatremia of exercise. Int J Sport Nutr 1992; 2: 205–228.
: Considering exercise-associated hyponatraemia as a continuum. BMJ Case Rep 2018; 2018.
: Response to a fluid load in athletes with a history of exercise induced hyponatremia. Med Sci Sports Exerc 2001; 33: 1434–1442.
: Exercise-Associated Collapse: Is Hyponatremia in Our Head? PM R 2016; 8: S61-S68.
: Non-nutrients in sports nutrition: Fluids, electrolytes, and ergogenic aids. e-SPEN 2011; 6: e217-e222.
, : Effects of different sodium concentrations in replacement fluids during prolonged exercise in women. Br J Sports Med 2003; 37: 300–303; discussion 303.
: Exercise associated hyponatraemia: quantitative analysis to understand the aetiology. Br J Sports Med 2006; 40: 98–105; discussion 198–105.
, : Weight changes and serum sodium concentrations after an ultradistance multisport triathlon. Clin J Sport Med 1997; 7: 100–103.
, : Hyponatremia in ultradistance triathletes. Med Sci Sports Exerc 1999; 31: 809–815.
, : Evaluation of renal function and fluid homeostasis during recovery from exercise-induced hyponatremia. J Appl Physiol (1985) 1991; 70: 342–348.
: Hyponatremia among runners in the Zurich marathon. Clin J Sport Med 2008; 18: 344–349.
. Exercise-associated hyponatremia: A review. Emerg Med (Fremantle) 2001; 13: 17–27.
, : Hyponatremia among runners in the Boston Marathon. N Engl J Med 2005; 352: 1550–1556.
: Exercise-associated hyponatremia, hypernatremia, and hydration status in multistage ultramarathons. Wilderness Environ Med 2017; 28: 291–298.
. Change in serum sodium concentration during a cold weather ultradistance race. Clin J Sport Med 2003; 13: 171–175.
: Weight changes, sodium levels, and performance in the South African Ironman Triathlon. Clin J Sport Med 2002; 12: 391–399.
, : Fluid balance during and after an ironman triathlon. Clin J Sport Med 2001; 11: 44–50.
: Hyponatremia and weight changes in an ultradistance triathlon. Clin J Sport Med 1997; 7: 180–184.
: Intracellular hyperhydration induced by a 7-day endurance race. Eur J Appl Physio 1999; 80: 353–359.
: Hyponatremia is associated with higher NT-proBNP than normonatremia after prolonged exercise. Clin J Sport Med 2012; 22: 488–494.
: Hyponatremia in runners requiring on-site medical treatment at a single marathon. Med Sci Sports Exerc 2002; 34: 185–189.
: Sodium supplementation and exercise-associated hyponatremia during prolonged exercise. Med Sci Sports Exerc 2015; 47: 1781–1787.
: Fluid replacement during prolonged exercise: effects of water, saline, or no fluid. Med Sci Sports Exerc 1991; 23: 811–817.
: Hyponatremia, cerebral edema, and noncardiogenic pulmonary edema in marathon runners. Ann Intern Med 2000; 132: 711–714.
: Brain dehydration and neurologic deterioration after rapid correction of hyponatremia. Kidney Int 1989; 35: 69–75.
: The incidence, risk factors, and clinical manifestations of hyponatremia in marathon runners. Clin J Sport Med 2003; 13: 41–47.
: Hyponatremia and physical exercise. Clin Ter 2012; 163: e349–e356.
: Hyponatremia and ultramarathon running. JAMA 1986; 255: 772–774.
: Case study: Symptomatic exercise-associated hyponatremia in an endurance runner despite sodium supplementation. Int J Sport Nutr Exerc Metab 2015; 25: 603–606.
: Three cases of severe hyponatremia during a river run in Grand Canyon National Park. Wilderness Environ Med 2015; 26: 189–195.
, Hew-Butler T: Rhabdomyolysis and hyponatremia: a cluster of five cases at the 161-km 2009 Western States Endurance Run. Wilderness Environ Med 2010; 21: 303–308.
: Case series: Hyponatremia associated with moderate exercise. Am J Med Sci 1996; 311: 86–91.
: Central pontine myelinolysis. Eur Neurol 2002; 47: 3–10.
