Heat-Stroke as a Cause of Liver Failure and Evaluation for Liver Transplant

Abstract

Background: Heat stroke is a multiple organ dysfunction syndrome of poorly understood pathogenesis. Potential complications related to severe heat stroke are liver failure, acute renal failure, disseminated intravascular coagulation, rhabdomyolysis, and acute respiratory distress syndrome. Acute hepatic failure is a rare complication of heat stroke with poor prognosis. Here we report two cases of acute liver failure induced by heat stroke. Goal: To report two cases of acute liver failure induced by heat stroke and review the literature. Results: The first patient is a 28-year-old man collapsed after running 15 Km. On his initial presentation he showed hyperthermia acute liver failure, kidney failure associated to rhabdomyolysis, DIC, and change of mental status. AST peaked 12,000 on day 2 and Tbili peaked 21.6 on day 4. The patient fulfilled Kings' college criteria for emergent liver transplantation. However, he was not transplanted because after few days his clinical condition improved. The second patient is a 27-year-old patient collapsed after running 2 Km. He presented with hyperthermia, acute liver failure (MELD 42), kidney failure, DIC, and change of mental status. AST peaked 26,610 on day 2. Creatinine was 7.5 on day 2, Tbili peaked 47.1. The patient fulfilled standard criteria for emergent liver transplantation, but we decided to wait for spontaneous clinical recovery. On day 20, a liver biopsy showed massive necrosis. After failing conservative management, on day 24 post admission, the patient finally underwent combined liver and kidney transplantation from a standard criteria donor (42years old). The post-op course was unremarkable. Discussion: There are less than 20 cases of acute liver failure associated with heat stroke. In 2/3 of cases there was spontaneously recovery and 1/3 died. There are only 4 previous cases of liver transplantation for heat stroke in the literature, and there are no guidelines available to guide transplantation. Out of 4 cases of liver transplant, three of the patients died shortly after transplant. Thus, conservative management appears to be justified in heat-stroke-associated liver failure even in the presence of accepted criteria for emergent liver transplantation. It is of crucial importance to rule-out irreversible brain damage before listing these patients. Long-term neurologic sequelae occur in approximately 20% of patients. Conclusions: Liver failure following heat-stroke is reversible in many cases and conservative management can be successful. If there is no clinical signs of recovery despite optimal conservative treatment, and the liver biopsy shows massive necrosis, liver transplant should be performed during the window of opportunity, before the patients develop complications.