Passive transfer of nut allergy after liver transplantation

Atopy and allergy following solid organ transplantation: A 15-year experience

AIM

There are increasing reports of atopy/allergy following solid organ transplantation, especially paediatric liver transplantation (LT) with minimal New Zealand (NZ) data. We describe the prevalence of transplant-acquired atopy and allergy (TAA) in NZ paediatric liver transplant recipients, compared to paediatric kidney and adult liver transplants.

METHODS

TAA focussed health questionnaires were sent to patients selected from the NZ transplant registry (transplanted between January 2003 and December 2017). Demographic and clinical data were also obtained from electronic health records and follow-up phone calls.

RESULTS

A total of 232 patients (62% male) participated (111 adult liver, 82 paediatric liver, 39 paediatric kidney transplant recipients). Tacrolimus was primary immunosuppression for all LT patients; with combined tacrolimus, mycophenolate and corticosteroids for kidney transplants. The number of patients who developed TAA was significantly higher (P < 0.001) in the paediatric LT group (36/82, 44%) compared to adult liver (12/111, 11%) and paediatric kidney transplants (4/39, 10%). Eczema was most common (73%), then IgE-mediated food allergy (FA, 33%), allergic rhinitis (19%) and asthma (17%). Six paediatric LT recipients developed eosinophilic oesophagitis (EoE). Egg was the most common allergen in the IgE-mediated FA group. TAAs were severe enough to warrant a switch from tacrolimus to another agent in seven paediatric LT patients. For paediatric LT patients, female gender and younger age at transplant were risk factors for developing TAA.

CONCLUSIONS

TAA is common in paediatric liver transplant recipients, with female gender and younger age at transplant being risk factors identified. This highlights the need for detailed atopic and allergy history to be incorporated in all pre-transplant assessments.

De novo Food Allergy After Pediatric Liver Transplantation: A Systematic Review

Background

Liver transplant (LT) recipients, particularly children, have an increased risk of developing de novo food allergies (FAs) after transplantation both compared to all the other transplant groups and to the general population. Little is known about the pathogenesis underlying this phenomenon and comprehensive recommendations or clinical practice guidelines are still lacking, mainly due to the scarcity of high-quality evidence.

Aim

We aimed to prepare a systematic review on de novo FA in pediatric LT recipients to assess epidemiology and risk factors, evaluate the correlation to specific food groups, describe clinical manifestations, investigate the rate of tolerance acquisition over time and report available therapeutic strategies.

Methods

We conducted this systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). MEDLINE, Scopus, Web of Science, Wiley online library, Cochrane Library, and ClinicalTrials.gov databases were systematically searched for studies published from January 1980 to September 2021. All the articles were checked independently by two reviewers in two steps. A total of 323 articles were screened, and 40 were included for data extraction.

Results and Conclusions

We found that de novo FAs develop in the 15% of pediatric LT recipients, especially in the first 2 years after surgery, with higher risk related to younger age at transplantation (especially <2 years of age) and tacrolimus immunosuppression. Subjects are often allergic to multiple foods, and 15% of them suffer from anaphylaxis. The majority of patients do not spontaneously outgrow their symptoms during follow-up. The discontinuation of tacrolimus in favor of cyclosporine or the association of tacrolimus with mycophenolate have been associated with the resolution or the improvement of FA in small retrospective case series and could be considered in case of severe or multiple, difficult to manage FAs. Prospective multicenter studies are needed to confirm these findings, guide the risk-based stratification of pediatric LT recipients, and provide for high-evidence therapeutic strategies for children with de novo FA.

Development of New White Fish Allergy after Bone Marrow Transplantation from a Non-atopic Donor

Background: Transplant-acquired food allergy has become increasingly recognized in solid organ and bone marrow transplantation. As food allergy has no cure and causes considerable impact on the lives of patients who require strict avoidance of foods to avoid potentially severe or fatal reactions, it is crucial for physicians to better understand the risk factors and mechanisms driving development of food allergy post-transplant. We report a case of new food allergy to whitefish in an elderly patient post-bone marrow transplant in which neither donor nor recipient had a history of atopy. Methods: A 70-year-old man experienced an anaphylactic reaction to Swai whitefish (Pangasius hypophthalmus) 6 months post-transplant that he had previously tolerated on multiple occasions both pre-transplant and in the preceding months post-transplant. This allergy was investigated by commercial serum specific IgE testing and fresh prick-to-prick skin test to Swai whitefish. Results: Fresh prick-to-prick demonstrated large positive reaction to the Swai whitefish with wheal of 10 mm and flare of 22 mm compared to positive histamine control with a wheal/flare of 5x8mm. Serum specific IgE testing to commercial whitefish was negative (specific IgE <0.10kU/L). The patient continues to strictly avoid Swai whitefish but tolerates all other fish and shellfish. Conclusions: The unique development of specific Swai whitefish allergy in an elderly man after bone marrow transplant where both donor and recipient had no prior history of atopy strongly supports transplant-related immunomodulation as a major mechanism for transplant-acquired allergy and suggests that that absence of atopy or advanced age may not necessarily be protective.

