Background and Aims: Exertional heatstroke (EHS) is as-sociated with strenuous physical activity in hot environments. The present study aimed to investigate dynamic changes of hepatic function indices in EHS patients and determine risk factors for death. Methods: This single-center retrospective cohort study considered all patients with EHS admitted to the intensive care unit at the General Hospital of Southern Theater Command of PLA from October 2008 to May 2019. Data on general characteristics, organ function parameters, and the 90-day outcome of enrolled patients were collected. Hepatic indices were collected dynamically, and patients with acute hepatic injury (AHI) were identified by plasma total bil-irubin (TBIL) ≥34.2 μmol/L and an international normalized ratio ≥1.5, or with any grade of hepatic encephalopathy. Re-sults: In patients who survived, TBIL, alanine aminotrans-ferase and aspartate aminotransferase were increased at 24 h, peaked at 2-3 days, and began to decrease at 5 days. In non-survivors, TBIL continuously increased post-admission. The area under the receiver operating characteristic curve for the prediction of mortality based on sequential organ failure assessment (SOFA) scores was 89.8％, and the optimal cut-off value was 7.5. Myocardial injury and infection were iden-tified as independent risk factors for death in EHS patients with AHI. Conclusions: In EHS patients, hepatic dysfunction usually occurred within 24 h. Patients with AHI had more severe clinical conditions, and significantly increased 90-day mortality rates. SOFA scores over 7.5, complicated with myo-cardial injury or infection, were found to be risk factors for death in EHS patients with AHI.