441
Ultra-Long-Distance Running and the Liver*
D. Nagel' , D. Seller1, H. Franz1, K. Jung2
1lnstitut für Klinische Chemie, Klinikum Ludwigshafen
2Abteilung Sportmedizin, Universität Mainz
Abstract
D. Nagel, D. Seller, H. Franz, and K. Jung,
Ultra-Long-Distance Running and the Liver. mt J Sports
Med,Volll,No6,pp441—445, 1990.
Accepted after revision: January 17, 1990
During an ultra-long-distance race (1000 km
in 20 days) the influence of running was examined on the
enzymes aspartate aminotransferase (AST), alanine
aminotransferase (ALT), alkaline phosphatase (AP),
gamma-glutamyl-transferase (GGT), and glutamate dehy-
drogenase (GLDH) with regard to their release from the
liver cells or their induction. Furthermore the liver synthetic
capacity was assayed by measuring the enzyme activity of
cholinesterase and the concentration of serum albumin
during the race.
Of the 110 participants, 55 finished the race
and only the results of these runners were used in our study.
AP increased continuously from day 0
(mean = 102 U/L) to day 19 (mean = 120 U/L). A
fivefold increase of AST and a twentyfold increase of CK
up to day 3 was followed by a significant decrease towards
the end of the race. ALT rose as well up to day 6 from a mean
value of 8 U/L to 24 U/L but remained at this level. Surpris-
ing was the individual increase of the enzymes GLDH (up
to twentyfold) and GGT (up to sixfold) in more than half of
the finishers on various days indicating liver cell injuries.
The activity of CHE and the concentration of
serum albumin decreased during the race, both were signifi-
cantly correlated.
Key words
Ultra-long-distance running, glutamate dehy-
drogenase, gamma-glutamyl-transferase, cholinesterase,
albumin
________________________________________
Int.J.SportsMed.ll(1990)441—445
GeorgThieme Verlag StuttgartNewYork
Introduction
There are numerous reports that physical exer-
cise like intense long-distance running can lead to an increase
in serum enzyme activities such as creatine kinase (CK), aspar-
tate aminotransferase (AST), alaninc aminotransferase
(ALT), and lactate dehydrogenase (LDH) (2, 3,4,8, 14, 15, 17,
19, 24, 26, 29, 33, 35). Many of the authors believe that this in-
crease in activity is due to the release of enzymes from skeletal
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muscle cells rather than from other organs like heart or liver,
where these enzymes are also located. Kindermann et al. (19)
found no evidence of liver disturbances in a study with 91
trained athletes. In their report in addition to the above-men-
tioned enzymes, gamma-glutamyl-transferase (GGT), gluta-
mate dehydrogenase (GLDH), cholinesterase (CHE) and al-
kaline phosphatase (AP) were measured. No increases in
GGT, GLDH, AP, and CHE were observed although the CK
activity sometimes was increased above 1000 U/L. Similar re-
sults were obtained by Berg and Keul (4) and by Wuschech et
al. (35).
Reports regarding the liver as a source of enzy-
matic changes after exercise are rather scarce (1, 15). A study
by Foigt et al. (13) with 6 volunteers showed that at least one of
the enzymes ALT, AP, sorbitol dehydrogenase (SDH), and
isocitrate dehydrogenase (lCD) was significantly increased in
hepatic venous blood as an expression of hepatic injury during
strenuous physical exercise.
The purpose of our study was to examine the
effect of a 1000-km race (20 days x approx. 50 km) in well-
trained male and female athletes on the serum activities of dif-
ferent enzymes such as AST, ALT, AP, CHE, GLDH, and
GGT as well as on serum albumin concentration with regard to
a possible liver cell injury caused by strenuous exercise.
Subjects and Methods
The study group consisted of 91 male and 19
female runners participating in a 1000-km race from the north
to the south of West Germany. The race lasted for 20 days with
an average daily running distance of 50 km. All runners were
medically examined before the race and were accustomed to a
running training between 70 and 140 km per week 6 months
prior to the start. In order to examine the influence of nutrition
on diet-dependent biochemical parameters (25, 32), the parti-
cipants were divided into two groups according to their dietary
habits 3—6 months before the competition; whereas one group
(60 people) consumed normal conventional western diet
* Dedicated to Professor Dr. med. Erich Kuhn, Heidelberg, on the
occasion of his 70th1 birthday.
442 mt. J. Sports Med. 11(1990) D. Nagel, D. Seller, H. Franz, K. Jung

T — C I( Fig. 1 Changes in the catalytic activities

(U L ) of the serum enzymes ALT, AST, and CK.
-2000 (Mean±S. D.) •---U CK; •—I AST;
A---A ALT
A1.T —1400
A ST
(U L) I T
—1000

