1
|
Oki K, Henderson CG, Ward SM, Ward JA, Plamper ML, Mayer TA, Caldwell AR, Leon LR. Identification of therapeutic targets in a murine model of severe exertional heat stroke. Am J Physiol Regul Integr Comp Physiol 2022; 323:R935-R950. [PMID: 36283086 PMCID: PMC9722257 DOI: 10.1152/ajpregu.00150.2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 10/20/2022] [Accepted: 10/21/2022] [Indexed: 11/22/2022]
Abstract
Exertional heat stroke (EHS) is a potentially lethal condition resulting from high core body temperatures (TC) in combination with a systemic inflammatory response syndrome (SIRS) with varying degrees of severity across victims, and limited understanding of the underlying mechanism(s). We established a mouse model of severe EHS to identify mechanisms of hyperthermia/inflammation that may be responsible for organ damage. Mice were forced to run on a motorized wheel in a 37.5°C chamber until loss of consciousness and were either removed immediately (exertional heat injury or EHI; TCMax = 42.4 ± 0.2°C) or remained in the chamber an additional 20 min (EHS; TCMax = 42.5 ± 0.4°C). Exercise control mice (ExC) experienced identical procedures to EHS at 25°C. At 3 h post-EHS, there was evidence for an immune/inflammatory response as elevated blood chemokine [interferon γ-induced protein 10 (IP-10), keratinocytes-derived chemokine (KC), macrophage inflammatory proteins (MIP-1α), MIP-1β, MIP-2] and cytokine [granulocyte colony-stimulating factor (G-CSF), interleukins (IL-10), IL-6] levels peaked and were highest in EHS mice compared with EHI and ExC mice. Immunoblotting of organs susceptible to EHS damage indicated that several kinases were sensitive to stress associated with heat/inflammation and exercise; specifically, phosphorylation of liver c-Jun NH2-terminal kinase (JNK) at threonine 183/tyrosine 185 immediately (0 h) postheating related to heat illness severity. We have established a mouse EHS model, and JNK [or its downstream target(s)] could underlie EHS symptomatology, allowing the identification of molecular pathways or countermeasure targets to mitigate heat illness severity, enable complete recovery, and decrease overall EHS-related fatalities.
Collapse
Affiliation(s)
- Kentaro Oki
- Thermal and Mountain Medicine Division, United States Army Research Institute of Environmental Medicine, Natick, Massachusetts
| | - Chloe G Henderson
- Thermal and Mountain Medicine Division, United States Army Research Institute of Environmental Medicine, Natick, Massachusetts
- Oak Ridge Institute of Science and Education, Oak Ridge, Tennessee
| | - Shauna M Ward
- Thermal and Mountain Medicine Division, United States Army Research Institute of Environmental Medicine, Natick, Massachusetts
| | - Jermaine A Ward
- Thermal and Mountain Medicine Division, United States Army Research Institute of Environmental Medicine, Natick, Massachusetts
| | - Mark L Plamper
- Thermal and Mountain Medicine Division, United States Army Research Institute of Environmental Medicine, Natick, Massachusetts
| | - Thomas A Mayer
- Thermal and Mountain Medicine Division, United States Army Research Institute of Environmental Medicine, Natick, Massachusetts
| | - Aaron R Caldwell
- Thermal and Mountain Medicine Division, United States Army Research Institute of Environmental Medicine, Natick, Massachusetts
- Oak Ridge Institute of Science and Education, Oak Ridge, Tennessee
| | - Lisa R Leon
- Thermal and Mountain Medicine Division, United States Army Research Institute of Environmental Medicine, Natick, Massachusetts
| |
Collapse
|
2
|
Tang S, Li M, Sun Y, Liao Y, Wu X, Zhong R, Chen L, Zhang H. Effects of chronic heat stress on the immunophenotyping of lymphocytes in immune organs of growing pigs. J Anim Sci 2022; 100:skac317. [PMID: 36198005 PMCID: PMC9671119 DOI: 10.1093/jas/skac317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 10/04/2022] [Indexed: 11/13/2022] Open
Abstract
This study aimed to investigate the effects of chronic heat stress on the immunophenotyping of lymphocytes in immune organs of growing pigs. A single-factor randomized block design was used, and 15 healthy growing large white barrows (5 litters, 3 pigs/litter) with similar body weight (40.8 kg) were assigned into 3 groups (5 pigs in each group). Groups were: control group (Con, in 23 °C environmental control chamber, fed ad libitum), heat stress group (HS, in 33 °C environmental control chamber, fed ad libitum), and pair-fed group (PF, in 23 °C environmental control chamber, fed diets according to the feed intake of HS group). After a 7-d adaption, the experiment lasted for 21 d. The results showed as follows: (1) activated T cells in the thymus of HS pigs were higher than those in PF pigs (P < 0.05). Monocytes and dendritic cells in the thymus of HS pigs were significantly higher than that in Con and PF pigs (P < 0.05), while the proportions of these 2 lymphocytes in the thymus of Con pigs did not differ from PF pigs (P > 0.05). Compared with Con pigs, the proportion of CD4+ (P < 0.05) and CD8+ T cells (P < 0.10) in the thymus was increased in HS pigs, while the proportion of CD4+ and CD8+ T cells in PF pigs did not differ from Con pigs (P > 0.05). (2) Compared with Con pigs, significantly decreased T cells, increased B cells and monocytes were found in the spleen of pigs exposed to heat stress (P < 0.05); the proportions of these 3 types of lymphocytes were not significantly different between Con and PF pigs (P > 0.05). The proportions of CD4+ T cells and Treg cells in the spleen of pigs exposed to heat stress tended to be lower than those in the Con pigs (P < 0.10). (3) The proportion of lymphocytes in the tonsils of pigs exposed to heat stress did not differ from Con pigs (P > 0.05); compared with PF pigs, the proportion of Treg cells was significantly decreased in HS pigs (P < 0.05). In conclusion, chronic heat stress stimulates the development and maturation of T cells in the pig thymus toward CD4+ and CD8+ T cells and increases the proportion of monocytes and dendritic cells; under the condition of chronic heat stress, the immune response process in the spleen of pigs is enhanced, but chronic heat stress impairs the survival of CD4+ T cells in the spleen.
