No hyponatremia despite continuous plasma sodium decline in female runners during a seven stage ultramarathon

The role of sodium supplements and sex in the occurrence of exercise-associated hyponatremia (EAH) remains controversial. This study investigated hydration status in ultrarunners (19 males and 9 females) who completed seven marathons over seven consecutive days. Due to the limited number of female participants, no statistical comparison between sexes was performed. Plasma sodium concentration ([Na$^{+}$]) and multiple hydration markers were assessed before, during, and after the race. Reported sodium supplement consumption showed no association with plasma [Na$^{+}$]. An overall decline in plasma [Na$^{+}$] was observed in females (regression slope = -1.278, p = 0.02) across the event, whereas no significant change was detected in males (slope = -0.325, p = 0.57). Additionally, no significant associations were found between plasma [Na$^{+}$] and other monitored variables, including sodium supplement intake, pre-race hydration strategy, body mass, total body water, plasma osmolality, hematocrit, hemoglobin, urine specific gravity, urinary [Na$^{+}$], thirst rating, or fluid intake reported pre-, during, and post-stage. No cases of symptomatic or asymptomatic hyponatremia were identified, suggesting that total fluid and sodium intake were adequate to maintain fluid-electrolyte balance and prevent EAH in both sexes.