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Differential Diagnosis

It is essential to consider VOD/SOS in the differential diagnosis

Many complications can occur before and after HSCT, adding complexity to the differential diagnosis1


Note. Adapted and reprinted with permission of Oncology Nursing Society (ONS) from “Hematopoietic Stem Cell Transplantation: Implications for Critical Care Nurses” by M.G. Saria & T.K. Gosselin-Acomb, 2007, Clinical Journal of Oncology Nursing, 11(1), 57. Copyright © 2007 by ONS. All rights reserved.

VOD/SOS with multi-organ dysfunction has one of the highest mortality rates among other post-HSCT complications2-8

Several post-HSCT complications are characterized by signs and symptoms that overlap with those of VOD/SOS9-13

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Rapid weight gainalso seen with:

  • Congestive heart failure
  • Renal failure
  • Sepsis syndrome (cholangitis lenta)
  • Capillary leak syndrome
  • Iatrogenic fluid overload
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Hepatomegalyalso seen with:

  • Congestive heart failure
  • Fungal infection
  • Epstein-Barr virus lymphoproliferative disease
  • Tumor involvement
  • Myeloproliferative disorders
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Jaundicealso seen with:

  • Acute GvHD
  • Biliary infection
  • Calcineurin inhibitor toxicity
  • Cholestasis
  • Drug or total parenteral nutrition injury
  • Hemolysis

Abdominal ultrasound can assist in the differential diagnosis of clinically suspected VOD/SOS14

  • Baseline and serial ultrasound measurements are recommended for early VOD/SOS detection and can also be used to confirm clinically suspected hepatomegaly and ascites10,14,15
  • Doppler can be used to assess hepatic and portal vascular flow10,15,16
  • It is important to note that lack of impairment of or reversal of portal vascular flow, a late finding of VOD/SOS, does not rule out a VOD/SOS diagnosis16
  • Although not a part of any diagnostic criteria, ultrasound shear wave elastography may identify VOD/SOS-related changes in the liver before other imaging findings or clinical signs are present17
It is important to keep VOD/SOS top of mind in the differential diagnosis, especially in patients with preexisting risk factors14

GvHD=graft-vs-host disease; HSCT=hematopoietic stem-cell transplantation; SOS=sinusoidal obstruction syndrome; VOD=veno-occlusive disease.

References: 1. Saria MG, Gosselin-Acomb TK. Hematopoietic stem cell transplantation: implications for critical care nurses. Clin J Oncol Nurs. 2007;11(1):53-63. 2. Coppell JA, Richardson PG, Soiffer R, et al. Hepatic veno-occlusive disease following stem cell transplantation: incidence, clinical course, and outcome. Biol Blood Marrow Transplant. 2010;16(2):157-168. 3. Gratwohl A, Hermans J, Apperley J, et al; Working Party Chronic Leukemia of the European Group for Blood and Marrow Transplantation. Acute graft-versus-host disease: grade and outcome in patients with chronic myelogenous leukemia. Blood. 1995;86(2):813-818. 4. Schuster MG, Cleveland AA, Dubberke ER, et al. Infections in hematopoietic cell transplant recipients: results from the organ transplant infection project, a multicenter, prospective, cohort study. Open Forum Infect Dis. 2017;4(2):1-7. 5. Panoskaltsis-Mortari A, Griese M, Madtes DK, et al; American Thoracic Society Committee on Idiopathic Pneumonia Syndrome. An official American Thoracic Society research statement: noninfectious lung injury after hematopoietic stem cell transplantation: idiopathic pneumonia syndrome. Am J Respir Crit Care Med. 2011;183(9):1262-1279. 6. Chang L, Frame D, Braun T, et al. Engraftment syndrome after allogeneic hematopoietic cell transplantation predicts poor outcomes. Biol Blood Marrow Transplant. 2014;20(9):1407-1417. 7. Afessa B, Tefferi A, Litzow MR, et al. Diffuse alveolar hemorrhage in hematopoietic stem cell transplant recipients. Am J Respir Crit Care Med. 2002;166(5):641-5. 8. Fan K, McArthur J, Morrison RR, Ghafoor S. Diffuse alveolar hemorrhage after pediatric hematopoietic stem cell transplantation. Front Oncol. 2020;10:1757. 9. Carreras E. Early complications after HSCT. In: Apperley J, Carreras E, Gluckman E, et al, eds. The EBMT Handbook. 6th ed. Paris, France: European School of Haematology; 2012:176-195. 10. Corbacioglu S, Carreras E, Ansari M, et al. Diagnosis and severity criteria for sinusoidal obstruction syndrome/veno-occlusive disease in pediatric patients: a new classification from the European Society for Blood and Marrow Transplantation. Bone Marrow Transplant. 2018;53(2):138-145. 11. Eisenberg S. Hepatic sinusoidal obstruction syndrome in patients undergoing hematopoietic stem cell transplant. Oncol Nurs Forum. 2008;35(3):385-397. 12. Tuncer HH, Rana N, Milani C, et al. Gastrointestinal and hepatic complications of hematopoietic stem cell transplantation. World J Gastroenterol. 2012;18(16):1851-1860. 13. Murakami J, Shimizu Y. Hepatic manifestations in hematological disorders. Int J Hepatol. 2013;2013:484903. 14. Carreras E. How I manage sinusoidal obstruction syndrome after haematopoietic cell transplantation. Br J Haematol. 2015;168(4):481-491. 15. Mohty M, Malard F, Abecassis M, et al. Revised diagnosis and severity criteria for sinusoidal obstruction syndrome/veno-occlusive disease in adult patients: a new classification from the European Society for Blood and Marrow Transplantation. Bone Marrow Transplant. 2016;51(7):906-912. 16. Bajwa RPS, Mahadeo KM, Taragin BH, et al. Consensus report by Pediatric Acute Lung Injury and Sepsis Investigators and Pediatric Blood and Marrow Transplantation Consortium Joint Working Committees: supportive care guidelines for management of veno-occlusive disease in children and adolescents, part 1: focus on investigations, prophylaxis, and specific treatment. Biol Blood Marrow Transplant. 2017;23(11):1817-1825. 17. Reddivalla N, Robinson AL, Reid KJ, et al. Using liver elastography to diagnose sinusoidal obstruction syndrome in pediatric patients undergoing hematopoietic stem cell transplant. Bone Marrow Transplant. 2020;55(3):523-530.