: Disturbances of sodium homeostasis. Anasthesiol Intensivmed Notfallmed Schmerzther 2018; 53: 492–502.
: Collapsed ultraendurance athlete: proposed mechanisms and an approach to management. Clin J Sport Med 1997; 7: 292–301.
, : Fluid intake and changes in limb volumes in male ultra-marathoners: does fluid overload lead to peripheral oedema? Eur J Appl Physiol 2012; 112: 991–1003.
: An increased fluid intake leads to feet swelling in 100-km ultra-marathoners – an observational field study. J Int Soc Sports Nutr 2012; 9: 11.
: Fatal water intoxication in a case of psychogenic polydipsia. J Forensic Sci 1980; 25: 332–335.
, Spradlin WW: Death from self-induced water intoxication among patients with schizophrenic disorders. J Nerv Ment Dis 1985; 173: 161–165.
: Beer potomania: two cases and review of the literature. Clin Nephrol 1996; 45: 61–64.
: Vitreous humor sodium levels in immersion deaths. J Forensic Sci 2011; 56: 643–644.
: Fatal water intoxication during olanzapine treatment: a case report. Leg Med (Tokyo) 2014; 16: 89–91.
: Hyponatremia at autopsy: an analysis of etiologic mechanisms and their possible significance. Forensic Sci Med Pathol 2008; 4: 149–152.
: Hyponatremia at autopsy: cause of death or simply a marker of severity of the underlying disease. Rev Med Chir Soc Med Nat Iasi 2013; 117: 1028–1034.
, Humen DP: Biochemical changes as a result of prolonged strenuous exercise. Br J Sports Med 2002; 36: 301–303.
: Plasma electrolyte and glucose changes during the Hawaiian Ironman Triathlon. Med Sci Sports Exerc 1985; 17: 219–221.
: Clinical and biochemical characteristics of collapsed ultra-marathon runners. Med Sci Sports Exerc 1994; 26: 1095–1101.
: Medical care at ultraendurance triathlons. Med Sci Sports Exerc 1989; 21: S222–225.
: Sex differences in voluntary fluid intake by older adults during exercise. Med Sci Sports Exerc 2005; 37: 789–796.
:. Exercise induced hyponatremia. Harefuah 2004; 143: 342–347+391.
: Exercise-associated hyponatremia in a lactating female. Clin J Sport Med 2017; 27: e55–e57.
: Exercise associated hyponatraemia leading to tonic-clonic seizure. BMJ Case Rep 2012; 2012.
: An unusual cause of exercise-induced hyponatremia. Emerg Med Australas 2007; 19: 377–378.
: Exercise-associated hyponatremia. Proc (Bayl Univ Med Cent) 2007; 20: 398–401.
: Severe exercise-associated hyponatremia in a collegiate American football player. Curr Sports Med Rep 2017; 16: 343–345.
: Dehydration and hyponatremia in professional rugby union players: a cohort study observing english premiership rugby union players during match play, field, and gym training in cool environmental conditions. J Strength Cond Res 2015; 29: 107–115.
: Hyponatremia in an 85-year-old hiker: When depletion plus dilution produces delirium. Wilderness Environ Med 2012; 23: 153–157.
: Exertional heat illness and hyponatremia in hikers. Am J Emerg Med 1999; 17: 532–539.
: Severe exercise-associated hyponatremia on the Kokoda Trail, Papua New Guinea. Wilderness Environ Med 2008; 19: 42–44.
. Vatten är ett farligt gift … Två fall av hyponatremi i samband med maratonsport och stort vätskeintag. Lakartidningen 2008; 105: 1650–1652.
: High incidence of hyponatremia in rowers during a four-week training camp. Am J Med 2015; 128: 1144–1151.
: Fatal hyponatremic encephalopathy as a result of child abuse from forced exercise. Am J Forensic Med Pathol 2016; 37: 7–8.
: Exercise-associated hyponatremia during a self-paced marathon attempt in a 15-year-old male teenager. Medicina (Kaunas) 2019; 55. pii: E63.
: An intervention study of oral versus intravenous hypertonic saline administration in ultramarathon runners with exercise-associated hyponatremia: A preliminary randomized trial. Clin J Sport Med 2011; 21: 200–203.
