Philippe Ichai1, Astrid Laurent-Bellue2, Christophe Camus3, David Moreau4, Mathieu Boutonnet5, Faouzi Saliba6, Jean Marie Peron7, Carole Ichai8, Emilie Gregoire9, Luc Aigle10, Julien Cousty11, Alice Quinart12, Bertrand Pons13, Marc Boudon6, Stephane André14, Audrey Coilly6, Teresa Antonini6, Catherine Guettier15, Didier Samuel6. 1. AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, Liver Intensive Care Unit, Villejuif F-94800, France; INSERM, Unité 1193, Université Paris-Saclay, Villejuif F-94800, France; DHU Hepatinov, Villejuif F-94800, France. Electronic address: philippe.ichai@aphp.fr. 2. APHP Hôpital Bicêtre, Department of Pathology, Le Kremlin-Bicêtre, France. 3. CHU de Rennes, Department of Infectious Disease and Intensive Care Unit, Hôpital Pontchaillou, Rennes, France. 4. Epidemiological Statistician, Barcelona, Spain. 5. Percy Military Teaching Hospital, French Ministry of Defence, Intensive Care Unit, Clamart 92000, France. 6. AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, Liver Intensive Care Unit, Villejuif F-94800, France; INSERM, Unité 1193, Université Paris-Saclay, Villejuif F-94800, France; DHU Hepatinov, Villejuif F-94800, France. 7. Hôpital Purpan, Department of Hepato-Gastro-Enterology, Université Paul Sabatier III, Toulouse 31059, France. 8. Hôpital Saint Roch, Liver Intensive Care Unit, Nice 06006, France. 9. AP-HM Hôpital La Timone, Département de chirurgie digestive, Marseille 13005, France. 10. 154(e) Antenne Médicale du 10(e) Centre Médical des Armées, France. 11. CHU de La Réunion, Intensive Care Unit, La Réunion, France. 12. CHU de Bordeaux, Hôpital Pellegrin, Bordeaux 33 076, France. 13. CHU Pointe à Pitre, Intensive Care Unit, 97159 Pointe à Pitre, France. 14. AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, Liver Intensive Care Unit, Villejuif F-94800, France. 15. INSERM, Unité 1193, Université Paris-Saclay, Villejuif F-94800, France; DHU Hepatinov, Villejuif F-94800, France; APHP Hôpital Bicêtre, Department of Pathology, Le Kremlin-Bicêtre, France.
Abstract
BACKGROUND & AIMS: Severe acute liver injury is a grave complication of exertional heatstroke. Liver transplantation (LT) may be a therapeutic option, but the criteria for LT and the optimal timing of LT have not been clearly established. The aim of this study was to define the profile of patients who require transplantation in this context. METHODS: This was a multicentre, retrospective study of patients admitted with a diagnosis of exertional heatstroke-related severe acute liver injury with a prothrombin time (PT) of less than 50%. A total of 24 male patients were studied. RESULTS: Fifteen of the 24 patients (median nadir PT: 35% [29.5-40.5]) improved under medical therapy alone and survived. Nine of the 24 were listed for emergency LT. At the time of registration, the median PT was 10% (5-12) and all had numerous dysfunctional organs. Five patients (nadir PT: 12% [9-12]) were withdrawn from the list because of an elevation of PT values that mainly occurred between day 2 and day 3. Ultimately, 4 patients underwent transplantation as their PT persisted at <10%, 3 days (2.75-3.25) after the onset of exertional heatstroke, and they had more than 3 organ dysfunctions. Of these 4 patients, 3 were still alive 1 year later. Histological analysis of the 4 explanted livers demonstrated massive or sub-massive necrosis, and little potential for effective mitoses, characterised by a "mitonecrotic" appearance. CONCLUSION: The first-line treatment for exertional heatstroke-related severe acute liver injury is medical therapy. LT is only a rare alternative and such a decision should not be taken too hastily. A persistence of PT <10%, without any signs of elevation after a median period of 3 days following the onset of heatstroke, was the trigger that prompted LT, was the trigger adopted in order to decide upon LT. LAY SUMMARY: Acute liver injury due to heatstroke can progress to acute liver failure with organ dysfunction despite medical treatment; in such situations, liver transplantation (LT) may offer a therapeutic option. The classic criteria for LT appear to be poorly adapted to heatstroke-related acute liver failure. We confirmed thatmedication is the first-line therapy acute liver injury caused by heatstroke, with LT only rarely necessary. A decision to perform LT should not be made hastily. Fluctuations in prothrombin time and the patient's clinical status should be considered even in the event of severe liver failure.
BACKGROUND & AIMS: Severe acute liver injury is a grave complication of exertional heatstroke. Liver transplantation (LT) may be a therapeutic option, but the criteria for LT and the optimal timing of LT have not been clearly established. The aim of this study was to define the profile of patients who require transplantation in this context. METHODS: This was a multicentre, retrospective study of patients admitted with a diagnosis of exertional heatstroke-related severe acute liver injury with a prothrombin time (PT) of less than 50%. A total of 24 male patients were studied. RESULTS: Fifteen of the 24 patients (median nadir PT: 35% [29.5-40.5]) improved under medical therapy alone and survived. Nine of the 24 were listed for emergency LT. At the time of registration, the median PT was 10% (5-12) and all had numerous dysfunctional organs. Five patients (nadir PT: 12% [9-12]) were withdrawn from the list because of an elevation of PT values that mainly occurred between day 2 and day 3. Ultimately, 4 patients underwent transplantation as their PT persisted at <10%, 3 days (2.75-3.25) after the onset of exertional heatstroke, and they had more than 3 organ dysfunctions. Of these 4 patients, 3 were still alive 1 year later. Histological analysis of the 4 explanted livers demonstrated massive or sub-massive necrosis, and little potential for effective mitoses, characterised by a "mitonecrotic" appearance. CONCLUSION: The first-line treatment for exertional heatstroke-related severe acute liver injury is medical therapy. LT is only a rare alternative and such a decision should not be taken too hastily. A persistence of PT <10%, without any signs of elevation after a median period of 3 days following the onset of heatstroke, was the trigger that prompted LT, was the trigger adopted in order to decide upon LT. LAY SUMMARY:Acute liver injury due to heatstroke can progress to acute liver failure with organ dysfunction despite medical treatment; in such situations, liver transplantation (LT) may offer a therapeutic option. The classic criteria for LT appear to be poorly adapted to heatstroke-related acute liver failure. We confirmed thatmedication is the first-line therapy acute liver injury caused by heatstroke, with LT only rarely necessary. A decision to perform LT should not be made hastily. Fluctuations in prothrombin time and the patient's clinical status should be considered even in the event of severe liver failure.
Authors: Jessica S Lin; Duha Zaffar; Haris Muhammad; Peng-Sheng Ting; Tinsay Woreta; Amy Kim; Ruhail Kohli; Kiyoko Oshima; Andrew Cameron; Benjamin Philosophe; Shane Ottmann; Russell Wesson; Ahmet Gurakar Journal: ACG Case Rep J Date: 2022-07-12