Biomarkers for Diagnosis and Prognosis of Sinusoidal Obstruction Syndrome after Hematopoietic Cell Transplantation

Reliable, noninvasive methods for diagnosing and prognosing sinusoidal obstruction syndrome (SOS) early after hematopoietic cell transplantation (HCT) are needed. We used a quantitative mass spectrometry-based proteomics approach to identify candidate biomarkers of SOS by comparing plasma pooled from 20 patients with and 20 patients without SOS. Of 494 proteins quantified, we selected 6 proteins (L-Ficolin, vascular cell adhesion molecule-1 [VCAM1], tissue inhibitor of metalloproteinase-1, von Willebrand factor, intercellular adhesion molecule-1, and CD97) based on a differential heavy/light isotope ratio of at least 2 fold, information from the literature, and immunoassay availability. Next, we evaluated the diagnostic potential of these 6 proteins and 5 selected from the literature (suppression of tumorigenicity-2 [ST2], angiopoietin-2 (ANG2), hyaluronic acid [HA], thrombomodulin, and plasminogen activator inhibitor-1) in samples from 80 patients. The results demonstrate that together ST2, ANG2, L-Ficolin, HA, and VCAM1 compose a biomarker panel for diagnosis of SOS. L-Ficolin, HA, and VCAM1 also stratified patients at risk for SOS as early as the day of HCT. Prognostic Bayesian modeling for SOS onset based on L-Ficolin, HA, and VCAM1 levels on the day of HCT and clinical characteristics showed >80% correct prognosis of SOS onset. These biomarkers may provide opportunities for preemptive intervention to minimize SOS incidence and/or severity.

Reversible sinusoidal obstruction syndrome associated with tacrolimus following liver transplantation

Sinusoidal obstruction syndrome (SOS), previously known as hepatic veno-occlusive disease, is a rare disorder in solid organ transplant patients, and is an uncommon complication after liver transplantation. Severe SOS with hepatic failure causes considerable mortality. Tacrolimus has been reported to be an offending agent, which potentially plays a role in the pathophysiological process of SOS. SOS due to tacrolimus has been reported in lung and pancreatic transplantations, but has never been described in a liver transplant recipient. Herein, we present a case of SOS after liver transplantation, which was possibly related to tacrolimus. A 27-year-old man developed typical symptoms of SOS with painful hepatomegaly, ascites and jaundice after liver transplantation, which regressed following withdrawal of tacrolimus. By excluding other possible predisposing factors, we concluded that tacrolimus was the most likely cause of SOS.

Tusanqi and hepatic sinusoidal obstruction syndrome

Hepatic sinusoidal obstruction syndrome (HSOS), characterized by hepatomegaly, ascites and hyperbilirubinemia, is caused by toxic injury to hepatic sinusoidal endothelial cells. One major etiology of HSOS in China is the intake of products containing pyrrolizidine alkaloids (PA) such as Tusanqi. The manifestations of patients with HSOS are usually non-specific, presenting with abnormal liver function and portal hypertension. Diagnosis of the disease depends mostly on liver histopathology when clinical and imaging data are not sufficient. A history of Tusanqi intake is mostly important for the diagnosis. Due to a lack of effective, evidence-based treatments for HSOS, avoiding the mistaken use of PA-containing products including Tusanqi is important for the prevention of HSOS.

Long-term outcome of percutaneous interventions for hepatic venous outflow obstruction after pediatric living donor liver transplantation: experience from a single institute

PURPOSE

To evaluate retrospectively the long-term outcome of percutaneous interventions for hepatic venous outflow obstruction (HVOO) occurring after pediatric living donor liver transplantation (LDLT).

MATERIALS AND METHODS

Between October 1997 and December 2012, 48 patients (24 boys, 24 girls; median age, 6 y) who had undergone LDLT were confirmed to have HVOO using percutaneous hepatic venography and manometry. All patients underwent percutaneous interventions, including balloon angioplasty with or without stent placement. Technical success, clinical success, patency rates, stent placement, and major complications were evaluated.