Transfer of peanut allergy from donor to recipient after liver transplant

31 years old female with a history of contact dermatitis, eczema, allergic rhinitis, pernicious anemia, alopecia areata and latent tuberculosis was treated concurrently with methotrexate along with isoniazid and pyridoxine. Five months into the therapy she developed acute onset jaundice progressing into fulminant liver failure with altered mentation and worsening liver function tests. Extensive workup including serological and histopathological evaluation revealed drug-induced liver injury as the etiology of her liver failure and she underwent a successful orthotropic liver transplant. On post-transplant follow-up at four months, she was noted to have an allergic reaction consisting of a perioral rash and swelling (without anaphylaxis) after receiving a kiss from her significant other who had just eaten a peanut butter chocolate. She denied any history of allergic reaction to peanuts prior to the transplant. Percutaneous skin testing revealed immediate hypersensitivity to peanut, hazelnut, and pecan believed to be acquired newly post-transplant. Further investigation revealed that the organ donor had a documented history of systemic anaphylaxis from the peanut allergy and a positive peanut-specific IgE level. Also, another parallel solid organ recipient (lung transplant) from the same organ donor experienced a serious anaphylactic reaction after peanut exposure. This is a case of food (peanut) allergy transfer from the donor to the recipient after the liver transplant. This case highlights the importance of incorporating known donor allergies as a part of pre-transplant screening, given the potentially serious consequences from the transfer of allergies to a previously anergic recipient.

Management of allergy transfer upon solid organ transplantation

Allergy transfer upon solid organ transplantation has been reported in the literature, although only few data are available as to the frequency, significance, and management of these cases. Based on a review of 577 consecutive deceased donors from the Swisstransplant Donor-Registry, 3 cases (0.5%) of fatal anaphylaxis were identified, 2 because of peanut and 1 of wasp allergy. The sera of all 3 donors and their 10 paired recipients, prospectively collected before and after transplantation for the Swiss Transplant Cohort Study, were retrospectively processed using a commercial protein microarray fluorescent test. As early as 5 days posttransplantation, newly acquired peanut-specific IgE were transiently detected from 1 donor to 3 recipients, of whom 1 liver and lung recipients developed grade III anaphylaxis. Yet, to define how allergy testing should be performed in transplant recipients and to better understand the impact of immunosuppressive therapy on IgE sensitization, we prospectively studied 5 atopic living-donor kidney recipients. All pollen-specific IgE and >90% of skin prick tests remained positive 7 days and 3 months after transplantation, indicating that early diagnosis of donor-derived IgE sensitization is possible. Importantly, we propose recommendations with respect to safety for recipients undergoing solid-organ transplantation from donors with a history of fatal anaphylaxis.

Incidence, clinical features, and outcomes of food allergy in children who underwent liver transplant: 16-year experience

Food allergies often develop after liver transplant, especially in young children. However, data are scarce on clinical characteristics and patient outcomes. When we evaluated our pediatric liver transplant patients over a 16-year period, food allergy incidence was 8% (19/236 patients). All patients with food allergies were <18 months old, with incidence in this age group of 19.2% (19/99). Two patients had a single food and 17 had multiple food allergies. Five patients showed only non-IgE-mediated food allergies. Eggs, milk, nuts, and wheat were the most common allergens. Presenting symptoms included diarrhea, flushing, angioedema attacks, wheezing/chronic cough, and vomiting. Seven patients had EBV, and two patients had CMV infections at time of food allergy diagnosis. Twelve patients had eosinophilia. Seven patients (36.8%) were able to regain tolerance to all food allergens. However, one patient with single nut allergy and three with multiple food allergies were still on allergen-eliminated diets. Eight patients with multiple food allergies gained tolerance to some of the food allergens. In conclusion, food allergies in our patients were mainly against multiple foods and IgE mediated. Infections like EBV and CMV may play a role in food allergies after liver transplant, especially in pretransplant-naive patients.

Asthma, Eczema, and Food Allergy in Children Following Liver Transplantation

OBJECTIVES

To describe the prevalence and the relationship between asthma, eczema, food allergy, and rhinitis in children after liver transplantation.

STUDY DESIGN

Children who were liver transplant recipients were investigated to assess whether the high prevalence of food allergies was accompanied by eczema, rhinitis, and asthma. Furthermore, we included 56 children with chronic liver disease to explore the risk of allergy, eczema, and asthma in this group.

RESULTS

After liver transplantation, children had higher prevalence of allergic reactions to food as compared with children with chronic liver disease (P < .001). Current asthma (P = .04) and eczema (P < .02) were observed more frequently in transplanted children as compared with children with chronic liver disease. For transplanted children who had ever received tacrolimus the relative risk (RR) of asthma was 1.7 (95% CI, 1.2-2.4; P = .02) as compared with children with chronic liver disease. Transplanted children with asthma had higher rates of sensitization to food allergens than those without asthma (RR, 3.6; 95% CI, 1.3-10.3; P = .01). The most frequent food allergens associated with asthma in transplanted children were milk (RR for asthma, 3.9; 95% CI, 1.6-9.4; P < .01), eggs (RR, 2.9; 95% CI, 1.2-7.0; P = .03), and peanuts (RR, 3.7; 95% CI, 1.6-8.3; P < .01). Food allergies occurred earlier than asthma, at 1.5 years after transplantation (IQR, 0.5-3.0 years) vs 2.5 years after transplantation (IQR, 1.0-4.5 years; P < .05). Food allergies were also associated with eczema, but not with sensitization to aero-allergens or rhinitis.

