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It is essential to consider VOD 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 with multi-organ dysfunction has one of the highest mortality rates among other post-HSCT complications2,3

Several post-HSCT complications are characterized by signs and symptoms that overlap with those of VOD4-8

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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

  • Baseline and serial ultrasound measurements are recommended for early VOD detection and can also be used to confirm clinically suspected hepatomegaly and ascites5,9,10,11
  • Doppler can be used to assess hepatic and portal vascular flow5,9,11
    • It is important to note that lack of impairment of or reversal of portal vascular flow, a late finding of VOD, does not rule out a VOD diagnosis
It is important to keep VOD top of mind in the differential diagnosis, especially in patients with preexisting risk factors

GvHD=graft-vs-host disease; HSCT=hematopoietic stem-cell transplantation; VOD=veno-occlusive disease (also known as sinusoidal obstruction syndrome, or SOS).

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; Chronic Leukemia Working Party 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. 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. 5. 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. 6. Eisenberg S. Hepatic sinusoidal obstruction syndrome in patients undergoing hematopoietic stem cell transplant. Oncol Nurs Forum. 2008;35(3):385-397. 7. 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. 8. Murakami J, Shimizu Y. Hepatic manifestations in hematological disorders. Int J Hepatol. 2013;2013:484903. 9. 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. 10. Carreras E. How I manage sinusoidal obstruction syndrome after haematopoietic cell transplantation. Br J Haematol. 2015;168(4):481-491. 11. 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.