Pyrrolizidine alkaloids-induced hepatic sinusoidal obstruction syndrome: Pathogenesis, clinical manifestations, diagnosis, treatment, and outcomes

Table 2 Diagnostic criteria for hepatic sinusoidal obstruction syndrome

HSCT-related HSOS			PAs-induced HSOS
Classical HSOS		Late onset HSOS (> 21 d after HSCT)	Criteria proposed by Gao et al[51]		Nanjing criteria[16]
Modified Seattle criteria[49]	Baltimore criteria[50]	New EBMT criteria[6]
Presence of 2 of the following criteria within 20 d after HSCT:	Presence of bilirubin ≥ 34.2 μmol/L within 21 d after HSCT and at least 2 of the following criteria:	Baltimore criteria beyond 21 d	1 Meeting the modified Seattle criteria		A definite history of taking herbs containing PAs
		OR
		Histologically proven HSOS			Pathological evidence	Presence of the following three criteria
			2 Meeting the criteria for DILI
						1 Abdominal distention and/or pain in the hepatic region, hepatomegaly, and ascites;
		OR
			3 A history of taking PAs-containing herbs; detection of PPAs
		Presence of at least 2 of the following criteria: Bilirubin ≥ 2 mg/dL (34.2 μmol/L)
						2 Increased serum total bilirubin or other abnormal liver function;
1 Bilirubin ≥ 34.2 μmol/L;	1 Hepatomegaly;	1 Hepatomegaly
2 Hepatomegaly or right upper quadrant pain;	2 Ascites;	2 Ascites
	3 Weight gain > 5%	3 Weight gain > 5%
3 Weight gain > 2%		AND hemodynamical or/and ultrasound evidence of HSOS
						3 Typical contrast-enhanced CT or MRI findings
				Other liver diseases were excluded

HSCT: Hematopoietic stem cell transplantation; HSOS: Hepatic sinusoidal obstruction syndrome; HVOD: Hepatic veno-occlusive disease; PAs: Pyrrolizidine alkaloids; DILI: Drug-induced liver injury; PPAs: Pyrrole-protein adducts; CT: Computed tomography; MRI: Magnetic resonance imaging.