: Dysnatremia among runners in a half marathon performed under warm and humid conditions. BMJ Open Sport Exerc Med 2018; 4: e000351.
, : Study of hematological and biochemical parameters in runners completing a standard marathon. Clin J Sport Med 2004; 14: 344–353.
: Exertional dysnatremia in collapsed marathon runners: A critical role for point-of-care testing to guide appropriate therapy. Am J Clin Pathol 2009; 132: 336–340.
: Risk factors for exercise-associated hyponatremia in non-elite marathon runners. Clin J Sport Med 2007; 17: 471–477.
: Exercise-associated hyponatremia masquerading as acute mountain sickness: Are we missing the diagnosis? Clin J Sport Med 2008; 18: 383–386.
: Serious complications following a marathon run – Interactive case report of a dramatic course. Anasthesiol Intensivmed Notfallmed Schmerzther 2012; 47: 696–702.
, : Exercise-associated hyponatremia in marathon runners: A two-year experience. J Emerg Med 2001; 21: 47–57.
: The prevalence and significance of post-exercise (postural) hypotension in ultramarathon runners. Med Sci Sports Exerc 1995; 27: 1595–1601.
: Fluid and electrolyte replacement in the ultramarathon runner. Am J Sports Med 1991; 19: 389–391.
, : Athletic performance and serial weight changes during 12- and 24-hour ultra-marathons. Clin J Sport Med 2008; 18: 155–158.
: A faster running speed is associated with a greater body weight loss in 100-km ultra-marathoners. J Sports Sci 2012; 30: 1131–1140.
: The influence of hydration state on thermoregulation during a 161-km ultramarathon. Res Sports Med 2016; 24: 212–221.
: No case of exercise-associated hyponatremia in male ultra-endurance mountain bikers in the “Swiss Bike Masters”. Chin J Physiol 2011; 54: 379–384.
, : No fluid overload in male ultra-runners during a 100 km ultra-run. Res Sports Med 2011; 19: 14–27.
: Higher prevalence of exercise-associated hyponatremia in Triple Iron ultra-triathletes than reported for Ironman triathletes. Chin J Physiol 2012; 55: 1–9.
: Physiologic alterations and predictors of performance in a 160-km ultramarathon. Clin J Sport Med 2012; 22: 146–151.
: Incidence of exercise-associated hyponatremia and its association with nonosmotic stimuli of arginine vasopressin in the GNW100s Ultra-endurance Marathon. Clin J Sport Med 2015; 25: 347–354.
: Fluid intake during an ultramarathon running race: relationship to plasma volume and serum sodium and potassium. J Sports Med Phys Fitness 1991; 31: 417–419.
, : Regulation of electrolyte and fluid metabolism in multi-stage ultra-marathoners. Horm Metab Res 2012; 44: 919–926.
, Burtscher M: Bike transalp 2008: Liquid intake and its effect on the body’s fluid homeostasis in the course of a multistage, cross-country, MTB marathon race in the central alps. Clin J Sport Med 2010; 20: 47–52.
: Body composition and hydration status changes in male and female open-water swimmers during an ultra-endurance event. J Sports Sci 2012; 30: 1003–1013.
: Higher prevalence of exercise-associated hyponatremia in female than in male open-water ultra-endurance swimmers: The ’Marathon-Swim’ in Lake Zurich. Eur J Appl Physiol 2012; 112: 1095–1106.
, : Prevalence of exercise-associated hyponatremia in male ultraendurance athletes. Clin J Sport Med 2011; 21: 226–232.
: Reported hydration beliefs and behaviors without effect on plasma sodium in endurance athletes. Front Physiol 2017; 8: 259.
: The prevalence of exercise-associated hyponatremia in 24-hour ultra-mountain bikers, 24-hour ultra-runners and multi-stage ultra-mountain bikers in the Czech Republic. J Int Soc Sports Nutr 2014; 11: 3.
: Maintained serum sodium in male ultra-marathoners the role of fluid intake, vasopressin, and aldosterone in fluid and electrolyte regulation. Horm Metab Res 2011; 43: 646–652.
. Exercise-associated hyponatremia in an ultra-endurance mountain biker: A case report. Sports Health 2013; 5: 334–336.
: Low prevalence of exercise-associated hyponatremia in male 100 km ultra-marathon runners in Switzerland. Eur J Appl Physiol 2011; 111: 1007–1016.
