Managing the effects of multi-stage events on kidney function
Posted on 11 May 2018
During each ABSA Cape Epic, Mediclinic deploys a team of clinicians, ranging from doctors and nurses to emergency medical personnel, to assist any rider in difficulty. “Understanding our riders and their health is of the utmost importance to us. We are happy that the participants understand that we are here to help and are engaging with us on their health needs,” Dr Jann Killops, Mediclinic race doctor, believes that the overall health of the riders is a priority for the medical team.
Because of the nature of the Epic – eight stages along intense routes, often in high temperatures – the chance of renal damage by riders remains a concern for medical staff. When riders are retrieved from the course or present themselves to the race hospital with symptoms of dehydration, the team applies a well-oiled process to evaluate the rider and the risk to his/her organs.
With the help of Pathcare, on-site during the race, Dr Killops’ team perform real time blood tests, which allows them to monitor the on-going hydration levels of the riders under observation. During an average epic race about 180 tests are performed to measure hydration of the riders.
As part of the 2018 edition of the race, diligent care was placed on investigating riders’ health with daily tests for at-risk riders. Eight riders were removed from the race and referred to Dr Geoff Bihl, a Nephrologist at Mediclinic Vergelegen, for additional care.
Most of these patients received treatment for a combination of severe dehydration (>7% body weight), rhabdomyolysis (the breakdown of muscle), and this can lead to life threatening blood electrolyte abnormalities i.e. potassium, acute kidney injury or heat stroke. Judicious fluid was given intravenously, with cardiac monitoring in Cardiac ICU and paracetamol IV if no liver enzyme abnormality was evident.
According to Dr Bihl, “Most riders spent 2-3 days in hospital. One patient presented with severe pericarditis/myocarditis with raised cardiac enzymes that required follow up by a cardiologist. One month later the enzymes were still not normal but the patient was feeling better and cardiac function was normal.”
The concerns for such patients, participating in extreme events such as the Epic, is around repeated injury to organs. From a cardiac perspective myocardial damage can be permanent and thus any flu like symptoms pre-race must be taken seriously. “Acute kidney injury is a serious medical illness often ignored. There is up to a 10% mortality with a risk for recurrence and a risk of long term chronic kidney disease. If the condition has occurred before it’s likely to happen again. I suggest a full medical and pathology investigation by a sports physician prior to such competitors being permitted to participate again,” explains Dr Bihl.
While the Epic is one of the best known extreme events in cycling, these risks are not isolated to this race. Any event in extreme conditions and prolonged time on the bike would fit the profile. Dr Bihl suggests simple adjustments like starting the riders who are likely to be on the bike for longer earlier in the day – or ensuring that there are strict qualifying criteria to participate in these extreme races.
Because the risk to participants is through repeated injury to their heart or kidneys, the longer term approach does need to be considered. Geoff goes on to explain the impact, “It is important to monitor these patients in the acute setting especially if rhabdomyolysis has occurred. Hyperkalemia can continue or re-occur if muscle temperature is not controlled. The very nature of stage events dictates that repeated physical insults will occur and this is very dangerous and thus such riders should be withdrawn from the event.” According to Dr Bihl, pre-ceding illness (colds/flu/infections), the use of anti-inflammatories or performance drugs, over supplementation with over the counter medication need to be carefully monitored by riders because of the potential impact to the organs.
In his view, Dr Bihl believes that all Epic training camps should include an in-depth course on fluid management, heat management and maintaining adequate hydration. “Those riders previously removed for such issues are well advised to undergo a full medical and then obtain a sports physician’s consent to ride again.”
“I believe that it is essential that riders are encouraged to co-operate with all medical staff and the treating doctor’s decision should be final. Dr Jann Killops and her medical team should really be lauded on their professional and efficient approach to these patients.”
We would like to thank Dr Bihl and his team at Mediclinic Vergelegen for the care of riders leaving the Absa Cape Epic.