RESULTS

Technical success was achieved in 92 of 93 sessions (99.0%) and in 47 of 48 patients (97.9%), and clinical success was achieved in 41 of 48 patients (85.4%). During the follow-up period (range, 1-182 mo; median, 51.5 mo), 28 patients were treated with a single session of balloon angioplasty, and 20 patients who developed recurrent stenosis were treated with repeated percutaneous interventions. The rates of primary and primary-assisted patency at 1, 3, 5, and 10 years after balloon angioplasty were 64%, 57%, 57%, and 52% (primary patency) and 98%, 95%, 95%, and 95% (primary-assisted patency). Of six patients with stent placement, four had no recurrent HVOO after the stent placement, but two developed recurrent stenosis. The stent migrated to the right atrium in one patient.

CONCLUSIONS

Percutaneous interventions were effective treatments for HVOO after LDLT.

Is there any relationship between pulmonary function tests and post-transplant complications of allogeneic hematopoetic stem cell transplantation?

AIM

Pulmonary function tests (PFT) have an important role in the assessment of pulmonary and nonpulmonary complications of hematopoetic stem cell transplantation (HSCT). In this study the relationship between PFTs and DLCOadj values and the complications of HSCT was investigated. The possible role of iron overload in the deterioration of the PFTs after HSCT was also searched.

METHODS

One hundred and fifty one patients who had undergone allogeneic HSCT between years 2003 through 2008, and had the records of PFTs prior to and at 1, 3, 6, 9 and 12 months after transplantation were included in the study. Prospectively collected data of these patients were analysed retrospectively.

RESULTS

Although no significant difference was identified in other PFT parameters, a significant decrease in DLCOadj was determined after 1st and 3rd months of HSCT. A significant correlation was found between pretransplant DLCOadj value <%70 and sinusoidal obstruction syndrome (SOS) (P=0.001, r=0.323), but in multivariate analysis pretransplant DLCOadj was not an independent predictor of SOS; only total body irradiation (TBI) (OR: 3.673, %95 CI: 0.880-15.804), the day of platelet engraftment (OR=1.093, %95 CI: 1.029-1.161) and serum ferritin (OR=1.001, %95 CI: 1.000-1.001) were significant. Advancing age and serum ferritin levels >600 ng/mL were the independent risk factors for pretransplant DLCOadj <%70 (OR: 0.970, %95 CI: 0.941-0.999 and OR: 2.355, %95 CI: 1.058-5.241 respectively).

CONCLUSION

Although a significant correlation exists between pretransplant DLCOadj values and post-transplant SOS development, pretransplant DLCOadj was not an independent predictor of SOS. Increased serum ferritin levels were common both for pretransplant DLCO decrease and post-transplant SOS development. Iron induced endothelial damage may be the common pathophysiologic mechanism causing lung and liver vulnerability, and DLCOadj may be a non-invasive method of demonstrating this vulnerability.

Successful treatment with danhong injection for hepatic veno-occlusive disease

Hepatic veno-occlusive disease (HVOD) is a clinical syndrome characterized as hepatomegaly, ascites, jaundice and elevation of hepatic enzymes as an outcome from fibrous obliteration of small centrilobular hepatic venules. It is recognized as a rare but life-threatening complication of organ transplantation, tumor eradication chemotherapy and is associated with haematopoietic stem cell transplantation (SCT). Recent researches report that ingestion of plants which contain pyrrolizidine alkaloids (PAs) is associated with the onset of HVOD with unclear pathogenesis. Nowadays, there is no effective therapeutic strategy for HVOD besides supportive care using diuretics or albumin. In our case, a 42-year-old woman administered a concoction of Chinese traditional medicine supposed to contain PAs, was found to develop HVOD confirmed by liver biopsy. A therapeutic strategy was developed using Danhong injection, accompanied with supportive care, and obtained a favorable response manifesting as regression of symptoms and decline of hepatic enzymes. Danhong injection, a Chinese medical product exerting a milder anticoagulation and antithrombotic effect, is beneficial to HVOD probably by promoting microcirculation, ameliorating liver function and inhibiting hepatic fibrosis.

Hepatic veno-occlusive disease associated with toxicity of pyrrolizidine alkaloids in herbal preparations

Hepatic veno-occlusive disease (VOD) is frequently linked to stem cell transplantation (SCT), mainly related to the conditioning regime, and contributes to considerable morbidity and mortality. However, pyrrolizidine alkaloid (PA)-induced VOD has long been overlooked. The pathogenesis of VOD remains poorly understood; studies suggest that endothelial cell injury, cytokines and haemostatic derangement are all involved in the pathogenesis of VOD. Until recently, treatment options have been limited and no uniformly effective therapy has been established. Thus, treatment is largely supportive and symptomatic. Ongoing work, including development of new animal models and clinical studies, is needed to help us fully understand the pathogenesis of VOD and enable us to devise effective solutions. Furthermore, it is strongly advised that supervisory measures be taken to standardise the use of herbal medication.