, : Water and sodium intake habits and status of ultra-endurance runners during a multi-stage ultra-marathon conducted in a hot ambient environment: an observational field based study. Nutr J 2013; 12: 13.
: Hyponatremia in the 2009 161-km Western States Endurance Run. Int J Sports Physiol Perform 2012; 7: 6–10.
. The responses of plasma biochemical parameters to a 56-km race in novice and experienced ultra-marathon runners. Eur J Appl Physiol 1982; 49: 179–186.
, : The need for salt: Does a relationship exist between cystic fibrosis and exercise-associated hyponatremia. J Strength Cond Res 2014; 28: 807–813.
: Can changes in body mass and total body water accurately predict hyponatremia after a 161-km running race? Clin J Sport Med 2010; 20: 193–199.
: Found in the field – a soldier with heat stroke, exercise-associated hyponatremia, and kidney injury. Curr Sports Med Rep 2018; 17: 123–125.
: Drinking water and disorientation: The perils of a long, hot, Australian summer. Emerg Med Australas 2017; 29: 370–371.
, : Body mass changes across a variety of running race distances in the tropics. Sports Med Open 2016; 2: 26.
: Exercise-associated hyponatremia and hydration status in 161-km ultramarathoners. Med Sci Sports Exerc 2013; 45: 784–791.
: Collapse in the heat – from overhydration to the emergency room – three cases of exercise-associated hyponatremia associated with exertional heat illness. Mil Med 2018; 183: e225-e228.
: Exercise-associated hyponatremia: A local case report. Hong Kong J Emerg Med 2009; 16: 88–92.
, : Hyponatremia in a cold weather ultraendurance race. Alaska Med 2002; 44: 51–55.
: No exercise-associated hyponatremia found in an observational field study of male ultra-marathoners participating in a 24-hour ultra-run. Phys Sportsmed 2010; 38: 94–100.
: Hazards of ultra-marathon running in the Scottish highlands: Exercise-associated hyponatraemia. Emergency Med J 2009; 26: 906–907.
, : Is the prevalence of exercise-associated hyponatremia higher in female than in male 100-KM ultra-marathoners? Human Movement 2012; 13: 94–101.
: No case of exercise-associated hyponatraemia in top male ultra-endurance cyclists: the “Swiss Cycling Marathon”. Eur J Appl Physiol 2012; 112: 689–697.
: Sex hormone effects on body fluid and sodium regulation in women with and without exercise-associated hyponatremia. J Appl Physiol 2009; 107: 864–872.
, : Maintained total body water content and serum sodium concentrations despite body mass loss in female ultra-runners drinking ad libitum during a 100 km race. Asia Pac J Clin Nutr 2010; 19: 83–90.
: Management of severe rhabdomyolysis and exercise-associated hyponatremia in a female with anorexia nervosa and excessive compulsive exercising. Case Rep Med 2016; 2016: 8194160.
: Hiker fatality from severe hyponatremia in Grand Canyon National Park. Wilderness Environ Med 2015; 26: 371–374.
: Exercise-associated hyponatremic encephalopathy in an endurance open water swimmer. Wilderness Environ Med 2015; 26: 59–61.
: A near-fatal case of exercise-associated hyponatremia. Am J Emerg Med 2014; 32: 813.e811–813.e812.
. Hyponatremic encephalopathy with non-cardiogenic pulmonary edema: Development following marathon run. Med Klin Intensivmed Notfmed 2013; 108: 234–238.
: Cerebral edema due to marathon run. Notf Rett Med 2009; 12: 287–289.
: Moderate exercise-induced hyponatremia. Clin J Sport Med 2006; 16: 72–73.
: Drowning in the desert: Exercise-induced hyponatremia at the Grand Canyon. J Emerg Nurs 1997; 23: 586–590.
: Medical clearance for desert and land sports, adventure, and endurance events. Clin J Sport Med 2015; 25: 418–424.
: Wilderness medical society practice guidelines for treatment of exercise-associated hyponatremia: 2014 update. Wilderness Environ Med 2014; 25: S30–S42.
, : Medical services at ultra-endurance foot races in remote environments: Medical issues and consensus guidelines. Sports Med 2014; 44: 1055–1069.
