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Objective: Determine prevalence, incidence, and risk factors of acute kidney injury (AKI) during multistage ultramarathons.

Design: Prospective observational cohort study.

Setting: Jordanian Desert 2012; Atacama Desert, Chile 2012 and 2013; and Gobi Desert 2013 RacingThePlanet 250 km, 6-stage, ultramarathons.

Participants: One hundred twenty-eight participants (384 measurements) from the Jordan (25, 19.5%), Gobi (35, 27.3%), 2012 Atacama (24, 18.8%), and 2013 Atacama (44, 34.4%) races.

Interventions: Blood samples and weights were gathered and analyzed immediately after stage 1 (40 km), 3 (120 km), and 5 (225 km).

Main Outcome Measures: Changes in serum creatinine (Cr), cumulative incidence, and prevalence of AKI were calculated for each stage with "risk of injury" defined as 1.5 x baseline Cr and "injury" defined as 2 x Cr.

Results: Cumulative incidence of AKI was 41.4%. Stage 1 had 56 (43.8%) with risk of AKI and 24 (18.8%) with injury; in stage 3, 61 (47.7%) were at risk, 41 (32%) had injury; in stage 5, 62 (48.4%) runners were at risk and 36 (28.1%) had injury. Acute kidney injury was significantly associated with females [odds ratio (OR), 4.64; 95% confidence interval (CI), 2.07-10.37; P < 0.001], lower pack weight (OR, 0.71; 95% CI, 0.56-0.91; P < 0.007), and percentage weight loss (OR, 0.87; 95% CI, 0.78-0.97; P < 0.015). Lowest quintile of finishers was less likely to develop AKI (OR, 0.18; 95% CI, 0.04-0.78; P < 0.022).

Conclusions: Prevalence of AKI was 63%-78% during multistage ultramarathons. Female sex, lower pack weight, and greater weight loss were associated with renal impairment.