— I
100—
— —600

-200
20-
0: .0
days

Table 1 Anthropometric data agentKitNo 791644 and 791652, Reagent KitNo 791458 and
Mean (range) 791466, respectively). GLDH (12) was determined on a Cobas

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Males Females Bio Analyzer (Fa. Hoffmann-La Roche, Switzerland, Reagent
(n= 42) (n= 13) Kit No 0712124). All enzyme activities were measured at a

41.0 47.8
temperature of 25 °C. Serum albumin was analysed by an elec-
Age (years) (21—72) (23—61)
Body mass (kg) 69.4 (532—85.4) 59.1 (492—73.2)
trophoresis-method using cellulose-acetate membranes and
Height (cm) 176 (154—186) 175 (163—183) staining by Ponceau S dye. For the densitometric quantifica-
tion of the stained bands a ZEISS KDF 5 densitometer was
used.

(fried or boiled meat, fruits, salads, canned vegetables, milk,
cheese, sweets, butter, refined flour products such as bread
etc.), the other group lived on a wholesome vegetarian diet
(lacto-ovovegetarians). During the race diets for both groups
were formulated to contain carbohydrates, fats, and proteins
in the ratio 60:30: 10. Runners were only offered the diet of
their respective group without restriction of caloric intake. In
this paper the effect of the different diets is not considered. All
participants were non-smokers and no alcohol was allowed
during the race.
Of the 110 participants (19 females and 91
males), only 55 runners (13 females and 42 males) finished the
race. Their anthropometric data are given in Table 1.
Venous blood samples were obtained in the
afternoon of the day before the race (day 0) and in the after-
noon on days 1,3,6,8,11, and 19. Runners were placed in re-
cumbent position and 30 ml of blood were drawn within 15
minutes after finishing their daily run. Food was available
during the race up to the 30-km control point. Thereafter only
mineral water was offered. Serum was separated from cells as
soon as the blood sample was coagulated and stored at — 20 °C.
Interassay variation was avoided by analysing samples from
individuals in a single analyser run.
ALT(l0), AST(l0), AP (10), andCK (11) were
quantified according to the recommendations of the Deutsche
Gesellschaft für Klinische Chemie on the Hitachi 737 Analy-
zer (Fa. Boehringer Mannheim, FRG, Reagent Kit No 791628
and 791636, Reagent Kit No 791598 and 79160!, Reagent Kit
No 791369 and 791377, Reagent Kit No 791474 and 791482
respectively). GGT (27) and CHE (20) were analysed on a Hi-
tachi 737 Analyzer (Fa. Boehringer Mannheim, FRG, Re-
Statistics: Results were expressed as
mean S. D. The significance of differences between inde-
pendent groups was evaluated by analysis of variance
(ANOVA) or by the independent t-test. The significance of in-
dividual changes during the race was evaluated by an analysis
of variance (REPEATED MEASURES ANOVA) or by the t-
test for correlated samples. Correlations were studied by
means of Pearson's product moment correlation coefficient or
by computing the multiple R by means of multiple linear re-
gression analysis with ALT as the dependent variable, and CK
and GLDH as the independent predictor variables (the latter
two variables being not correlated).
Results
There were no statistically significant differ-
ences between the wholesome and conventional diet groups
and between female and male runners for the presented data.
Therefore the results of all participants were grouped together.
Only the results of 54 of the 55 finishers were used because not
enough blood could be obtained from one runner on all days.
Fig. I shows the changes of the catalytic activ-
ities of the enzymes ALT and AST in comparison to CK. After
an initial rise on day 3 of CK from 59 30 U/L to
1225 1064 U/L (p < 0.05) and AST from 12 5 U/L to
62±45 U/L (p <0.05), these enzymes fell towards the end of
the race, ALT rose as well to a maximum on day 6 from 8
U/L to 24±18 U/L (p <0.05), thereafter remaining at this
level until the end of the race.
The catalytic activity of the enzyme AP showed
a significant (p <0.05) increase from day 0 (102 25 U/L) to
day 19 (120 31 U/L). The enzyme activities did not exceed
Ultra-Long-Distance Running and the Liver Int.J.SportsMed. 11 (1990) 443

Table 2 GLDH-activities (U/L) of individual runners with more than Table 4 Correlation coefficients and significance levels of ALT vs
one patho logical GLDH-value ( >4 U/L) dun ng the race CK, respectively, vs CK and GLDH

