Veno-occlusive disease of the liver after blood and marrow transplantation: Analysis of pre- and post-transplant risk factors associated with severity and results of therapy with tissue plasminogen activator

We reviewed our blood and marrow transplantation (BMT) database from April 1982 to July 1996 and identified 111 of 474 patients with serum bilirubin concentration (SBR) ≥ 34 μmol/l for two onsecutive days within the first 20 days after related allogeneic or autologous BMT. Of the 111, 73 fulfilled the Seattle criteria for veno-occlusive disease of the liver (VOD) and had no other obvious cause for liver dysfunction. The patients were 16-60 years old (median, 39 years), and 41 were male (56%). Fourteen patients (19%) had autologous BMT, and 59 (81%) had allogeneic BMT. Twenty-eight (38%), 12 (16%), and 33 (45%) patients had severe, moderate, and mild VOD, respectively, by Seattle criteria. None of 23 patients with maximum (max) SBR ≥ 257 μmol/l survived, all patients with max SBR ≤ 128 μmol/l survived, and 7 of 15 patients (47%) with max SBR 128-257 μmol/l survived. The only pre-transplantation risk factor predictive of severe VOD was advanced disease state (P = 0.035), and the only transplant factors that predicted severe VOD were max SBR (P = 0.01) and maximum blood urea level (P = 0.03). Ten patients (all with creatinine levels ≥ 150 μmol/l) were treated with tissue plasminogen activator; only two had a significant response and only one survived beyond day 120.