Chair & Presenter, Kenneth R. Cooke, MD, Megan Burris, MSN, CPNP-PC/AC, and Megan Burris, MSN, CPNP-PC/AC, prepared useful Practice Aids pertaining to VOD/SOS for this CME/MOC/NCPD/CPE activity titled “Collaborative Strategies for Managing VOD/SOS: Interprofessional Insights on Advances in Diagnosis, Severity Grading, and Treatment.” For the full presentation, downloadable Practice Aids, and complete CME/MOC/NCPD/CPE information, and to apply for credit, please visit us at https://bit.ly/2TeQSga. CME/MOC/NCPD/CPE credit will be available until September 23, 2022.

1. a
Second HCT also increases risk for VOD.b
Probably or definitely secondary to VOD/SOS and not other etiologies.c
Patients with an already elevated bilirubin prior to HCT conditioning; this criteria should not be
utilized in the diagnostic criteria.
1. Dalle JH, Giralt SA. Biol Blood Marrow Transplant. 2016;22:400-409. 2. Mohty M et al. Bone Marrow Transplant. 2015;50:781-789. 3. Mohty M et al. Bone Marrow Transplant. 2016;51:906-912. 4. Corbacioglu S
et al. Biol Blood Marrow Transplant. 2019;25:1271-1280. 5. Cairo MS et al. Br J Haematol. 2020;190:822-836.
Tools for Capturing the Emergence
of VOD/SOS: Risk Assessment,
Diagnostic Criteria, and Clinical Signs
Full abbreviations, accreditation, and disclosure information available at PeerView.com/PGX40
OR
These recommendations are designed to facilitate early identification of risk factors
and a more timely and accurate diagnosis of VOD/SOS
Revised Criteria for VOD Diagnosis5
Understanding the risk for VOD in HCT candidates can help determine appropriate modifications
to conditioning regimens or the need for pharmacologic prophylaxis
Any Two of the
Following Criteria HCTb
Any One of the
Following Criteria HCTb
 Hepatic biopsy consistent
with VOD
or
 Unexplained elevated portal
venous wedge pressure
 Elevated bilirubin (≥2 mg/dL; ≥34.2 μmol/L) or greater than
upper institutional limitsc
 Unexpected weight gain (≥5% compared with baseline
weight pre HCT)
 Excessive platelet transfusions consistent with refractory
thrombocytopenia post HCT
 Hepatomegaly for age or increased size over pre HCT
 Right upper quadrant pain
 Ascites confirmed by physical exam and/or imaging studies
 Reversal of portal venous flow by Doppler ultrasound
3-10 Times Greater Risk >10 Times Greater Risk
Pretransplantation factors
Unmodifiable1
• Increased recipient age
• Increased serum transaminase
• Hyperferritinemia (>1,000 ng/mL)
• Preexisting liver disease
• Thalassemia; CML or immunodeficiency diagnosis
• CMV seropositivity
• Use of acyclovir pretransplantation
• Use of parenteral alimentation
• Genetic factors (GSTM1 polymorphism)
• Sepsis syndrome
Conditioning
• High-dose (myeloablative) regimens: busulfan-containing
(vs nonbusulfan) prior to cyclophosphamide,
TBI + cyclophosphamide, fludarabine containing
Transplantation
• Allogeneic (vs autologous) transplantation
GVHD prophylaxis
• Sirolimus + tacrolimus
• Methotrexate + cyclosporine
• Cyclosporine containing
• Serum bilirubin >1.5 mg/L
(>26 µmol/L) before
transplantation
• Prior gemtuzumab ozogamicin
• Prior inotuzumab ozogamicin
• Prior norethisterone
Transplantation-related factorsa
Modifiable2-5
–

2. Tools for Capturing the Emergence of VOD/SOS:
Risk Assessment, Diagnostic Criteria, and Clinical Signs1,2
Full abbreviations, accreditation, and disclosure information available at PeerView.com/PGX40
a
Weight gain (usually from ascites), elevated bilirubin, and RUQ pain/hepatomegaly are common in severe VOD. b
Signs/symptoms such as shortness of breath and tachypnea may indicate potential organ (in this case, lung) dysfunction and not VOD per se.
1. Dalle JH, Giralt SA. Biol Blood Marrow Transplant. 2016;22:400-409. 2. Chao N. Blood. 2014;123:4023-4026.
Symptoms of VOD/SOS usually occur within 30 days after HCT,
but they can occur later
VOD/SOS Onset Timeline
-1 week -4 to +6 days Day +10 to +14 Day +30
Hospital
discharge
Stem cells
infused day 0
Central catheter placed and
conditioning administered
Count
recovery
Day +90 to +100
Patient
admitted
Follow-up
after patient
discharge
Laboratory Values
 Elevated transaminases
 Hyperbilirubinemia (conjugated)a
 Prolonged PTa
 Signs of decreased synthetic
function (low albumin)
 Elevated creatinine
 Decreased GFR
 Decreased O2
saturation
Signs/Symptoms
 RUQ paina
 Hepatomegalya
 Weight gaina
 Ascites
 Jaundice
 Shortness of breathb
 Tachypneab
 Decreased urine output

3. VOD/SOS Management: Guide to Current Therapeutic Options
Full abbreviations, accreditation, and disclosure information available at PeerView.com/PGX40
1. Defitelio (defibrotide) Prescribing Information. https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/208114lbl.pdf. 2. Dignan FL et al. Br J Haematol. 2013;163:444-457. 3. Kikuta A et al. 44th Annual Meeting of the European Society for Blood and Marrow
Transplantation (EBMT 2018). Abstract A233.
Defibrotide1
Supportive Care2
Clinical Considerations With Defibrotide
Contraindication: Concomitant systemic anticoagulant
or fibrinolytic therapy
Severe hypersensitivity: Permanently discontinue
Bleeding (first episode): Hold; treat bleed; consider
resuming at same dose once bleeding has stopped and
patient is hemodynamically stable
Recurrent bleeding: Permanently discontinue
Invasive procedure: Discontinue ≥2 h before procedure;
resume postprocedure, if no bleeding
Clinical note: Earlier initiation of defibrotide is consistently
associated with improved outcomes. For example, initiating
treatment ≤2 d postdiagnosis is associated with better
survival vs initiation ≥3 d postdiagnosis3
Dosing: 6.25 mg/kg every 6 h as a 2-h IV infusion
FDA
Approved
Treatment of adult and pediatric patients
with hepatic VOD/SOS with renal or
pulmonary dysfunction following HCT
Provide supplemental oxygen support as needed.
Mechanical ventilation may be required in
severe cases
Patients with MOF will require management in a
high-dependency or intensive care environment
Renal replacement therapy may be required in
severe cases
 Fluid/salt restriction
 Diuresis
 Paracentesis
 Hemofiltration
 Supplemental
oxygen support
 Mechanical
ventilation
Total amount of fluids should be restricted and
diuretic therapy should be administered in cases
of severe fluid overload