. In reply to clinical practice guidelines for treatment of exercise-associated hyponatremia. Wilderness Environ Med 2013; 24: 468–471.
: Description of three female 24-h ultra-endurance race winners in various weather conditions and disciplines. Chin J Physiol 2017; 60: 231–241.
: Exercise-associated hyponatremia and the Varon-Ayus syndrome. Crit Care & Shock 2009; 12: 104–108.
: Life-threatening hyponatremia in marathon runners: The Varon-Ayus syndrome revisited. Crit Care & Shock 2005; 8: 23–27.
: Exercise-associated hyponatremia: Why are athletes still dying? Clin J Sport Med 2008; 18: 379–381.
, : Osmotic and nonosmotic regulation of arginine vasopressin during prolonged endurance exercise. J Clin Endocrinol Metab 2008; 93: 2072–2078.
: Do male 100-km ultra-marathoners overdrink? Int J Sports Physiol Perform 2011; 6: 195–207.
: Pre- and post-race hydration status in hyponatremic and non-hyponatremic ultra-endurance athletes. Chin J Physiol 2016; 59: 173–183.
, Tomášková I: Pre-race characteristics and race performance in hyponatremic and normonatremic finishers of Czech ultra-races. Acta Gymnica 2016; 46: 109–116.
, : Rhabdomyolysis and exercise-associated hyponatremia in ultra-bikers and ultra-runners. J Int Soc Sports Nutr 2015; 12:29.
, : First reported cases of exercise-associated hyponatremia in Asia. Int J Sports Med 2011; 32: 297–302.
. Serum biochemistry and morbidity among runners presenting for medical care after an australian mountain ultramarathon. Clin J Sport Med 2007; 17: 307–310.
: Body weight, serum sodium levels, and renal function in an ultra-distance mountain run. Clin J Sport Med 2015; 25: 341–346.
: Exercise-associated hyponatremia, renal function, and nonsteroidal antiinflammatory drug use in an ultraendurance mountain run. Clin J Sport Med 2007; 17: 43–48.
: Creatine kinase, exertional rhabdomyolysis, and exercise-associated hyponatremia in ultra-endurance athletes: A critically appraised paper. Int J Athl Ther Train 2016; 21: 13–15.
: Proof of concept: hypovolemic hyponatremia may precede and augment creatine kinase elevations during an ultramarathon. Eur J Appl Physiol 2016; 116: 647–655.
: Exercise-associated hyponatremia with exertional rhabdomyolysis: Importance of proper treatment. Clin Nephrol 2015; 83: 235–242.
: Characteristics of 161-km ultramarathon finishers developing exercise-associated hyponatremia. Res Sports Med 2013; 21: 164–175.
: Exercise-associated hyponatremia with rhabdomyolysis during endurance exercise. Phys Sportsmed 2009; 37: 126–132.
, Hyponatremia in marathon runners due to inappropriate arginine vasopressin secretion. Am J Med 2007; 120: 461.e411–461.e417.
, Stuempfle KJ: Increasing creatine kinase concentrations at the 161-km Western States Endurance Run. Wilderness Environ Med 2012; 23: 56–60.
: Recurrent rhabdomyolysis in a teenager with psychosis-intermittent hyponatremia-polydipsia syndrome. Pediatr Emerg Care 2015; 31: 274–276.
: Exertional rhabdomyolysis in carbonic anhydrase 12 deficiency. J Pediatr Endocrinol Metabol 2018; 31: 697–699.
: Serum sodium changes in marathon participants who use NSAIDs. BMJ Open Sport Exerc Med 2018; 4: e000364.
: NSAID use increases the risk of developing hyponatremia during an Ironman triathlon. Med Sci Sports Exerc 2006; 38: 618–622.
: Exercise-associated hyponatremia: Overzealous fluid consumption. Wilderness Environ Med 2009; 20: 139–143.
, : Dysnatremia predicts a delayed recovery in collapsed ultramarathon runners. Clin J Sport Med 2007; 17: 289–296.
: Are we being drowned by overhydration advice on the Internet? Phys Sportsmed 2016; 44: 343–348.
, Twycross-Lewis R: Intended hydration strategies and knowledge of exercise-associated hyponatraemia in marathon runners: A questionnaire-based study. J Athl Train 2018; 53: 696–702.