Collapse
Affiliation(s)
- Shanlong Tang
- State Key Laboratory of Animal Nutrition, Institute of Animal Science, Chinese Academy of Agricultural Sciences, Beijing 100093, PR China
| | - Meijing Li
- State Key Laboratory of Animal Nutrition, Institute of Animal Science, Chinese Academy of Agricultural Sciences, Beijing 100093, PR China
| | - Yue Sun
- Beijing Animal Husbandry Station, Beijing 100020, PR China
| | - Yuanyuan Liao
- Hubei Bangzhide Animal Husbandry Technology Co., Ltd, Wuhan 430061, PR China
| | - Xiaofeng Wu
- Hubei Bangzhide Animal Husbandry Technology Co., Ltd, Wuhan 430061, PR China
| | - Ruqing Zhong
- State Key Laboratory of Animal Nutrition, Institute of Animal Science, Chinese Academy of Agricultural Sciences, Beijing 100093, PR China
| | - Liang Chen
- State Key Laboratory of Animal Nutrition, Institute of Animal Science, Chinese Academy of Agricultural Sciences, Beijing 100093, PR China
| | - Hongfu Zhang
- State Key Laboratory of Animal Nutrition, Institute of Animal Science, Chinese Academy of Agricultural Sciences, Beijing 100093, PR China
| |
Collapse
|
3
|
Incidence, risk factors, characteristics and prognosis of exertional heat stroke and heat exhaustion in Reunion Island, 2014–2018: A retrospective multicentre study. Sci Sports 2022. [DOI: 10.1016/j.scispo.2021.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
4
|
Tang S, Xie J, Fang W, Wen X, Yin C, Meng Q, Zhong R, Chen L, Zhang H. Chronic heat stress induces the disorder of gut transport and immune function associated with endoplasmic reticulum stress in growing pigs. ANIMAL NUTRITION 2022; 11:228-241. [PMID: 36263409 PMCID: PMC9556788 DOI: 10.1016/j.aninu.2022.08.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 08/06/2022] [Accepted: 08/11/2022] [Indexed: 02/07/2023]
|
5
|
Rublee C, Dresser C, Giudice C, Lemery J, Sorensen C. Evidence-Based Heatstroke Management in the Emergency Department. West J Emerg Med 2021; 22:186-195. [PMID: 33856299 PMCID: PMC7972371 DOI: 10.5811/westjem.2020.11.49007] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 11/20/2020] [Indexed: 11/14/2022] Open
Abstract
Introduction Climate change is causing an increase in the frequency and intensity of extreme heat events, which disproportionately impact the health of vulnerable populations. Heatstroke, the most serious heat-related illness, is a medical emergency that causes multiorgan failure and death without intervention. Rapid recognition and aggressive early treatment are essential to reduce morbidity and mortality. The objective of this study was to evaluate current standards of care for the emergent management of heatstroke and propose an evidence-based algorithm to expedite care. Methods We systematically searched PubMed, Embase, and key journals, and reviewed bibliographies. Original research articles, including case studies, were selected if they specifically addressed the recognition and management of heatstroke in any prehospital, emergency department (ED), or intensive care unit population. Reviewers evaluated study quality and abstracted information regarding demographics, scenario, management, and outcome. Results In total, 63 articles met full inclusion criteria after full-text review and were included for analysis. Three key themes identified during the qualitative review process included recognition, rapid cooling, and supportive care. Rapid recognition and expedited external or internal cooling methods coupled with multidisciplinary management were associated with improved outcomes. Delays in care are associated with adverse outcomes. We found no current scalable ED alert process to expedite early goal-directed therapies. Conclusion Given the increased risk of exposure to heat waves and the time-sensitivity of the condition, EDs and healthcare systems should adopt processes for rapid recognition and management of heatstroke. This study proposes an evidence-based prehospital and ED heat alert pathway to improve early diagnosis and resource mobilization. We also provide an evidence-based treatment pathway to facilitate efficient patient cooling. It is hoped that this protocol will improve care and help healthcare systems adapt to changing environmental conditions.
