Molecular Adsorbent Recirculating System Support Followed by Liver Transplantation for Multiorgan Failure from Exertional Heatstroke

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IntroductionExertional heatstroke is an extremely rare cause of fulminant hepatic failure, and when complicated by multiorgan failure, is fatal without liver transplantation. The ability to support patients with heat stroke complicated by massive hepatic necrosis with mechanical replacement therapies while awaiting recovery or transplantation has not been reported. We utilized a multidisciplinary approach of critical care and liver transplant specialists to rapidly identify and treat cases of heat stroke-induced liver failure.MethodsA retrospective review of three consecutive cases of male patients with fulminant hepaticfailure from exertional heatstroke was performed after IRB approval.ResultsAll patients developed multiorgan failure, and required intubation, renal replacement therapy, and vasopressor support. All patients were listed urgently for liver transplantation, and were supported with the Molecular Adsorbent Recirculating System while awaiting transplantation. All patients underwent liver transplantation alone, and the liver explant showed massive hepatic necrosis in all cases. All patients required multiple operations including fasciotomy, serial washout, and wound closure. Renal replacement therapy was weaned within 30 days.All patients remain alive and well, with normal renal function, normal liver allograft function,and no long term sequelae of their multiorgan failure at 1, 2, and 4 years post-transplant.ConclusionExtreme heatstroke leading to whole-body organ dysfunction and fulminantliver failure is a complex entity that can be successfully treated with liver transplantation as a component of a multidisciplinary, multiorgan system approach.

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