Heat stroke leading to acute liver injury & failure: A case series from the Acute Liver Failure Study Group

Abstract

Background & Aims In the United States, nearly 1000 annual cases of heat stroke are reported but the frequency and outcome of severe liver injury in such patients is not well described. The aim of this study was to describe cases of acute liver injury (ALI) or failure (ALF) caused by heat stroke in a large ALF registry. Methods Amongst 2675 consecutive subjects enrolled in a prospective observational cohort of patients with ALI or ALF between January 1998 and April 2015, there were eight subjects with heat stroke. Results Five patients had ALF and three had ALI. Seven patients developed acute kidney injury, all eight had lactic acidosis and rhabdomyolysis. Six patients underwent cooling treatments, three received N-acetyl cysteine (NAC), three required mechanical ventilation, three required renal replacement therapy, two received vasopressors, one underwent liver transplantation, and two patients died—both within 48 hours of presentation. All cases occurred between May and August, mainly in healthy young men because of excessive exertion. Conclusions Management of ALI and ALF secondary to heat stroke should focus on cooling protocols and supportive care, with consideration of liver transplantation in refractory patients.

Review article: Environmental heatstroke and long‐term clinical neurological outcomes: A literature review of case reports and case series 2000–2016

“…The high rate of exertion as a contributing factor highlights the importance of behaviour modification on hot days for all people, including healthy individuals. Better awareness of the potentially devastating long‐term effects of heatstroke will enable promotion of appropriate and necessary behaviour modification on hot days in the future, including occupational adaptations . This is essential to achieve the Sustainable Development Goals 2015–2030, of strengthening resilience and adaptive capacity to climate related hazards …”

A Case of Exertional Heat Stroke Complicated by Hypoxic Hepatitis

“…Successful treatments with emergency liver transplantation [6][7][8][9][10][11][12][13][14][15], MARS [16], plasma exchange alone [17,18], and hemofiltration [19] as well as cold dialysis and hemofiltration [20] have been published. ere is growing evidence that conservative management seems to be sufficient for the management of most cases, and a delayed transplant strategy is reasonable [8,12,[21][22][23][24][25][26][27][28][29][30][31], with cases reporting successful transplant after delaying transplantation in favour of spontaneous recovery [8,12]. Most reported cases survived, but fatalities have been reported due to liver failure [8,[32][33][34] or transplant complications [35][36][37].…”

“…ere is growing evidence that conservative management seems to be sufficient for the management of most cases, and a delayed transplant strategy is reasonable [8,12,[21][22][23][24][25][26][27][28][29][30][31], with cases reporting successful transplant after delaying transplantation in favour of spontaneous recovery [8,12]. Most reported cases survived, but fatalities have been reported due to liver failure [8,[32][33][34] or transplant complications [35][36][37]. Nevertheless, early induction of cooling treatment, ideally reaching <38.9°C within 30 minutes, seems to be paramount [20,38,39].…”

“…Nevertheless, early induction of cooling treatment, ideally reaching <38.9°C within 30 minutes, seems to be paramount [20,38,39]. Also, the administration of N-acetyl-cysteine was shown to improve transplant-free survival [40,41] and has been reported in acute liver failure secondary to heat stroke [8,21,22]. It could also be shown that hypophosphatemia <0.5 mmol/l at admission, as was present in our patient, could predict the occurrence of acute liver failure [42], although it is unclear whether there is a causative connection.…”

“…It could also be shown that hypophosphatemia <0.5 mmol/l at admission, as was present in our patient, could predict the occurrence of acute liver failure [42], although it is unclear whether there is a causative connection. Predictors of an unfavorable outcome are core temperature >42°C, rapid multiorgan failure requiring artificial organ support and need of vasopressors [8].…”