Collapse
Affiliation(s)
- Caitlin Rublee
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado
| | - Caleb Dresser
- Harvard Medical School, Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Catharina Giudice
- Los Angeles County and University of Southern California, Department of Emergency Medicine, Los Angeles, California
| | - Jay Lemery
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado
| | - Cecilia Sorensen
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado
| |
Collapse
|
6
|
Leyk D, Hoitz J, Becker C, Glitz KJ, Nestler K, Piekarski C. Health Risks and Interventions in Exertional Heat Stress. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 116:537-544. [PMID: 31554541 DOI: 10.3238/arztebl.2019.0537] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 06/11/2019] [Accepted: 06/11/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND With climate change, heat waves are expected to become more frequent in the near future. Already, on average more than 25 000 "heat deaths" are estimated to occur in Europe every year. However, heat stress and heat illnesses arise not just when ambient temperatures are high. Physical exertion increases heat production within the organism many times over; if not enough heat is lost, there is a risk of exertional heat stress. This review article discusses contributing factors, at-risk groups, and the diagnosis and treatment of heat illnesses. METHODS A selective literature search was carried out on PubMed. Current guidelines and expert recommendations were also included. RESULTS Apart from muscular heat production (>70% of converted energy), there are other factors that singly or in combination can give rise to heat stress: clothing, climate/acclimatization, and individual factors. Through its insulating properties, clothing reduces the evaporation of sweat (the most effective physiological cooling mechanism). A sudden heat wave, or changing the climate zone (as with air travel), increases the risk of a heat-related health event. Overweight, low fitness level, acute infections, illness, dehydration, and other factors also reduce heat tolerance. In addition to children, older people are particularly at risk because of their reduced physiological adaptability, (multi-)morbidity, and intake of prescription drugs. A heat illness can progress suddenly to life-threatening heat stroke. Successful treatment depends on rapid diagnosis and cooling the body down as quickly as possible. The aim is to reduce core body temperature to <40 °C within 30 minutes. CONCLUSION Immediately effective cooling interventions are the only causal treatment for heat stroke. Time once lost cannot be made up. Prevention (acclimatization, reduced exposure, etc.) and terminating the heat stress in good time (e.g., stopping work) are better than any cure.
Collapse
Affiliation(s)
- Dieter Leyk
- Bundeswehr Institute for Preventive Medicine; German Sport University Cologne; Bundeswehr Hospital Hamburg; Department of Geriatrics and Geriatric Rehabilitation at the Robert-Bosch-Hospital Stuttgart; Bundeswehr Hospital Koblenz; Institute and Policlinic for Occupational Medicine, Environmental Medicine and Prevention Research, University of Cologne
| | | | | | | | | | | |
Collapse
|
7
|
Beyond Heat Stress: Intestinal Integrity Disruption and Mechanism-Based Intervention Strategies. Nutrients 2020; 12:nu12030734. [PMID: 32168808 PMCID: PMC7146479 DOI: 10.3390/nu12030734] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 03/05/2020] [Accepted: 03/06/2020] [Indexed: 12/11/2022] Open
Abstract
The current climate changes have increased the prevalence and intensity of heat stress (HS) conditions. One of the initial consequences of HS is the impairment of the intestinal epithelial barrier integrity due to hyperthermia and hypoxia following blood repartition, which often results in a leaky gut followed by penetration and transfer of luminal antigens, endotoxins, and pathogenic bacteria. Under extreme conditions, HS may culminate in the onset of “heat stroke”, a potential lethal condition if remaining untreated. HS-induced alterations of the gastrointestinal epithelium, which is associated with a leaky gut, are due to cellular oxidative stress, disruption of intestinal integrity, and increased production of pro-inflammatory cytokines. This review summarizes the possible resilience mechanisms based on in vitro and in vivo data and the potential interventions with a group of nutritional supplements, which may increase the resilience to HS-induced intestinal integrity disruption and maintain intestinal homeostasis.
Collapse
|
8
|
The Fire from Within: Multiorgan Failure with Bimodal Rhabdomyolysis from Exertional Heat Stroke. Case Reports Hepatol 2020; 2020:1305730. [PMID: 32089909 PMCID: PMC7029301 DOI: 10.1155/2020/1305730] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 01/14/2020] [Indexed: 12/11/2022] Open
Abstract
Heat stroke (HS) is a condition characterized by a rise in core body temperature and central nervous system dysfunction. It is divided into two types: classical and exertional. Exertional heat stroke (EHS) is accompanied by organ failure. Liver injury, presenting only with a rise in liver enzymes, is common but in rare conditions, acute liver failure (ALF) may ensue, leading to a potentially lethal condition. Most cases of EHS-induced ALF are managed conservatively. However, liver transplantation is considered for cases refractory to supportive treatment. Identifying patients eligible for liver transplantation in the context of an EHS-induced ALF becomes a medical dilemma since the conventional prognostic criterion may be difficult to apply, and there is paucity of literature about these specific sets of individuals. Recently, extracorporeal liver support has been gaining popularity for patients with liver failure as a bridge to liver transplant. In this case report, we present a young Filipino athlete with symptoms and clinical course consistent with EHS that developed multiorgan failure, initially considered a candidate for liver transplant and total plasma exchange, but clinically improved with supportive management alone. This patient was also found to have bimodal rhabdomyolysis during the course of his hospital stay as manifested by the bimodal rise in his creatine kinase enzymes.
