ONS Connect - March 2008 - (Page 23)

Having an unrelated donor and advanced-stage malignancy also are substantial risk factors for hepatic SOS in pediatric patients. Symptoms and Diagnosis Clinical symptoms of hepatic SOS include unexplained weight gain, painful hepatomegaly, and jaundice. Diagnostic criteria include jaundice (total bilirubin > 2.0 mg/dl) and at least two of the following. • Hepatomegaly • Ascites • A gain of more than 5% of the patient’s total body weight Hepatic SOS is difficult to diagnose because of the many causes of hepatic toxicity in patients undergoing HSCT and because the diagnostic criteria overlap with many other complications that can occur following HSCT. Because of the danger of bleeding or infection from invasive procedures during HSCT, diagnosis of hepatic SOS often is made clinically based on the classic signs of weight gain, painful hepatomegaly, hyperbilirubinemia, and ascites. Transfemoral or transjugular liver biopsy and wedged hepatic venous pressure gradient measurement are the preferred methods of pathologic diagnosis of hepatic SOS. Percutaneous liver biopsy is not recommended. Doppler ultrasound of the liver, computed tomography of the abdomen, magnetic resonance imaging of the liver, and a hepatitis panel can assist in the clinical diagnosis. Management No definitive treatment exists for hepatic SOS, and recommendations center around supportive care measures. Approximately 70% of cases of hepatic SOS following HSCT will resolve spon- Case Study J.M., a 43-year-old man with acute myelogenous leukemia with a monosomy 7 cytogenetic abnormality, received an allogeneic hematopoietic stem cell transplant (HSCT) from his human leukocyte antigen–matched brother. Past treatments included idarubicin and cytarabine induction therapy followed by a cycle of high-dose cytarabine. J.M. was in complete remission prior to the HSCT. The conditioning regimen for the HSCT was busulfan and cyclophosphamide. Eighteen days after his HSCT, J.M.’s total bilirubin rose from 1.0 mg/dl to 3.6 mg/dl within 24 hours. His alkaline phosphatase, aspartate aminotransferase, and alanine aminotransferase were normal. J.M. complained of mild right upper-quadrant abdominal pain (3 on a 0–10 scale). J.M. had been gaining one to two pounds per day over the past few days, for a total of 10 pounds in the past week. He was slightly jaundiced. The transplantation team suspected that J.M. was developing hepatic sinusoidal obstruction syndrome (SOS). What were J.M.’s risk factors for hepatic SOS? What were J.M.’s diagnostic signs of hepatic SOS? What are the most reasonable management options for J.M.’s hepatic SOS? Visit http://bloodmarrow.vc.ons.org/page/4917 to discuss the case with other readers. taneously with supportive care. • Maintain adequate intake and output. • Adjust medication doses if hepatic and renal impairment is present. • Protect the patient’s kidney function. Defibrotide has been studied in the prevention and treatment of hepatic SOS. For recommendations, refer to Krimmel and Williams (2008). Nursing assessments should include monitoring mental status changes to detect the development of hepatic encephalopathy, daily measurement of abdominal girth for ascites, and daily weight measurement to assess fluid retention. Supportive care should continue until the hepatic SOS resolves and liver cells regenerate. ✱ Krimmel, T., & Williams, L.A. (2008). Hepatic sinusoidal obstruction syndrome following hematopoeitic stem cell transplantation. Oncology Nursing Forum, 35(1), 37– 40. March 2008 ONS CONNECT 23 http://bloodmarrow.vc.ons.org/page/4917

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ONS Connect - March 2008 Contents Editor's Note Just In From Then to Now A Year in the Life—Month Three Web Connect Capitol Connection Notice Nursing Now Recognize Hepatic Sinusoidal Obstruction Syndrome in Patients With Cancer Caregiver Care Elasticity of Cells May Help Researchers to Identify Cancer Calendar of Events ONS Congress Your Thoughts and Comments Are a Valued Decision-Making Resource Staying On Top

ONS Connect - March 2008

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