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Imaging biomarkers to predict the development of sinusoidal obstruction syndrome of the liver in pediatric hematopoietic cell transplant recipients

Bone Marrow Transplantation (2026)Cite this article

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To the editor,

Sinusoidal obstruction syndrome (SOS), is a potentially life-threatening complication with high mortality that affects 20–60% of pediatric patients undergoing hematopoietic cell transplantation (HCT) [1]. Early recognition and prompt initiation of treatment are associated with improved survival. The current diagnostic criteria for SOS in children rely on clinical signs and symptoms, often leading to delayed diagnosis, with high variability in timing of diagnosis and initiation of treatment among providers [2,3,4,5]. Ultrasound is a widely available tool that is commonly used to evaluate the liver, however currently there is no consensus on which ultrasound parameters are most helpful to diagnose of SOS early [6]. We performed a retrospective single-center cohort study to evaluate the association between multiple ultrasound imaging biomarkers, including novel parameters such as the Doppler perfusion index (DPI) and liver stiffness measurement (LSM), and the development of SOS in pediatric HCT recipients.

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Fig. 1: Longitudinal trend analysis of DPI and LSM in HCT recipients with and without SOS.

Data availability

The original dataset will be shared for academic purposes upon request to the corresponding author at akshay.sharma@stjude.org

References

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Acknowledgements

The authors thank Keith A. Laycock, PhD, ELS, for scientific editing of the manuscript.

Funding

This study was supported by the National Institutes of Health (NIH)/National Cancer Institute (NCI) grant P30CA021765, including support by St. Jude Biostatistics Shared Resource (BSR), and by the American Lebanese Syrian Associated Charities (ALSAC). Elizabeth M. Holland and Akshay Patwardhan were participants in the Pediatric Oncology Education program at St. Jude, which is supported by NCI grant R25CA23944. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

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Authors and Affiliations

  1. University of Maryland School of Medicine, Baltimore, MD, USA

    Elizabeth M. Holland

  2. Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children’s Research Hospital, Memphis, TN, USA

    Elizabeth M. Holland, Shruthi Suryaprakash, Akshay Patwardhan, Dinesh Keerthi & Akshay Sharma

  3. Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN, USA

    Yu Bi & Subodh Selukar

  4. Department of Radiology, Cincinnati Children’s Hospital, Cincinnati, OH, USA

    Cara E. Morin

  5. Division of Radiology, Children’s Mercy, Kansas City, MO, USA

    Sherwin Chan

Authors
  1. Elizabeth M. Holland
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  2. Shruthi Suryaprakash
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  9. Akshay Sharma
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Contributions

Contribution: AS and EH initiated and designed the research; EH, DK and AP collected the data; EH, YB, AS, SSu and SSe analyzed the data; EH, YB, and SSu prepared the figures and wrote the initial draft of the manuscript; AS directed and supervised the research; CM and SC provided critical inputs to study design and analysis. All authors reviewed the manuscript critically and provided inputs to the final draft.

Corresponding author

Correspondence to Akshay Sharma.

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Competing interests

Akshay Sharma has received consultant fees from Medexus Inc., Vertex Pharmaceuticals, Editas Medicine, BioLineRx, and Gamida-Cell. He is a medical monitor for an RCI BMT clinical trial for which he receives financial compensation. Akshay Sharma is also the St. Jude Children’s Research Hospital site principal investigator for clinical trials of genome editing for sickle cell disease sponsored by Vertex Pharmaceuticals/CRISPR Therapeutics (NCT03745287), Novartis Pharmaceuticals (NCT04443907), and Beam Therapeutics (NCT05456880). The industry sponsors provide funding for the clinical trials, which includes salary support paid to the investigator’s institution. Akshay Sharma has no direct financial interest in these therapies. These conflicts are managed through the compliance office at St. Jude Children’s Research Hospital in accordance with their conflict-of-interest policy. The other authors have nothing to disclose.

Ethics approval and consent to participate

Study procedures were performed in accordance with the relevant guidelines and regulations. The study was approved by institutional review board (IRB) at St. Jude Children’s Research Hospital (IRB Reference Number: 040351) and was granted an exemption to obtain informed consent from every participant.

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Holland, E.M., Suryaprakash, S., Bi, Y. et al. Imaging biomarkers to predict the development of sinusoidal obstruction syndrome of the liver in pediatric hematopoietic cell transplant recipients. Bone Marrow Transplant (2026). https://doi.org/10.1038/s41409-026-02815-2

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