Refined diagnostic criteria for SOS/VOD in adult patients: 2023 update by the EBMT

The European Society for Blood and Marrow Transplantation (EBMT) has published a paper on the refined diagnostic criteria for Veno-Occlusive Disease (VOD), also known as Sinusoidal Obstruction Syndrome (SOS). These updated guidelines mark a significant advancement in the early detection and management of this potentially fatal liver condition, particularly affecting patients undergoing high-dose chemotherapy or hematopoietic stem cell transplantation (HSCT).

Background: Understanding VOD

VOD is a severe hepatic complication characterised by the occlusion of small hepatic veins, leading to liver enlargement, jaundice, and fluid retention. It is a condition with high morbidity and mortality rates if not promptly recognised and treated. Historically, the diagnosis of VOD has been challenging due to the overlap of its symptoms with other post-transplantation complications, making the refinement of diagnostic criteria a critical need in the medical community.

The Need for Refinement

The EBMT's 2023 criteria aim to address the limitations of previous guidelines by incorporating new clinical insights and advancements in medical research. These refined criteria are designed to enhance specificity and sensitivity in diagnosing VOD, thereby facilitating earlier intervention and improving patient outcomes.

Key Changes in the Refined Criteria

1. New Diagnostic Categories:
   
   • The updated criteria introduce 3 diagnostic categories for VOD: probable, clinical, and proven. This stratification helps in identifying the disease at various stages of certainty and clinical manifestation.
     
     • Probable VOD: Based on clinical signs and laboratory findings suggestive of VOD but lacking full confirmatory evidence.
     • Clinical VOD: Diagnosed through more definitive clinical signs and imaging results.
     • Proven VOD: Confirmed by histological evidence or autopsy findings.
   • The criteria advocate for the use of non-invasive diagnostic methods to reduce patient risk. Advanced imaging techniques, including elastography for liver stiffness measurement (LSM), provide valuable diagnostic information without the need for invasive procedures like liver biopsies.
2. Diagnostic Parameter:
   
   • EASIX-d0 (Endothelial Activation and Stress Index at day 0) seems to be a promising biomarker to identify populations at high risk of VOD. Further studies examining its correlation with established SOS/VOD risk factors and severity are needed, according to the updated criteria.
3. Risk Factors Classification:
   • The criteria now classify risk factors into modifiable and unmodifiable categories, to provide guidance on reducing risk factors and improving patients’ management.
4. Severity Grading:
   
   • The severity grading of mild, moderate, severe, and very severe, must be applied once the diagnosis of VOD/SOS is performed, and can be applied for probable, clinical, or proven VOD.
   • Multiple organ dysfunction (MOD) is preferred over multiple organ failure (MOF), and thus the term MOD has been dropped.
   • The Sequential Organ Failure Assessment (SOFA) score is newly incorporated into the SOS/VOD severity grading system.

Implications for Clinical Practice

The implementation of the refined EBMT criteria is expected to revolutionize the approach to diagnosing and managing VOD. For healthcare providers, these guidelines offer a more precise framework for early identification and appropriate treatment.
The introduction of the Probable, Clinical, and Proven diagnostic categories, combined with the severity grading system and the SOFA score, allows for more tailored and timely therapeutic interventions. Early diagnosis and intervention are crucial for improving patient outcomes and preventing the progression of VOD to severe stages.

Future Directions

Ongoing research and clinical trials are essential to further validate these refined criteria and explore new diagnostic and therapeutic modalities. The integration of precision medicine and personalized treatment approaches holds promise for the future management of VOD.

Conclusion

The publication of the refined EBMT criteria for the diagnosis and severity assessment of Veno-Occlusive Disease represents a significant milestone in the field of hematopoietic stem cell transplantation and liver disease management. By providing clearer, more comprehensive guidelines, the EBMT aims to enhance early detection, improve diagnostic accuracy, and guide effective treatment strategies.
For clinicians and healthcare providers, staying informed about these updates is crucial for delivering high-quality care to patients at risk of VOD. As these refined criteria are adopted in clinical practice, they are expected to lead to better patient outcomes, reduced complications, and ultimately, saved lives.
The EBMT's commitment to refining and updating medical guidelines underscores the importance of continual improvement in healthcare standards, ensuring that advancements in clinical research translate into enhanced patient care.

Read the full published article:
Mohty M, et al. Diagnosis and severity criteria for sinusoidal obstruction syndrome/veno-occlusive disease in adult patients: a refined classification from the European society for blood and marrow transplantation (EBMT). Bone Marrow Transplant. 2023:58;749–754. https://doi.org/10.1038/s41409-023-01992-8



Posted on 19 June 202423 June 2024