Collapse
|
9
|
Monzon B, Hegarty K, Rech MA. A knack for "NAC": Treatment for heat stroke induced acute liver injury. Am J Emerg Med 2019; 38:853.e1-853.e3. [PMID: 31831341 DOI: 10.1016/j.ajem.2019.11.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 11/14/2019] [Indexed: 10/25/2022] Open
Abstract
INTRODUCTION Heat stroke occurs when the body's core temperature becomes elevated above 40 °C, which may impact multiple organ systems. We present a case of heat stroke resulting in acute liver injury (ALI) successfully treated with intravenous N-acetylcysteine (NAC). CASE PRESENTATION A 24-year-old unresponsive male without significant past medical history presented to the emergency department with heat stroke; his initial temperature was 107.4 °F. During his hospital course, he developed ALI with significant elevation in aspartate aminotransferase, alanine aminotransferase, and total bilirubin. These laboratory findings peaked by hospital day two, but improved prior to discharge on hospital day five and throughout his follow up clinic visits. His treatment course included cooling measures, supportive care, supplemental oxygen and airway management, seizure control, and intravenous NAC therapy. CONCLUSION Hepatocellular injury is one of the most serious complications of heat stroke. We discuss the incidence and outcomes for patients who develop acute liver injury secondary to heat stroke and the use of NAC as an early potential therapeutic option.
Collapse
Affiliation(s)
- Brian Monzon
- Department of Pharmacy, Loyola University Medical Center, 2160 S 1st Ave, Maywood, IL 60153, United States.
| | - Kathleen Hegarty
- Department of Emergency Medicine, Loyola University Medical Center, 2160 S 1st Ave, Maywood, IL 60153, United States.
| | - Megan A Rech
- Department of Pharmacy, Loyola University Medical Center, 2160 S 1st Ave, Maywood, IL 60153, United States; Department of Emergency Medicine, Loyola University Medical Center, 2160 S 1st Ave, Maywood, IL 60153, United States.
| |
Collapse
|
10
|
AVE 0991 Attenuates Pyroptosis and Liver Damage after Heatstroke by Inhibiting the ROS-NLRP3 Inflammatory Signalling Pathway. BIOMED RESEARCH INTERNATIONAL 2019; 2019:1806234. [PMID: 31531346 PMCID: PMC6720052 DOI: 10.1155/2019/1806234] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 07/09/2019] [Accepted: 07/21/2019] [Indexed: 12/18/2022]
Abstract
We previously demonstrated that angiotensin-(1-7) (Ang-(1-7)), an essential endocrine factor, inhibits the NLRP3 inflammasome by regulating reactive oxygen species (ROS) in fibrotic livers. We also demonstrated that the NLRP3 inflammasome contributes to the liver damage induced by pyroptosis after heatstroke. However, the role of Ang-(1-7) in the hepatocytes under heat stress remains uncertain. We aimed to examine the change in angiotensin peptides in the livers affected by heatstroke and the effect on the ROS-NLRP3 inflammatory signalling pathway. In vivo, increased angiotensin II (Ang II) and decreased Ang-(1-7) in the serum of heatstroke patients suffering from hepatic dysfunction were observed. The change in angiotensin peptides was considered a potential biomarker that could be used to predict hepatic dysfunction. Enhanced Ang II and attenuated Ang-(1-7) levels were also observed in the liver tissue of heatstroke rats, which were consistent with their receptors and converting enzymes. Hepatic damage associated with increased ROS and protein expression levels of NOX4, NLRP3, caspase-1, and IL-1β was attenuated by AVE 0991, an analogue of Ang-(1-7). In vitro, pyroptosis, characterized by activated caspase-1 and IL-1β, was observed in hepatocytes under heat stress, which was enhanced by Ang II and attenuated by antioxidants, NOX4 siRNA, and AVE 0991. In summary, AVE 0991 attenuates pyroptosis and liver damage induced by heat stress by inhibiting the ROS-NLRP3 inflammatory signalling pathway.
Collapse
|
11
|
Figiel W, Morawski M, Grąt M, Kornasiewicz O, Niewiński G, Raszeja-Wyszomirska J, Krasnodębski M, Kowalczyk A, Hołówko W, Patkowski W, Zieniewicz K. Fulminant liver failure following a marathon: Five case reports and review of literature. World J Clin Cases 2019; 7:1467-1474. [PMID: 31363475 PMCID: PMC6656669 DOI: 10.12998/wjcc.v7.i12.1467] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 04/29/2019] [Accepted: 05/01/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The growing popularity of marathon and half-marathon runs has led to an increased number of patients presenting with exertion-induced heat stroke. Mild hepatic involvement is often observed in these patients; however, fulminant liver failure may occur in approximately 5% of all cases. Liver transplantation is a potentially curative approach for exertion-induced liver failure, although there is a lack of consensus regarding the criteria and optimal timing of this intervention.
