Summary:We evaluated 40 patients undergoing high-dose chemo/ radiotherapy (HDCT) and hematopoietic stem cell transplantation (HSCT) (allogeneic (22), autologous (18)) to determine the safety and feasibility of administering low molecular weight heparin (LMWH) as hepatic veno-occlusive disease (VOD) prophylaxis. Patients received a once daily subcutaneous injection of dalteparin 2500 anti-Xa i.u. commencing the day prior to starting HDCT, and continuing until day +30 post HSCT or hospital discharge, whichever came first. Dosage adjustments were made for patients developing renal failure. All bleeding episodes were recorded and graded and VOD was diagnosed and graded according to Seattle criteria. At 100 days of follow-up, the overall survival and probability of regimen-related mortality were 85 and 15%, respectively. Nine patients developed VOD. The probability of developing VOD post allogeneic and autologous HSCT was 28% (95% CI, 6-45) and 17% (95% CI, 0-32), respectively. VOD was graded as moderate (n ¼ 8) and severe (n ¼ 1). VOD resolved in all cases except for one patient who died secondary to severe VOD and multiorgan failure. Clinically significant bleeding episodes occurred in three patients; 24 patients developed minor bleeding not requiring specific therapy. All bleeding episodes resolved. These results suggest that LMWH for VOD prophylaxis is safe with a low incidence of serious bleeding events. Whether it is superior to unfractionated heparin, however, is unknown and should be addressed within the context of a randomized controlled trial. Bone Marrow Transplantation (2003) 31, 1143-1149. doi:10.1038/sj.bmt.1704087 Keywords: low molecular weight heparin; VOD High-dose chemo/radiotherapy (HDCT) and hematopoietic stem cell transplantation (HSCT) are widely used to treat many malignant and nonmalignant conditions. Regimen-related toxicity (RRT) remains a frequent and major complication of HSCT. 1 Hepatic veno-occlusive disease (VOD) is one of the most common life-threatening RRTs reported to occur in 5-60% of patients undergoing HSCT. [2][3][4][5][6][7][8] Clinically, VOD is characterized by jaundice, painful hepatomegaly, ascites and weight gain from fluid retention. In its most severe form, it often leads to multiorgan failure and death. 6-8 Hepatic VOD is thought to result from injury to hepatocytes surrounding the central veins in zone 3 of the liver acinus. Early pathologic changes include edema of the subendothelium of hepatic venules, followed by thrombosis of the venular lumen. 9 Risk factors for VOD have been reported to include a previous history of viral hepatitis, abnormal liver function tests at the time of HDCT and HSCT, the use of high-dose preparative regimens, mismatched or unrelated donor HSCTs, and the use of vancomycin or amphotericin B. [2][3][4][5][6][7][8][10][11][12][13] A number of prophylactic strategies have been explored in an attempt to prevent the injury and subsequent thrombosis of hepatic venules and therefore decrease the risk of VOD. They include the administration of pros...