Days Day ALTvsCK ALTvsCKandGLDH

No 0 1 3 6 8 11 19
0 r=0.542; p=0.l3l r=0.583; p=0.287
1 6 5 6 45 15 6 19 1 r=0.237; p=0.458 r=O.269; p=0.714
2 2 8 5 6 6 7 10 3 r = 0.382; p = 0.220 r = 0.908; p <0.001
3 5 3 25 9 4 6 6 6 r=0.637; p =0.003 r=0.897; p <0.001
4 24 14 4 7 6 11 3 8 r=0.794; p <0.001 r=0.910; p <0.001
5 3 2 3 20 12 8 6 11 r=0.778; p <0.001 r=0.857; p <0.001
6 5 5 5 7 4 3 3 19 r=0.523; p=O.O30 r=0.893; p <0.001
7 2 3 3 12 8 5 5
8 3 4 2 17 14 9 8
9 3 3 3 8 18 10 58
10 3 4 11 9 10 5 3
11 15 13 5 3 3 4 9 no significant correlation could be shown between GLDH-
12 2 2 2 4 9 5 5 and CK-values, representing the release of enzymes from the
13 1 2 13 18 5 3 3 liver or the muscle, respectively. On days 0 and 1 no significant
14 4 5 5 3 2 2 5 relationship between ALT, CK, and GLDH was found. Com-
15 2 1 2 8 8 6 3
paring only the results of the runners with increased GLDH ac-
16 3 3 2 1 1 5 5
17 3 3 2 4 2 5 31
tivities (>4 U/L), the correlation of ALT with CK was poor
18 5 1 1 3 2 2 6 on the days 3, 6, and 19, when the influence of the liver repre-
sented by GLDH was neglected, but was excellent when ALT
pathological values are printed in boldface.

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was correlated to CK and GLDH. On days 8 and lithe corre-
lation of ALT and CK was good but improved even further
when GLDH as a second independent variable was con-
Table 3 GGT-activities (U/L) of individual runners with more than sidered (Table 4).
one pathological GGT-value (>28 U/L) during the race
In order to investigate a possible influence of
Days
No 0 1 3 6 8 11 19 ultra-long-distance running on the liver synthetic capacity, we
measured the catalytic activity of CHE and the concentration
1 40 42 54 238 197 183 199 of serum albumin during the race. CHE and serum albumin,
3 20 21 29 30 26 24 16 after an initial increase possibly due to hemoconcentration,
4 38 47 35 41 36 38 37
5 20 17 21 39 34 36 32 decreased significantly from day 0 to day 19 (p <0.05) (Fig.
6 21 21 18 41 33 29 24 2). These two parameters were significantly correlated during
7 17 18 16 51 50 43 27 the whole endurance run (0.690 <r < 0.800; p <0.001).
8 46 42 36 61 53 49 33
10 35 35 35 38 40 39 28 Discussion
11 45 47 38 35 34 32 38
13 13 13 36 68 58 42 30 In studies on the elevation of the catalytic ac-
19 18 18 20 38 31 25 18
40 43 90
tivities of serum enzymes by physical exercise such as long-dis-
20 42 40 38 45
tance running, usually the enzyme activities of CK, LDH,
pathological values are printed in boldface. AST, and occasionally ALT are measured. Increased values of
these enzymes are mostly attributed to release from skeletal
muscle cells. Another reason for the increase in enzyme activi-
the reference range during the complete race except for one ty could also be liver disturbance because LDH, AST, and
ALT are located in the liver cell as well (22).
runner.