[Usefulness of serum plasminogen activator inhibitor-1 for diagnosis and monitoring of late-onset sinusoidal obstruction syndrome after allogeneic stem cell transplantation]

Sinusoidal obstruction syndrome (SOS) was originally defined as a clinical syndrome occurring by three weeks after transplantation; however, it occurs even after three or more weeks, and such cases are called late-onset SOS. We report here a case of late-onset SOS. The patient was a 17-year-old male with acute myeloid leukemia in second complete remission. He received a preparative regimen including busulfan followed by allo-peripheral blood stem cell transplantation from an HLA-matched sibling donor. On day 28 after transplantation, he developed hepatomegaly with pain. On day 33 PAI-1 level was increased. Two days later ascites developed, leading to a diagnosis of late-onset SOS. The symptoms improved with conservative therapy and the level of PAI-1 was normalized. When hepatic impairment appears three or more weeks after transplantation, late-onset SOS should be considered. PAI-1 is a useful marker for the diagnosis and follow up of late-onset SOS.

An unusual presentation of infantile fibrosarcoma in a male newborn

We describe a 10-day-old male presenting with drop foot and immobility in his right leg; no abnormality in physical examination had been found upon delivery or discharge. Magnetic resonance imaging showed a pelvic mass with an extension to the great sciatic foramen. Fine-needle aspiration biopsy revealed congenital infantile fibrosarcoma. He was started on vincristine, actinomycin-D, cyclophosphamide chemotherapy. However, he died soon after the second cycle due to veno-occlusive disease of the liver. Differential diagnosis of drop foot and immobility in lower extremity must include infiltrating neoplasms in pelvis.

Vascular disorders of the liver

This guideline has been approved by the American Association for the Study of Liver Diseases (AASLD) and represents the position of the association.

[Veno-occlusive disease of the liver]

Veno-occlusive disease (VOD) is seen most often in the group of bone marrow transplant recipients. The essence of this disease is the obstruction of the hepatic sinusoidal and centrolobular venous outflow, because of the injury to the endothelium of the liver vessels. It results in congestion of the liver and hepatomegaly. The typical clinical symptoms of VOD are: jaundice, portal hypertension with peripheral oedemas and the weight gain. Depending on the extent of the injury of the hepatic vessels, VOD is divided into three grades: mild, moderate and severe. The clinical markers that inform about the severity of the disease are: the rate of the serum bilirubin growth and the rate of the weight gain growth within the first 2 weeks since the beginning of the disease. Severe VOD is the third of the most often cause of death among people who underwent bone marrow transplantation. The mortality rate is diverse and depends on severity of the disease. The effectiveness of the VOD therapy is limited, so it is worth putting greater pressure on the prophylaxis of VOD or on finding more effective modes of treatment.

[Sinusoidal obstruction disease (SOS), previous hepatic venoocclusive disease (VOD)--still serious complication after hematopoietic stem cell transplantation]

Hepatic venocclusive disease (VOD) lastly named sinusoidal obstruction syndrome (SOS) is a serious toxicity associated with high dose therapy used to prepare patients for stem cell transplantation. A sizable proportion of patients who develop VOD/SOS die. It is clear that injury to endothelial cells and hepatocytes in zone 3 of the liver acinus is the initial event in the pathogenesis of VOD/SOS. Although clinical presentation and diagnostic criteria are well known, the cause of VOD/SOS, its prevention and treatment remain still unclear. Currently treatment of VOD/SOS has largely consisted of supportive measures designed to maintain intravascular volume and decrease interstitial edema. Other treatments used with various measures of success have included substitution of antitrombine and glutamine or aggressive fibrinolitic and antithrombotic therapy. Despite these treatments, the outcome remains fairly dismal.

