Rhabdomyolysis - what is the risk?
A good friend of mine just ran the Richmond marathon as his first marathon. He collapsed in the last mile, suffering from what was later determined to be rhabdomyolysis. He spent several days in the hospital and was apparrently very close to a life-threatening situation. Below is his account of the day. He's an experienced runner, did three 20-milers in training, trained in the Richmond heat during the summer, and by my estimation did everything right in terms of hydration and nutrition. He had course-supplied Powerade at every aid station (2 mile intervals) and took Gu gels @ miles 6, 11, 15, and 19, chased with water. It seems to me to be a complete mystery how he developed such a life-threatening condition. Does anyone have any ideas what could have happened and what the risk may be for the rest of us?
Here's his account:
Now that my head is a bit clearer, I have made more sense of things, including what the doctor has told me. I believe I didn't correctly state the case by saying "dehydration". What I had was rhabdomyolysis, which you may know more about but I had never heard of. Below is a decent article. The description they give of the marathoner is exactly how I felt and (confidentially) I did honestly think I might not make it during the ambulance ride. That may explain why my doc says I hit the lottery by stopping (not that I had a choice) and getting the treatment so fast. He said I probably had less than an hour otherwise.
www.sportsinjurybulletin.com/archiv...lysis.html
I carbed up the days before with normal sized meals but with calories highly focused on carbs. Drank a lot of water the week of, including sports drink the day before. On raceday I had 1.5 PB&J sandwiches, and a bunch of powerade and water at 4:45AM. This is slightly more than I had on the morning long runs but otherwise the same. The 20 milers all went well for me with paces from 8:23-8:30 range with no problem at all.
I drank at least one cup of sports drink at every water stop and had water at the stops when I had gels (4 of them total). A few of the stops I had 2 cups.
My splits were fairly consistent with my gameplan. I wanted to run an average (effort) of 8:15-8:20 range until mile 20 and then see what I had left.
7-8 were faster due to the downhill and there were other hill fluctuations. After the Lee bridge I was slower and hitting the wall but still keeping 8:30-8:45. Lombardy, Grace and the final turns were where I was starting to feel really rough but I didn't feel like I couldn't go on until the very end when it hit me. Mile 26 is of course where I stopped and you all found me.
I feel like maybe I could've perhaps eaten more or drank more before and during but I didn't feel that was enough to have the trouble that I did based on past training. I'm open to the fact that maybe I'm more susceptible to the "rhabdo" than others. I'd be interested and open to any thoughts you might have on all of this. Thanks again for everything.
Split Time Distance Avg Pace
Summary 7:20:58.5 35.75 12:20
1 8:16.5 1.00 8:17
2 8:14.4 1.00 8:14
3 8:07.6 1.00 8:08
4 8:10.4 1.00 8:10
5 8:10.4 1.00 8:10
6 8:16.8 1.00 8:17
7 7:52.3 1.00 7:52
8 7:57.9 1.00 7:58
9 8:27.6 1.00 8:28
10 7:58.2 1.00 7:58
11 8:25.9 1.00 8:26
12 8:36.8 1.00 8:37
13 8:35.2 1.00 8:35
14 8:15.7 1.00 8:16
15 8:25.5 1.00 8:25
16 8:12.6 1.00 8:13
17 8:35.7 1.00 8:36
18 8:40.7 1.00 8:41
19 8:44.2 1.00 8:44
20 8:38.8 1.00 8:39
21 8:43.1 1.00 8:43
22 8:48.5 1.00 8:48
23 8:54.8 1.00 8:55
24 8:48.7 1.00 8:49
25 8:55.2 1.00 8:55
26 24:02.5 1.00 24:03
Comments
First of all I'm glad he is okay now. Very interesting!! Couple of questions to assist in the puzzle.
1. What medical conditions does he have?
2. Did he take any form of NSAID prior to or during the marathon?
3. What supplements does/did he use leading up to or during besides the Gels?
Thanks
Looking at his splits, he over cooked his first 8+ miles. Yes, some may have been downhill, but after that his pace kept dropping off. Although there are no real breaks late in the run so either his 'hitting' the wall was an insignificant sensation or he really drove his body under the bus to keep his paces. Hard to say.
Looking forward to hear more.
He has no medical history, takes no meds, and did not take any NSAIDs. He does take a multivitamin but did not take one race morning (took one the day before). He said he takes either a generic multivitamin or one Airborne tablet in water per day to keep away any colds that the kids are passing around. He had ~22oz of Gatorade the day before the race and 16oz of Powerade 3.5 hourse before the race plus an equal amount of water. He uses a protein drink after long runs but hadn't had any for two weeks prior since he was in taper.
Any chance that the Airborne or vitamin intake caused any predisposition? I'm not sure what's in Airborne - is that a zinc thing?
Mild to moderate elevations in CK (aka CPK) is not surprising in endurance events. I could not find an actual incidence in marathoners but suspect that CK levels would be elevated in a good portion of finishers. There were some very good questions posted by others. Temperature, hydration status, alcohol/NSAID use. Also any pseudophed, cold remedies may affect thermoregulation.
Here are the blood numbers (at peak):
CK: 6820
Creatine: 1.7
Myoglobin: 5355
The doctor talked about dialysis…if the other things didn’t work (IV’s and bicarbonate I think)…which thankfully they did.
Outside Temp: 45 @ start, 65 @ finish
No alcohol or medications of any kind. One of my coaches who was with me at the scene (and is also a nurse practitioner) mentioned that I was still sweating and my veins weren’t flat, for what it’s worth.
Thankfully the blood levels are now coming down so I should be able to run in a couple of weeks if all continues well. Doc says no permanent liver damage.
Natural history of exertional rhabdomyolysis: a population-based analysis.
Alpers JP, Jones LK Jr.
Source
Department of Neurology, Wright- Patterson Medical Center, Wright-Patterson Air Force Base, Ohio, USA.
Abstract
Exertional rhabdomyolysis is a potentially catastrophic syndrome with an incidence and rate of recurrence that are unknown. In this study patients with rhabdomyolysis were identified retrospectively from the Wilford Hall Medical Center records. A population-based analysis was performed on exertional rhabdomyolysis patients enrolled in basic military training. A retrospective cohort was analyzed for rate and risks of recurrence. Of 177 rhabdomyolysis patients, 63 were exertional in mechanism. The rate of renal failure was lower in exertional rhabdomyolysis patients (odds ratio 0.45, 95% confidence interval 0.22-0.95, P = 0.04). There were 44 cases of exertional rhabdomyolysis from a population of 198,399 total military trainees over the study period, or 22.2 cases per 100,000 per year. A cohort of 22 exertional rhabdomyolysis patients was followed for a mean of 31.2 months, with only 1 recurrence (recurrence risk of 0.08% per person per year). Exertional rhabdomyolysis is associated with lower rates of complications than other causes of rhabdomyolysis. Among young, physically active patients, the incidence of exertional rhabdomyolysis is low, as is the risk of recurrence.
Great info, thanks. It's scary when something like this happens to a well-trained athlete and there's no specific cause to pin it on. I guess it's a bit comforting that the risk of recurrence is extraordinarily low.