Michelle Kenyon, Post-BMT Clinical Nurse Specialist at King’s College Hospital, summarises the types of risk factors and explains the role of risk assessment for in transplant care.
Identify VOD promptly
VOD is one of many complications that can occur in patients undergoing HSCT.1
Cases vary in severity and require careful monitoring as severe VOD is associated with a mortality rate of over 80%.2
While the incidence of VOD varies between studies,2 with careful management, even severe VOD can be expectable, predictable and survivable.3-5
Scroll to view the steps to making an accurate diagnosis, and click to explore the content.
Risk assessment is vital in facilitating prompt diagnosis and early treatment of severe VOD.6,7
Risk factors for developing VOD fall into three distinct categories (as defined by the EBMT):6
– Patient- and disease-related risk factors – e.g. older age; advanced disease; Karnofsky score <90%; genetic factors; metabolic syndrome; thalassaemia; norethisterone use in women
– Transplant-related risk factors – e.g. unrelated or HLA-mismatched donor; regimen-dependent risks, such as oral or high-dose busulfan, or high-dose TBI or myeloablative conditioning; non-T-cell–depleted transplant or second HSCT
– Hepatic-related risk factors – e.g. cirrhosis; active viral hepatitis; abdominal/hepatic irradiation; specific previous drug use including hepatotoxic agents; elevated transaminases (>2.5 ULN) or serum bilirubin (>1.5 ULN)
Dr Amit Patel outlines the rationale behind carrying out a VOD risk assessment and staying vigilant in the context of other post-transplant complications.
For more expert videos on risk assessment, please visit the Resources page.
Best practice maintains that daily, strict monitoring is essential for detecting early signs and symptoms of VOD.3,8,9
The following parameters should be monitored and recorded:
- Abdominal girth
- Bilirubin levels
In addition, continuously monitor: Fluids in/out, urea and electrolytes, blood tests, coagulation, liver function.
Immediately report to team/senior doctors on duty if you observe:
- Weight gain
- Increased abdominal tenderness
- Fluid retention
- Increased abdominal girth
Dr Manos Nikolousis describes the monitoring practice at his trust, as well as the value of a 24-hour blood and marrow transplantation chart in maintaining best practice.
Michelle Kenyon, Post-BMT Clinical Nurse Specialist at King’s College Hospital, discusses the crucial daily monitoring practice in patients at risk of VOD.
For more expert videos on monitoring for the signs and symptoms for VOD, please visit the Resources page.
Diagnosis of vod
The diagnostic criteria for VOD can identify a differential diagnosis.6
- The Baltimore and modified Seattle criteria are traditionally used to diagnose VOD in both children and adults10–12
- Both require the presence of VOD to be within 21 days of HSCT10–12
- The Baltimore criteria also require elevated bilirubin levels (≥2 mg/dL [34 µmol/L])10
The evolving criteria for earlier diagnosis and treatment:
- New clinical data show that the use of criteria, which do not require elevated bilirubin levels for classical VOD, may allow for earlier identification and diagnosis of VOD10–13
- New clinical data also showed VOD was diagnosed both before and after Day 21 in both age groups13
- Therefore, there is a need to strictly monitor the possibility of VOD at any time after HSCT, even in the absence of elevated bilirubin levels13
See the Baltimore and modified Seattle diagnostic criteria
Late cases of VOD have been reported (>21 days)13 and are included in the EBMT diagnostic criteria for adults.6
See the EBMT diagnostic criteria
Michelle Kenyon, Post-BMT Clinical Nurse Specialist at King’s College Hospital, on escalating observations, prompting interventions, and why speed is so vital when it comes to identifying VOD.
Dr Manos Nikolousis talks about the value of diagnosing VOD in an accurate and timely manner.
For more expert videos on diagnosing VOD, please visit the Resources page.
The EBMT severity grading can aid in differential diagnosis, enhanced vigilance and prompt intervention.6
The guiding principles for severity grading are:6
Determine severity from patient presentation
Classification based on the category for which they fulfil ≥2 criteria
Take into account criteria fulfilled in other categories
Classification based on ≥2 criteria across two different categories fulfilled?
Classified in the most severe category
Consider risk factors
Classification based on ≥2 mild or ≥2 moderate criteria and ≥2 risk factors for VOD?
Move up a grade
While severe and very severe VOD decreases OS rates compared with mild or moderate VOD, prompt intervention with Defitelio® can improve survival.14,15
Use this poster as a handy reminder of the severity grading criteria and principles.
ADVERSE EVENTS REPORTING
Adverse events should be reported. Reporting forms and information for the UK can be found at: https://yellowcard.mhra.gov.uk/
For Ireland, reporting forms and information can be found at: www.hpra.ie
Adverse events should also be reported to Jazz Pharmaceuticals at: AEreporting@jazzpharma.com
Defitelio® is indicated for the treatment of severe hepatic veno-occlusive disease (VOD) also known as sinusoidal obstruction syndrome (SOS) in haematopoietic stem-cell transplantation (HSCT) therapy. It is indicated in adults and in adolescents, children and infants over 1 month of age.