CASE SUMMARY This paper describes 5 patients (4 men and 1 woman) who were referred to the department where this study was performed with the diagnosis of exertion-induced acute liver failure. Three patients underwent liver transplantation, 1 recovered spontaneously, and 1 patient died on day 11 following the exertion.
CONCLUSION Exertion-induced heat stroke may present as fulminant liver failure. These patients may recover with conservative treatment, may require liver transplantation, or may die. No definitive criteria are available to determine patient suitability for a conservative vs surgical approach.
Collapse
Affiliation(s)
- Wojciech Figiel
- Department of General, Transplant, and Liver Surgery, Medical University of Warsaw, Warsaw 02097, Poland
| | - Marcin Morawski
- Department of General, Transplant, and Liver Surgery, Medical University of Warsaw, Warsaw 02097, Poland
| | - Michał Grąt
- Department of General, Transplant, and Liver Surgery, Medical University of Warsaw, Warsaw 02097, Poland
| | - Oskar Kornasiewicz
- Department of General, Transplant, and Liver Surgery, Medical University of Warsaw, Warsaw 02097, Poland
| | - Grzegorz Niewiński
- Department of Anaesthesiology and Intensive Care, Medical University of Warsaw, Warsaw 02097, Poland
| | - Joanna Raszeja-Wyszomirska
- Liver and Internal Medicine Unit, Department of General, Transplant, and Liver Surgery, Medical University of Warsaw, Warsaw 02097, Poland
| | - Maciej Krasnodębski
- Department of General, Transplant, and Liver Surgery, Medical University of Warsaw, Warsaw 02097, Poland
| | - Arkadiusz Kowalczyk
- Department of General, Transplant, and Liver Surgery, Medical University of Warsaw, Warsaw 02097, Poland
| | - Wacław Hołówko
- Department of General, Transplant, and Liver Surgery, Medical University of Warsaw, Warsaw 02097, Poland
| | - Waldemar Patkowski
- Department of General, Transplant, and Liver Surgery, Medical University of Warsaw, Warsaw 02097, Poland
| | - Krzysztof Zieniewicz
- Department of General, Transplant, and Liver Surgery, Medical University of Warsaw, Warsaw 02097, Poland
| |
Collapse
|
12
|
Ichai P, Laurent-Bellue A, Camus C, Moreau D, Boutonnet M, Saliba F, Peron JM, Ichai C, Gregoire E, Aigle L, Cousty J, Quinart A, Pons B, Boudon M, André S, Coilly A, Antonini T, Guettier C, Samuel D. Liver transplantation in patients with liver failure related to exertional heatstroke. J Hepatol 2019; 70:431-439. [PMID: 30521841 DOI: 10.1016/j.jhep.2018.11.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 11/07/2018] [Accepted: 11/19/2018] [Indexed: 01/16/2023]
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.
Collapse
Affiliation(s)
- Philippe Ichai
- 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.
| | | | - Christophe Camus
- CHU de Rennes, Department of Infectious Disease and Intensive Care Unit, Hôpital Pontchaillou, Rennes, France
| | | | - Mathieu Boutonnet
- Percy Military Teaching Hospital, French Ministry of Defence, Intensive Care Unit, Clamart 92000, France
| | - Faouzi Saliba
- 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
| | - Jean Marie Peron
- Hôpital Purpan, Department of Hepato-Gastro-Enterology, Université Paul Sabatier III, Toulouse 31059, France
| | - Carole Ichai
- Hôpital Saint Roch, Liver Intensive Care Unit, Nice 06006, France
| | - Emilie Gregoire
- AP-HM Hôpital La Timone, Département de chirurgie digestive, Marseille 13005, France
| | - Luc Aigle
- 154(e) Antenne Médicale du 10(e) Centre Médical des Armées, France
| | - Julien Cousty
- CHU de La Réunion, Intensive Care Unit, La Réunion, France
| | - Alice Quinart
- CHU de Bordeaux, Hôpital Pellegrin, Bordeaux 33 076, France
| | - Bertrand Pons
- CHU Pointe à Pitre, Intensive Care Unit, 97159 Pointe à Pitre, France
| | - Marc Boudon
- 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
| | - Stephane André
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, Liver Intensive Care Unit, Villejuif F-94800, France
| | - Audrey Coilly
- 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
| | - Teresa Antonini
- 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
| | - Catherine Guettier
- 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
| | - Didier Samuel
- 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
| |
Collapse
|
13
|
Martínez-Insfran LA, Alconchel F, Ramírez P, Cascales-Campos PA, Carbonell G, Barona L, Pons JA, Sánchez-Bueno F, Robles-Campos R, Parrilla P. Liver Transplantation for Fulminant Hepatic Failure Due to Heat Stroke: A Case Report. Transplant Proc 2019; 51:87-89. [PMID: 30661899 DOI: 10.1016/j.transproceed.2018.03.137] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 03/15/2018] [Indexed: 11/16/2022]
Abstract
Heat stroke is a condition caused by an excessive increase in body temperature in a relatively short period of time, and is clinically characterized by central nervous system dysfunction, including delirium, seizures, coma, and severe hyperthermia. In this context, the resulting fulminant hepatic failure makes liver transplant the best choice when there are no guarantees of better results with conservative treatment. We present our experience in this case, possible alternative choices, and the current role of liver transplantation in the resolution of fulminant liver failure due to heat stroke. CASE REPORT: We report the case of a 32-year-old man with a history of malabsorption syndrome and unconfirmed celiac disease controlled with a gluten-free diet, who, while working on a typical summer midday in southern Spain (approximately 40°C), abruptly presented with loss of consciousness, coma, and a temperature of 42°C, as well as seizures at the initial medical assessment that subsided after the administration of diazepam. On the third day, the patient presented with multiple organ dysfunction syndrome, requiring mechanical ventilation, hemodialysis, and inotropic support. He did not improve with the support of conservative treatment, therefore it was decided to perform an urgent liver transplant, after which he recovered completely. CONCLUSIONS: Liver transplantation should be a main choice of treatment for cases in which, despite intensive medical treatment, there is still clinical and analytical evidence of massive and/or irreversible hepatocellular damage.
