Working Diagnosis:
Exertional heat stroke with severe rhabdomyolysis resulting in acute kidney injury and fulminant liver failure requiring liver transplantation

Treatment:
The patient ultimately underwent liver transplantation for fulminant liver failure. His postoperative course was complicated by a biliary anastomotic stricture requiring stent placement. Because of acute kidney injury associated with severe rhabdomyolysis, he required continuous renal replacement therapy and was later transitioned to hemodialysis.

Outcome:
The patient continues to follow with Transplant Hepatology, Nephrology, and Psychology.

At his most recent clinic visit eight months after transplantation, he was ambulating with a walker and had recently traveled to Europe. He continued to experience bilateral ankle swelling that worsened with prolonged standing and ambulation.

Author's Comments:
Exertional heat stroke with rhabdomyolysis is a rare but potentially catastrophic complication of endurance sports. Acute kidney injury is common among marathon runners, with studies reporting Stage 1 acute kidney injury in up to 80% of participants following a race.1

Athletes may be predisposed to renal injury during prolonged endurance events, particularly in warm environments where elevated core body temperatures occur. This process is multifactorial and may involve dehydration from sweat losses, inadequate fluid replacement, redistribution of blood flow from visceral organs to exercising musculature, nonsteroidal anti-inflammatory drug use, and reduced renal perfusion during strenuous exercise.2,3

Although less common, heat stroke-induced liver failure has been reported in approximately 5% of patients with exertional heat stroke and may ultimately require liver transplantation.4

This case highlights the potentially life-altering consequences of endurance exercise under extreme physiologic stress. As participation in long-distance running continues to increase, clinicians should remain aware of the rare but serious complications associated with exertional heat stroke, including rhabdomyolysis, acute kidney injury, disseminated intravascular coagulation, and fulminant liver failure. Early recognition, aggressive cooling, and prompt escalation of care remain critical to optimizing outcomes in severe exertional heat illness.1-4

Editor's Comments:
This case serves as an important reminder that exertional heat stroke is a medical emergency requiring rapid recognition and aggressive treatment. While most athletes recover fully, delayed diagnosis or severe presentations may result in multiorgan dysfunction involving the kidneys, liver, coagulation system, and central nervous system.

Sports medicine clinicians frequently encounter runners with dehydration, heat illness, or post-race fatigue. However, persistent altered mental status, hyperthermia, rhabdomyolysis, or rapidly worsening laboratory abnormalities should prompt immediate escalation of care. This case demonstrates the most severe end of the exertional heat illness spectrum and highlights the importance of early recognition, cooling, and multidisciplinary management.

References:
1. Mansour SG, Verma G, Pata RW, Martin TG, Perazella MA, Parikh CR. Kidney Injury and Repair Biomarkers in Marathon Runners. Am J Kidney Dis. 2017;70(2):252-261. doi:10.1053/j.ajkd.2017.01.045.

2. Braschler L, Nikolaidis PT, Thuany M, et al. Physiology and Pathophysiology of Marathon Running: A Narrative Review. Sports Med Open. 2025;11:10. doi:10.1186/s40798-025-00810-3.

3. Poortmans JR. Exercise and Renal Function. Sports Med. 1984;1(2):125-153. doi:10.2165/00007256-198401020-00003.

4. Figiel W, Morawski M, Grąt M, et al. Fulminant Liver Failure Following a Marathon: Five Case Reports and Review of Literature. World J Clin Cases. 2019;7(12):1467-1474. doi:10.12998/wjcc.v7.i12.1467.1.

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