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Effects of Bodybuilding Supplements on the Kidney

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Effects of Bodybuilding Supplements on the Kidney Ali et al. BMC Nephrology (2020) 21:164 https://doi.org/10.1186/s12882-020-01834-5 RESEARCH ARTICLE Open Access Effects of bodybuilding supplements on the kidney: A population-based incidence study of biopsy pathology and clinical characteristics among middle eastern men Alaa Abbas Ali1, Safaa E. Almukhtar2†, Dana A. Sharif3†, Zana Sidiq M. Saleem4†, Dana N. Muhealdeen1 and Michael D. Hughson1* Abstract Background: The incidence of kidney diseases among bodybuilders is unknown. Methods: Between January 2011 and December 2019, the Iraqi Kurdistan 15 to 39 year old male population averaged 1,100,000 with approximately 56,000 total participants and 25,000 regular participants (those training more than 1 year). Annual age specific incidence rates (ASIR) with (95% confidence intervals) per 100,000 bodybuilders were compared with the general age-matched male population. Results: Fifteen male participants had kidney biopsies. Among regular participants, diagnoses were: focal segmental glomerulosclerosis (FSGS), 2; membranous glomerulonephritis (MGN), 2; post-infectious glomeruonephritis (PIGN), 1; tubulointerstitial nephritis (TIN), 1; and nephrocalcinosis, 2. Acute tubular necrosis (ATN) was diagnosed in 5 regular participants and 2 participants training less than 1 year. Among regular participants, anabolic steroid use was self- reported in 26% and veterinary grade vitamin D injections in 2.6%. ASIR for FSGS, MGN, PIGN, and TIN among regular participants was not statistically different than the general population. ASIR of FSGS adjusted for anabolic steroid use was 3.4 (− 1.3 to 8.1), a rate overlapping with FSGS in the general population at 2.0 (1.2 to 2.8). ATN presented as exertional muscle injury with myoglobinuria among new participants. Nevertheless, ASIR for ATN among total participants at 1.4 (0.4 to 2.4) was not significantly different than for the general population at 0.3 (0.1 to 0.5). Nephrocalcinosis was only diagnosed among bodybuilders at a 9-year cumulative rate of one per 314 vitamin D injectors. Conclusions: Kidney disease rates among bodybuilders were not significantly different than for the general population, except for nephrocalcinosis that was caused by injections of veterinary grade vitamin D compounds. Keywords: Acute kidney injury, Bodybuilding, Nephrocalcinosis, Anabolic steroids, Supplements, Focal segmental glomerulosclerosis * Correspondence: [email protected] †Safaa E. Almukhtar, Dana A. Sharif and Zana Sidiq M. Saleem contributed equally to this work. 1Department of Pathology, University of Sulaimani College of Medicine and Shoresh Teaching Hospital, Quirga Road, Sulaimani, Iraq Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Ali et al. BMC Nephrology (2020) 21:164 Page 2 of 10 Background biopsied because of an elevated serum creatinine and/or Weight training has become popular throughout much proteinuria. All patients completed a supplement use of the world, and it is estimated that 15–20% of United questionaire and gave written permission for use of their States (US) and European populations are members of information and biopsy results. All biopsies were studied gymnasiums [1]. Most gymnasiums sell supplements that by light microscopy in 18 serial sections using typically consists of protein powders, creatine, and oral hematoxylin and eosin, periodic acid-Shiff, Masson tri- vitamins and minerals. Credible gymnasiums will not chrome, and Jones methenamine silver stains, and by market anabolic steroids, but they are readily available in immunofluorescence microscopy with fluorescein conju- the outside community. The injection of subcutaneous gated anti-human IgG, IgM, IgA, C3, C1q, and albumin. and intramuscular high dose veterinary vitamin D and K Electron microscopy was not performed on any of the compounds is practiced in South America and the Mid- bodybuilding cases. dle East with an apparently high frequency of end-stage renal disease (ESRD) [2–4]. Estimates of the bodybuilding population and the A majority of competitive bodybuilders and weight frequency of supplement use athletes are likely to use anabolic steroids even though The number of regional bodybuilders