Collapse
Affiliation(s)
- L A Martínez-Insfran
- Liver Transplant Unit, Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca (Murcia)-IMIB-Arrixaca, Murcia, Spain
| | - F Alconchel
- Liver Transplant Unit, Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca (Murcia)-IMIB-Arrixaca, Murcia, Spain.
| | - P Ramírez
- Liver Transplant Unit, Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca (Murcia)-IMIB-Arrixaca, Murcia, Spain
| | - P A Cascales-Campos
- Liver Transplant Unit, Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca (Murcia)-IMIB-Arrixaca, Murcia, Spain
| | - G Carbonell
- Department of Radiology, Hospital Clínico Universitario Virgen de la Arrixaca (Murcia)-IMIB-Arrixaca, Murcia, Spain
| | - L Barona
- Department of Pathology, Hospital Clínico Universitario Virgen de la Arrixaca (Murcia)-IMIB-Arrixaca, Murcia, Spain
| | - J A Pons
- Department of Hepatology, Hospital Clínico Universitario Virgen de la Arrixaca (Murcia)-IMIB-Arrixaca, Murcia, Spain
| | - F Sánchez-Bueno
- Liver Transplant Unit, Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca (Murcia)-IMIB-Arrixaca, Murcia, Spain
| | - R Robles-Campos
- Liver Transplant Unit, Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca (Murcia)-IMIB-Arrixaca, Murcia, Spain
| | - P Parrilla
- Liver Transplant Unit, Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca (Murcia)-IMIB-Arrixaca, Murcia, Spain
| |
Collapse
|
14
|
LaMattina JC, Akbar H, Sultan S, Hanish SI, Bruno DA, Hutson WR, Stein DM, Bartlett ST, Scalea TM, Barth RN. Molecular Adsorbent Recirculating System Support Followed by Liver Transplantation for Multiorgan Failure From Heatstroke. Transplant Proc 2018; 50:3516-3520. [PMID: 30577229 DOI: 10.1016/j.transproceed.2018.07.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 07/09/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Exertional heatstroke is an extremely rare cause of fulminant hepatic failure. Maximal supportive care has failed to provide adequate survival in earlier studies. This is particularly true in cases accompanied by multiorgan failure. METHODS AND MATERIALS Our prospectively collected transplant database was retrospectively reviewed to identify patients undergoing liver transplantation for heatstroke between January 1, 2012, and December 31, 2016. We report 3 consecutive cases of male patients with fulminant hepatic failure from exertional heatstroke. RESULTS All patients developed multiorgan failure and required intubation, vasopressor support, and renal replacement therapy. 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 are alive and well, with recovered renal function, normal liver allograft function, and no chronic sequelae of their multiorgan failure at more than one year. CONCLUSION Extreme heatstroke leading to whole-body organ dysfunction and fulminant liver failure is a complex entity that may benefit from therapy using the Molecular Adsorbent Recirculating System while waiting for liver transplantation as a component of a multidisciplinary, multiorgan system approach.
Collapse
Affiliation(s)
- J C LaMattina
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland.