The catalytic activities of the enzymes GLDH
and GGT, generally regarded as indicative of liver injuries,
showed no significant changes during the race, but strong
short-term increases from day to day were found for more than
half of the runners (Table 2, Table 3). No increase above the
reference range for GGT in 36 runners and for GLDFI in 25
runners were found at any time during the run. These partici-
pants were omitted from Tables 2 and 3 as well as the runners
with only one pathological value during the run. Only the re-
sults of the runners with at least two GLDH- or GGT-values
above the reference range are expressed as numbers in Tables
2 and 3. In these tables the same number represents the same
runner.
If GLDH is released from liver cells, the same
should apply to ALT because this enzyme is also found in the
hepatic cells in high concentrations (22). At any time of the run
In our study, a corresponding increase
(p <0.05) of CK and AST up to day 3 was found, followed by
a continuous decrease towards the end of the race. ALT rose
significantly as well (p <0.05) up to day 6 but remained at this
level until the end of the race (Fig. 1). Despite all runners being
well-trained athletes, the sudden increase of exercise at the
beginning of the race causes release of enzymes from muscle
cells into the blood stream increasing CK, AST, and ALT ac-
tivities. After getting accustomed to longer running distances,
the effect of training leads to the known effect of a better
coordination of muscle fibers, resulting in less damage of the
muscle and subsequently a reduced release of CK, AST, and
ALT into the blood stream, explaining the decrease of CK and
AST after day 3. In contrast, ALT did not decrease further until
the end of the race, a fact that cannot be explained solely by the
longer half-life of this enzyme in comparison to CK and AST
(23), but may be explained by liver cell injuries with subse-
444 mt. J. Sports Med. 11(1990)
-r
ALBUMIN
Cg.L1)
i I
I I
I I T T
T T
55-
50-
45-
01 11
days
quent release of ALT into the blood stream. Foigt et al. (13)
found increased activities of at least one of the enzymes ALT,
SDH, and lCD in 5 out of his 6 volunteers in hepatic venous
blood in comparison with systemic arterial blood after physi-
cal exercise. A very specific parameter expressing liver cell in-
jury is the enzyme GLDH, located in the mitochondria of the
cells (6, 30). In 29 runners we found a rise above the reference
rangeat least once during the race and in 18 runners several
times (Table 2). (The individual increase of the GLDH activity
could not be correlated to the running time at the day of sampl-
ing or the days before). The increase in GLDH activity could
be the result of a reduced oxygen saturation of hepatic venous
blood during the race in some runners, causing liver cell dam-
age and subsequent release of GLDH into the blood stream.
Because the GLDH is unequally distributed within the liver
lobule with a nearly twofold higher concentration in the cen-
trolobular region as compared to the peripheral part (16), the
greater sensitivity of the central area of the lobules to changes
in oxygen supply (6) could even more contribute to the in-
creased GLDH activity found in some runners (up to fifteen-
fold of the upper reference limit of 4 U/L). The relative hy-
poxia in liver is also consistent with measurements of Foigt Ct
al. of a decrease in hepatic venous oxygen saturation during
exercise (13).
Kindermann et al. (19) did not find any liver
disturbance in their study of 91 trained athletes. Similar results
were obtained by Berg and Keul (3, 4). Although Wuschech et
al. (35) found an increase in the size of the liver in a group of
endurance athletes (long-distance runners, skiers, and cy-
clists), they found no increase in activities of the enzymes ALT
and SDH after these athletes had had an exhaustive exercise
on a bicycle ergometer. It seems that only strenuous exercise
leading to liver hypoxia can cause liver cell injury with subse-
quent increase of GLDH. If GLDH is released from damaged
liver cells into the blood stream, the same should apply to other
enzymes such as AST and ALT. Because AST is also located in
skeletal muscle cells in high concentration, it was not possible
to differentiate between these two origins. Instead, ALT is in a
much higher concentration in the liver than in skeletal muscle
(approximately sevenfold, (22)) and therefore we compared
the 3 enzymes ALT, CK, and GLDH in individuals with
pathological GLDH values (>4 U/L). A good to excellent
correlation was found when ALT was correlated with CK and
GLDHondays 3,6,8, 11, and 19. BycomparingALTwith CK
D. IVageJ, D. Seller, H. Franz, K. Jung
CHE Fig. 2 Changes of serum albumin concen-
(kU-L1) tration and of the catalytic activities of CHE.
(Mean±S. D.) •—• albumin; O---O
CHE
1 -5,5
- 5,0
-4,5
-4,0
19
only, we found a poorer correlation indicating that the en-
hancement of ALT activity is due to the release of ALT from
damaged muscle and liver cells in these runners.
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Another sensitive but unspecific indicator for
hepatobiliary disease is the enzyme GGT (9, 21, 31). GGT ac-
tivities showed no significant change during the race, but again
strong significant changes from day to day were found in in-
dividual runners (Table 3), indicating liver disturbance in
these participants.
A very important function of the liver is the syn-
thesis of proteins. It is known that hepatocellular damage may
result in decreased plasma levels of some proteins (34). Two
proteins often used to assay liver synthetic capacity are the
enzymes cholinesterase and serum albumin. Fig. 2 shows the
change of CHE activity and serum albumin concentration
during the run. After an initial increase, possibly due to hemo-
concentration, both analytes decreased significantly until the
end of the race. Very good correlation was found for CHE ac-
tivity and serum albumin concentration during the run. The re-
duction of serum albumin concentration could be the result of
increased interleukin-l concentration (7) caused by physical
exercise (5, 28). Elevated interleukin-1 is known to reduce the
biosynthesis of albumin and also probably of CHE, whose
biosynthesis is closely associated with that of albumin (same
operon? (18)) thus leading to a reduction of CHE and serum
albumin.
In our study we could demonstrate that various
factors can cause liver disturbance during an ultra-long-dis-
tance race leading to an elevation of liver-specific enzymes or
to a decrease of synthetic liver capacity. To our knowledge, it is
the first extensive study on endurance runners, where liver cell
injury was found, probably because liver-disturbance might
only be caused by strenuous physical exercise. Furthermore,
changes in enzyme activities often occur only 1 to 2 days after a
run, a period usually not followed up in most of the cited
studies.
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