was tabulated they are banned from most organized sports [5]. In from 2019 client registration lists by managers of gym- 2013, the current superheavyweight Worlds Weight Lift- nasiums in Erbil, Sulaimania, and Dohuk and extrapo- ing Champion and more than 100 other weight lifters lated to the number of gymnasiums registered in 2015 from virtually every region of the world served bans after by the Kurdistan Regional Government Licensing Com- being tested positive for anabolic steroids [6]. Focal seg- mittee. A bodybuilder was defined as any persons par- mental glomerulosclerosis (FSGS) is frequently attrib- ticipating in weight training at regional gymnasiums. uted to both anaboloic steroids and excess protein The gymnasium registrations were divided into two cat- intake [7–9]. Nevertheless, the scale of the risk of FSGS, egories. Category A: all registrants. Category B: regular or any kidney disease, with bodybuilding supplements registrants who participated in weight training for more compared to the general population is currently than 1 year. The average annual retention rate for new- undetermined. comers at major gymnasiums was 44%. For the year The Kudistan region in Northern Iraq has established 2015, all registrants were estimated at 56,000 and regular nephrology practices and a centralized renal biopsy ser- registrants at 25,000. The ages of 94% of the registrants vice [10]. We have developed a particular interest in were between 18 and 39 years old. Gymnasium use is supplement induced kidney injury, because several gender restricted and offers machine weights, free otherwise healthy young men have been identified with weights, cycling machines, and treadmills. acute and chronic renal disease whose common back- To determine the frequency of training and rate of ground was a participation in gymnasium affiliated supplement use among gymnasium participants, ques- bodybuilding and the use of supplements [11]. This tionnaires developed by DAS and DNM were filed out current population-based renal biopsy study estimates by 150 gymnasium users at three major gymnasiums in the incidence of specific diagnoses of renal disease Sulaimania in the presence of investigator DNM and among bodybuilders and compares the incidence to age gymnasium supervisors. Informed consent to participate matched, biopsy-defined kidney disease in the general was indicated in writing by a coded initial on the ques- population. tionaire form. Completion of the questionnaire was followed by an exit interview, and the compiled data was Methods reviewed by the gymnasium supervisors. Participants at The study was observational for two defined periods of all level of training took part in the questionnaire and time. One for bodybuilders and one for the general interview process, i.e. the process was not directed to- population. The inclusion criteria were a renal biopsy ward more or less experienced trainees. for both groups, and there were no exclusion criteria. While this was a review of existing data and not a true ASIR estimates in the general population cross-sectional study, the STROBE reporting checklist The annual ASIR of kidney biopsy diagnoses per 100, for cross-sectional studies was followed for items that 000 males among the general Kurdistan population was seemed appropriate. This included the methods of esti- calculated for the 2 year period 2012–2013 as previously mating population sizes and precision estimates of the reported [10]. An estimate of the Kurdistan population quantitative variable of age specific incidence rate at 4,900,000 persons was derived from 2011 to 2012 (ASIR). United Nations Iraq population data and the 2012 Iraqi Bodybuilders and patients from the general population Cancer Registry [12]. The estimated number of males were residents of Sulaimania, Erbil, or Dohuk and were between 15 to 39 years of age was 1,100,000. Ali et al. BMC Nephrology (2020) 21:164 Page 3 of 10 ASIR estimates of kidney disease among bodybuilders Results Kidney biopsies were obtained on 15 bodybuilders over Bodybuilding patients: clinical findings and renal biopsy a 9.0 year period from January 1, 2011 to December 31, results 2019. The annual ASIR of kidney biopsy disease diagno- The clinical characteristics, selected laboratory data, bi- ses per 100,000 bodybuilders
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