| | - H Akbar
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - S Sultan
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - S I Hanish
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - D A Bruno
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - W R Hutson
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - D M Stein
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - S T Bartlett
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - T M Scalea
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - R N Barth
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| |
Collapse
|
15
|
Eichner ER. College Football: Conditioning Them to Death; Splenic Infarction: Keeping it in the Family. Curr Sports Med Rep 2018; 17:278-279. [PMID: 30204628 DOI: 10.1249/jsr.0000000000000510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
16
|
Knechtle B, Nikolaidis PT. Physiology and Pathophysiology in Ultra-Marathon Running. Front Physiol 2018; 9:634. [PMID: 29910741 PMCID: PMC5992463 DOI: 10.3389/fphys.2018.00634] [Citation(s) in RCA: 152] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 05/11/2018] [Indexed: 12/31/2022] Open
Abstract
In this overview, we summarize the findings of the literature with regards to physiology and pathophysiology of ultra-marathon running. The number of ultra-marathon races and the number of official finishers considerably increased in the last decades especially due to the increased number of female and age-group runners. A typical ultra-marathoner is male, married, well-educated, and ~45 years old. Female ultra-marathoners account for ~20% of the total number of finishers. Ultra-marathoners are older and have a larger weekly training volume, but run more slowly during training compared to marathoners. Previous experience (e.g., number of finishes in ultra-marathon races and personal best marathon time) is the most important predictor variable for a successful ultra-marathon performance followed by specific anthropometric (e.g., low body mass index, BMI, and low body fat) and training (e.g., high volume and running speed during training) characteristics. Women are slower than men, but the sex difference in performance decreased in recent years to ~10–20% depending upon the length of the ultra-marathon. The fastest ultra-marathon race times are generally achieved at the age of 35–45 years or older for both women and men, and the age of peak performance increases with increasing race distance or duration. An ultra-marathon leads to an energy deficit resulting in a reduction of both body fat and skeletal muscle mass. An ultra-marathon in combination with other risk factors, such as extreme weather conditions (either heat or cold) or the country where the race is held, can lead to exercise-associated hyponatremia. An ultra-marathon can also lead to changes in biomarkers indicating a pathological process in specific organs or organ systems such as skeletal muscles, heart, liver, kidney, immune and endocrine system. These changes are usually temporary, depending on intensity and duration of the performance, and usually normalize after the race. In longer ultra-marathons, ~50–60% of the participants experience musculoskeletal problems. The most common injuries in ultra-marathoners involve the lower limb, such as the ankle and the knee. An ultra-marathon can lead to an increase in creatine-kinase to values of 100,000–200,000 U/l depending upon the fitness level of the athlete and the length of the race. Furthermore, an ultra-marathon can lead to changes in the heart as shown by changes in cardiac biomarkers, electro- and echocardiography. Ultra-marathoners often suffer from digestive problems and gastrointestinal bleeding after an ultra-marathon is not uncommon. Liver enzymes can also considerably increase during an ultra-marathon. An ultra-marathon often leads to a temporary reduction in renal function. Ultra-marathoners often suffer from upper respiratory infections after an ultra-marathon. Considering the increased number of participants in ultra-marathons, the findings of the present review would have practical applications for a large number of sports scientists and sports medicine practitioners working in this field.
Collapse
Affiliation(s)
- Beat Knechtle
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
| | | |
Collapse
|
17
|
Abstract
Zusammenfassung. Wir stellen die wichtigsten Erkenntnisse zu Organschädigungen durch einen Ultramarathon zusammen. Nach einem Ultramarathon können kardiale Biomarker wie CK, CK-MB, kardiales Troponin I (cTnI) und N-terminales pro-Brain Natriuretic Peptide (NT-pro BNP) erhöht sein. Bis 80 % und mehr der Finisher klagen über Verdauungsprobleme, die einer der Hauptgründe sind, einen Ultramarathon nicht zu finishen. Bis zu 90 % der Läufer, die einen Ultramarathon aufgeben, klagen über Übelkeit. Nach einem Ultramarathon steigen die Leberwerte oft an, schwerwiegende Konsequenzen bleiben meist aus. Risikofaktoren für eine Einschränkung der Nierenfunktion sind eine ausgeprägte Muskelschädigung mit Rhabdomyolyse, Dehydratation, Hypotonie, Hyperurikämie, Hyponatriämie, geringe Wettkampferfahrung sowie die Einnahme von NSARs. Ultraläufer leiden nach einem Ultramarathon oft an Infekten der oberen Atemwege.
Collapse
Affiliation(s)
- Beat Knechtle
- 1 Medbase St. Gallen
- 2 Institut für Hausarztmedizin, Universität Zürich
| | | |
Collapse
|
18
|
Jiao J, Zhou F, Kang H, Liu C, Yang M, Hu J. Unexpected extrapyramidal symptoms and pulmonary aspergillosis in exertional heatstroke with fulminant liver failure: a case report. J Med Case Rep 2017; 11:37. [PMID: 28183359 PMCID: PMC5301367 DOI: 10.1186/s13256-016-1184-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 12/25/2016] [Indexed: 03/11/2023] Open
Abstract
Background Exertional heatstroke is a life-threatening condition with high mortality because of the rapid progress of multiple organ dysfunction syndrome even if aggressive treatments are initiated rapidly. Mild to moderate hepatic injury is common in exertional heatstroke, while fulminant liver failure is rare. Extrapyramidal symptoms and pulmonary aspergillosis secondary to liver failure induced by exertional heatstroke have never been reported in prior cases. Case presentation A 25-year-old Han Chinese man presented with exertional heatstroke with fulminant liver failure, subsequent pulmonary aspergillosis, and extrapyramidal symptoms. Moreover, he also presented with coma, rhabdomyolysis, acute kidney injury, and disseminated intravascular coagulation. He recovered under conservative treatment including therapeutic plasma exchange plus continuous veno-venous hemofiltration, fluid resuscitation, antibiotics, and other support therapy. Conclusions Therapeutic plasma exchange plus continuous veno-venous hemofiltration could be effective for patients with heatstroke who suffer liver failure and other organ failure. Patients with liver failure are at high risk for pulmonary aspergillosis. Movement disorder in these patients might be extrapyramidal symptoms induced by consistent low level of cholinesterase resulted from hepatic injury besides brain injury.
