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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

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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
  • 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.