The first prenatal diagnosis for veno-occlusive disease and immunodeficiency syndrome, an autosomal recessive condition associated with mutations in SP110

OBJECTIVES

We present the first prenatal diagnosis of familial hepatic veno-occlusive disease with immunodeficiency (VODI). Homozygous mutations in the gene SP110 are the genetic basis of VODI. The proband in this report presented at three months of age with hepatomegaly hepatic failure and was found to have hypogammaglobulinemia. He died one month after hepatic transplant at eight months of age due to hemophagocytic syndrome. DNA testing detected a homozygous truncating mutation in exon 5; SP110 c.642delC. Prenatal testing was offered to this family in a subsequent pregnancy.

METHODS

Chorion villus was sampled at 12 weeks' gestation. DNA was extracted using standard techniques, and sequencing of SP110 exon 5 was performed using flanking primers. Maternal contamination was excluded by examining STR markers in CVS and maternal DNA.

RESULTS

A heterozygous SP110 c.642delC mutation was detected in exon 5. This mutation was present in heterozygous form in both parents.

CONCLUSIONS

The prenatal test result is predictive of a child with a normal immune and hepatic phenotype. This report presents the first prenatal molecular diagnosis for VODI and shows the importance of molecular genetic research in not only defining the aetiology of syndromes but also in assisting reproductive choices through the collaboration of genetic and feto-maternal services.

Hepatic veno-occlusive disease after tranexamic acid administration in patients undergoing allogeneic hematopoietic stem cell transplantation

Tranexamic acid is one of the widely used antifibrinolytic agents. In spite of its effective inhibitory activity against plasminogen, thromboembolic adverse events caused by tranexamic acid are rare. We encountered three recipients of allogeneic hematopoietic stem cell transplantation (HSCT) who developed hepatic veno-occlusive disease (VOD) shortly after the administration of tranexamic acid. Hepatic VOD was resolved completely in all patients with the discontinuation of the drug, and with supportive measures with or without intravenous tissue plasminogen activator administration. These findings suggest that administration of tranexamic acid could be one of the possible risk factors for developing hepatic VOD in HSCT recipients.

Hepatic complications following preoperative chemotherapy with oxaliplatin or irinotecan for hepatic colorectal metastases

AIMS

The aim of this article is to review the current state of knowledge in relation to the development of chemotherapy associated steatohepatitis (CASH) and sinusoidal obstruction syndrome (SOS) occurring following the administration of irinotecan and oxaliplatin respectively to patients with colorectal liver metastases and also to highlight potential concerns relating to other new agents.

METHODS

An electronic search was performed of the medical literature using the MEDLINE database to identify relevant articles related to the incidence, aetiology, pathology and effects of CASH and SOS outcome in patients undergoing hepatic resection.

RESULTS

CASH and SOS are relatively common findings in liver resection specimens following the administration of irinotecan and oxaliplatin-based regimes being reported in up to 50% and 20% of cases respectively. Whilst the aetiology and pathological changes are well-described, the relationship between the presence of these pathologies and outcomes is less well defined. The data in relation to SOS following oxaliplatin is limited but there may be an increased morbidity associated with the presence of SOS. There is significantly more evidence that the presence of CASH is associated with an increased morbidity and possibly mortality following hepatic resection as a result of the development of liver failure. Further studies are required to clarify these early observations.

CONCLUSIONS

The frequent identification of distinct pathological entities in association with oxaliplatin and irinotecan chemotherapy means that patients undergoing liver resection following treatment with these agents should be carefully monitored to accurately determine the morbidity and mortality attributable to the use of these agents. Furthermore, additional studies are required to clarify risk factors for the development of CASH and SOS so that certain regimens can be avoided in at risk populations thus reducing hepatic damage and increasing the chances of cure and survival following liver resection.

Veno occlusive disease: update on clinical management

Hepatic veno-occlusive disease is a clinical syndrome characterized by hepatomegaly, ascites, weight gain and jaundice, due to sinusoidal congestion which can be caused by alkaloid ingestion, but the most frequent cause is haematopoietic stem cell transplantation (STC) and is also seen after solid organ transplantation. The incidence of veno occlusive disease (VOD) after STC ranges from 0 to 70%, but is decreasing. Survival is good when VOD is a mild form, but when it is severe and associated with an increase of hepatic venous pressure gradient > 20 mmHg, and mortality is about 90%. Prevention remains the best therapeutic strategy, by using non-myeloablative conditioning regimens before STC. Prophylactic administration of ursodeoxycholic acid, being an antioxidant and antiapoptotic agent, can have some benefit in reducing overall mortality. Defibrotide, which has pro-fibrinolytic and antithrombotic properties, is the most effective therapy; decompression of the sinusoids by a transjugular intrahepatic portosystemic shunt (TIPS) can be tried, especially to treat VOD after liver transplantation and when multiorgan failure (MOF) is not present. Liver transplantation can be the last option, but can not be considered a standard rescue therapy, because usually the concomitant presence of multiorgan failure contraindicates this procedure.