: Restricting dietary sodium reduces plasma sodium response to exercise in the heat. Scand J Med Sci Sports 2017; 27: 1213–1220.
: Near-fatal outcome from absence of information about exercise-associated hyponatremia in a Wilderness Medicine Field Guidebook. Wilderness Environ Med 2015; 26: 284–285.
: Sodium supplementation has no effect on endurance performance during a cycling time-trial in cool conditions: A randomised cross-over trial. J Int Soc Sports Nutr 2013; 10: 30.
: Hydration strategies of runners in the London Marathon. Clin J Sport Med 2012; 22: 152–156.
, : The effect of physiology and hydration beliefs on race behavior and postrace sodium in 161-km ultramarathon finishers. Int J Sports Physiol Perform 2013; 8: 536–541.
: Hydration strategies, weight change and performance in a 161 km ultramarathon. Res Sports Med 2014; 22: 213–225.
: Case study: Symptomatic exercise-associated hyponatremia in an endurance runner despite sodium supplementation. Int J Sport Nutr Exerc Metab 2015; 25: 603–606.
: Is sodium supplementation necessary to avoid dehydration during prolonged exercise in the heat? J Strength Cond Res 2016; 30: 615–620.
: Association of gastrointestinal distress in ultramarathoners with race diet. Int J Sport Nutr Exerc Metab 2013; 23: 103–109.
: Electrolytes: Oral electrolyte solutions. FP Essent 2017; 459: 35–38.
: Fluid replacement during marathon running. Clin J Sport Med 2003; 13: 309–318.
: Nutrition and ultra-endurance: An overview. In: Bagchi D, Nair S, Sen CK: Nutrition and Enhanced Sports Performance: Muscle Building, Endurance, and Strength. London, Elsevier: 2013. 161–170.
: Sodium supplementation is not required to maintain serum sodium concentrations during an Ironman triathlon. Br J Sports Med 2006; 40: 255–259.
: Sodium replacement and fluid shifts during prolonged exercise in humans. Eur J Appl Physiol 2001; 84: 419–425.
: Oral salt supplementation during ultradistance exercise. Clin J Sport Med 2002; 12: 279–284.
: What are effective approaches to preventing exercise-associated hyponatremia? Evidence-Based Pract 2016; 19: E9.
: Practical management of exercise-associated hyponatremic encephalopathy: The sodium paradox of non-osmotic vasopressin secretion. Clin J Sport Med 2008; 18: 350–354.
: Predicted risk for exacerbation of exercise-associated hyponatremia from indiscriminate postrace intravenous hydration of ultramarathon runners. J Emerg Med 2019; 56: 177–184.
: Large-volume hypertonic saline therapy in endurance athlete with exercise-associated hyponatremic encephalopathy. J Emerg Med 2013; 44: 1132–1135.
: Electrolytes: sodium disorders. FP Essent 2017; 459: 11–20.
: Oral versus intravenous hypertonic saline for exercise-associated hyponatraemia. J Paediatr Child Health 2017; 53: 507–509.
: Management of suspected fluid balance issues in participants of wilderness endurance events. Curr Sports Med Rep 2017; 16: 98–102.
: Injuries and health considerations in ultramarathon runners. Phys Med Rehabil Clin N Am 2016; 27: 203–216.
: Exercise-induced hyponatremia: Causes, risks, prevention, and management. Cleve Clin J Med 2006; 73: S13–S18.
: Exercise-associated hyponatremia: role of cytokines. Am J Med 2006; 119: S74–S78.
: Current challenges in the evaluation and management of hyponatremia. Kidney Dis (Basel) 2016; 2: 56–63.
: Exercise-associated hyponatremia. In: Simon EE (Hrsg.). Hyponatremia: Evaluation and Treatment. Berlin; Springer Science & Business Media: 2013. 175–192.
: Hyponatremia: Clinical diagnosis and management. Am J Med 2007; 120: 653–658.
, : Statement of the second international exercise-associated hyponatremia consensus development conference, New Zealand, 2007. Clin J Sport Med 2008; 18: 111–121.
, : Statement of the 3rd international exercise-associated hyponatremia consensus development conference, Carlsbad, California, 2015. Br J Sports Med 2015; 49: 1432–1446.