Collapse
Affiliation(s)
- Jie Jiao
- Critical Care Medicine, Hainan Branch of Chinese PLA General Hospital, Haitangwan District, Sanyan, Hainan Province, 572000, China
| | - Feihu Zhou
- Critical Care Medicine, Chinese PLA General Hospital, 28th Fuxing Road, Haidian District, Beijing, 100853, China
| | - Hongjun Kang
- Critical Care Medicine, Chinese PLA General Hospital, 28th Fuxing Road, Haidian District, Beijing, 100853, China
| | - Chao Liu
- Critical Care Medicine, Chinese PLA General Hospital, 28th Fuxing Road, Haidian District, Beijing, 100853, China
| | - Mengmeng Yang
- Critical Care Medicine, Chinese PLA General Hospital, 28th Fuxing Road, Haidian District, Beijing, 100853, China
| | - Jie Hu
- Critical Care Medicine, Chinese PLA General Hospital, 28th Fuxing Road, Haidian District, Beijing, 100853, China.
| |
Collapse
|
19
|
Abstract
Exertional heatstroke (EHS) is a life-threatening disease characterized clinically by central nervous system dysfunction and severe hyperthermia. It frequently occurs among athletes, soldiers, and laborers. While cardiopulmonary symptoms are common in patients undergoing EHS, irreversible acute liver failure is a rarely described phenomenon. When managing cases of EHS complicated by acute liver failure, it is crucial to act promptly with aggressive total body cooling in order to prevent progression of the clinical syndrome. However, an urgent liver transplantation can be a therapeutic strategy when patients fail to improve with supportive measures.
Collapse
Affiliation(s)
- Faisal Inayat
- Department of Medicine, New York-Presbyterian Hospital, Weill Cornell Medical College, New York City, New York
| | - Hafeez Ul Hasan Virk
- Department of Medicine, St. Luke's-Roosevelt Hospital Center , Icahn School of Medicine at Mount Sinai, New York City, New York ; Memorial Sloan Kettering Cancer center, Memorial Sloan Kettering Cancer Center, New York City, New York
| |
Collapse
|
20
|
Diagnostic value of coagulation factor and intracranial pressure monitoring in acute liver failure from heat stroke: case report and review of the literature. Transplant Proc 2016; 47:817-9. [PMID: 25891738 DOI: 10.1016/j.transproceed.2015.02.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 02/10/2015] [Indexed: 12/26/2022]
Abstract
BACKGROUND Exertional heat stroke (HS) with resultant acute liver failure (ALF) is a rare condition with high mortality. Diagnosis of ALF in the context of HS is confounded by numerous laboratory abnormalities related to multisystem organ dysfunction. CASE REPORT We present the case of a 20-year-old male athlete with exertional HS who developed ALF and was treated successfully with orthotopic liver transplantation. He remained well after 1 year with normal liver function and no permanent neurologic impairment. Diagnosis and treatment was guided by serial monitoring of coagulation factors and intracranial pressure (ICP). CONCLUSIONS Currently, there are no well validated prognostic tools that predict the need for or survival with orthotopic liver transplantation for HS. We propose that serial monitoring of coagulation factors and, when safe and feasible, ICP monitoring may help to guide clinical decision making in this context.
Collapse
|
21
|
Sanabria Mateos R, Hogan NM, Dorcaratto D, Heneghan H, Udupa V, Maguire D, Geoghegan J, Hoti E. Total hepatectomy and liver transplantation as a two-stage procedure for fulminant hepatic failure: A safe procedure in exceptional circumstances. World J Hepatol 2016; 8:226-230. [PMID: 26855693 PMCID: PMC4733465 DOI: 10.4254/wjh.v8.i4.226] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 12/17/2015] [Accepted: 01/19/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the outcomes of two-stage liver transplant at a single institution, between 1993 and March 2015.
METHODS: We reviewed our institutional experience with emergency hepatectomy followed by transplantation for fulminant liver failure over a twenty-year period. A retrospective review of a prospectively maintained liver transplant database was undertaken at a national liver transplant centre. Demographic data, clinical presentation, preoperative investigations, cardiocirculatory parameters, operative and postoperative data were recorded.
RESULTS: In the study period, six two-stage liver transplants were undertaken. Indications for transplantation included acute paracetamol poisoning (n = 3), fulminant hepatitis A (n = 1), trauma (n = 1) and exertional heat stroke (n = 1). Anhepatic time ranged from 330 to 2640 min. All patients demonstrated systemic inflammatory response syndrome in the first post-operative week and the incidence of sepsis was high at 50%. There was one mortality, secondary to cardiac arrest 12 h following re-perfusion. Two patients required re-transplantation secondary to arterial thrombosis. At a median follow-up of 112 mo, 5 of 6 patients are alive and without evidence of graft dysfunciton.
CONCLUSION: Two-stage liver transplantation represents a safe and potentially life-saving treatment for carefully selected exceptional cases of fulminant hepatic failure.
Collapse
|