Value of CT and Doppler Sonography in the Evaluation of Hepatic Vein Stenosis After Dual-Graft Living Donor Liver Transplantation

OBJECTIVE

The purpose of this study was to evaluate the imaging findings and role of CT and Doppler sonography in the diagnosis of hepatic vein (HV) stenosis after dual-graft living donor liver transplantation (LDLT).

MATERIALS AND METHODS

Using hepatic venography as the reference standard, 73 grafts with venographic evaluation in 43 dual-graft LDLT recipients were classified into either a stenosis (n = 39) or a nonstenosis (n = 34) group. CT scans were evaluated for relative attenuation, enhancement pattern, and HV abnormality for each graft. Doppler sonography evaluation of the flow pattern of HVs for each graft was performed. CT and Doppler sonography findings were compared in the stenosis and nonstenosis groups using the independent sample Student's t test and Fisher's exact test. Multifactorial logistic regression analysis was performed to determine the best predictors of the diagnosis of HV stenosis.

RESULTS

Heterogeneous enhancement (p = 0.046), abnormal HV on CT (p = 0.025), and HV wave pattern on Doppler sonography (p = 0.005) were significant findings. The accuracy for the diagnosis of HV stenosis was 60.0% for heterogeneous enhancement, 61.5% for abnormal HV, and 66.2% for a monophasic flow pattern. Heterogeneous enhancement and HV wave pattern were significant independent findings on multifactorial logistic regression analysis. The overall accuracy of the logistic model in the diagnosis of HV stenosis was 71.7%.

CONCLUSION

Although CT and Doppler sonography can be helpful in diagnosing HV stenosis, given the low accuracy of individual imaging findings, the diagnosis of HV stenosis should be made cautiously, with both CT and Doppler sonography regarded as complementary examinations.

Defibrotide for the treatment of hepatic veno-occlusive disease in children

BACKGROUND

This retrospective report describes experience with defibrotide in children with hepatic veno-occlusive disease (HVOD) following hematopoietic progenitor cell transplant (HPCT) in a single institution.

PROCEDURE

Children who had undergone HPCT between February 1999 and June 2001 and between July 2003 and September 2004 and who received defibrotide during their admission were identified. Demographic data and information regarding the clinical course of these patients were abstracted from their health records.

RESULTS

Fourteen children (mean age: 9.3 years; range: 0.4-18.1) who underwent HPCT during the study period received defibrotide for the treatment of HVOD; nine were girls. Most patients underwent HPCT for hematologic malignancies (8/14) and received matched unrelated donor transplants (8/14). Conditioning regimens included cyclophosphamide with total body irradiation (5/14) and busulfan followed by cyclophosphamide (7/14). HVOD was diagnosed on transplant day -4 to +33 (median: +10.5); defibrotide was started on transplant day -4 to +40 (median: +12). The median initial defibrotide dose was 33 mg/kg/day (11-40 mg/kg/day); the median maximum defibrotide dose was 38.5 mg/kg/day (11-81 mg/kg/day). The median duration of defibrotide therapy was 16 days (4-37 days). Defibrotide was discontinued due to clinical improvement (9), death (3), drug unavailability (1), and neurological toxicity (1). Gastrointestinal hemorrhage was observed in two patients and intra-cranial hemorrhage was observed in one patient during defibrotide therapy. The survival rate to day +100 was 79%.

CONCLUSIONS

Defibrotide appears to be an effective and relatively safe treatment for children with HVOD.

Gynura root induces hepatic veno-occlusive disease: A case report and review of the literature

Gynura root has been used extensively in Chinese folk medicine and plays a role in promoting microcirculation and relieving pain. However, its hepatic toxicity should not be neglected. Recently, we admitted a 62-year old female who developed hepatic veno-occlusive disease (HVOD) after ingestion of Gynura root. Only a few articles on HVOD induced by Gynura root have been reported in the literature. It is suspected that pyrrolizidine alkaloids in Gynura root might be responsible for HVOD. In this paper, we report a case of HVOD and review the literature.