CONCLUSIONS

The high risk of food allergies in children who were liver transplant recipients was associated with eczema and asthma, but not rhinitis. The most frequent food allergens associated with asthma were milk, eggs, and peanuts.

Liver-associated immune abnormalities

In recent years, the cross talk between the liver and the immune system is being uncovered, in part by studying liver involvement in primary immune deficiencies (PID) and in part by investigating the alterations of the immune system following orthotopic liver transplantation (OLT). Here we review some of the reciprocal interactions between the liver and the immune system. Patients with PID, particularly those involving inherited defects in T and B cells or innate immunity are prone to infections and inflammatory responses that often involve the liver. Omenn's syndrome, familial hemophagocytic lymphohistiocytosis, AIRE, FOXP3 and CD25 deficiencies, common variable immunodeficiency, CD40 ligand deficiency, chronic granulomatous disease and autoimmune lymphoproliferative syndrome are some of the notable PID associated with typical hepatobiliary abnormalities. Knowledge gained from studying these PID together with laboratory and histological evaluations can assist in managing PID-associated liver dysfunction. The liver itself also has important effects on the immune system, as evident from the growing experience with patients surviving OLT. Up to 40% of pediatric patients who receive OLT suffer from post transplantation allergy, autoimmunity, and immune-mediated disorders (PTAA). PTAA is more common after liver and heart transplantations than kidney transplantations. Potential contributing factors for the increased frequency of PTAA after OLT include the age of the patients, the prolonged use of tacrolimus and the reduced regulatory immune function with a shift towards a TH2 immune response. Better understanding of the mechanisms leading to the development of PTAA after OLT will also improve the management of these conditions.

Post-transplantation Development of Food Allergies

PURPOSE OF REVIEW

The development of food allergies is increasingly being recognized as a post-solid organ transplant complication. In this article, we review the spectrum of post-transplant food allergy development and the proposed mechanisms for de novo food allergies and the clinical significance they pose.

RECENT FINDINGS

The development of new food allergies is disproportionately associated with pediatric liver transplants, where it occurs in up to 38% of select populations. The mechanism of food allergy development is not completely understood; however, it is likely promoted by unbalanced immune suppression. De novo food allergy development is a common complication of solid organ transplants with the highest risk occurring in pediatric liver transplant recipients. There are likely multiple mechanisms for food allergy development including passive transfer of membrane-bound IgE and lymphocytes from donor to recipient, as well as loss of food tolerance and active development of new food allergies. The optimal management of food allergies following organ transplants has not been well researched but may include changing the immune suppression regimen if the food allergy does not resolve without intervention.

Donor-derived infections in solid organ transplant patients: toward a holistic approach

PURPOSE OF REVIEW

Solid organ demand far exceeds organ supply. Strategies to increase the donor pool include the liberalization of selection criteria without increasing the risk of unexpected donor-derived infection (DDI), a rare complication of transplantation carrying high morbidity and mortality. We review the challenging aspects in the prevention of DDI, focusing on the complexities of data sharing and efficient communication and the role infectious diseases specialists play in the process.

RECENT FINDINGS

Advances in donor screening, transmission recognition and reporting allow for a better estimation of the risk of DDI. However, there is great variability in the frequency and methods with which organ procurement organizations report transmission events.Moreover, the Scientific Registry of Transplant Recipients provides limited donor and recipient outcome infectious diseases related data. Infectious disease contribution to the allocation process has been found to improve organ donation efficiency and communication between involved parties. Although communication gaps are strongly associated with infection transmission (relative risk 2.36%, confidence interval 1.48-3.78), effective communication minimizes or prevents infection in transplant recipients (X(1) 13.13, P = 0.0003).

SUMMARY

Prospective research is still required to define optimal screening protocols and further prevent transmission of infection. A holistic approach is likely to result in enhanced transplantation safety. Toward this goal, development of standards of investigation; improvement in reporting and data sharing; and strategies ensuring coordinated and rapid communication among parties involved in the allocation process need to be pursued.

Transplant-acquired food allergy: current perspectives

Mechanisms that regulate the tolerance to dietary proteins or the loss of this and subsequent development of disease are poorly understood. In food allergy, there is growing awareness of the urgency in understanding these events to aid in the development of next-generation therapies and interventions. This review focuses on the accumulating evidence related to food allergy that develops after transplantation. This intriguing immunological phenomenon has been described in several different types of transplant settings and to variety of different foods. We outline these studies and the evidence from them that support transplant-acquired food allergy being a process regulated by both the donor allergic status and the recipient genetics and treatments. A number of key risk factors seem prevalent throughout transplant-acquired food allergy and include type of transplant, age and general health of the recipient, modality of immunosuppression and potentially the genetics of both donor and recipient. Importantly, these studies provide a window into better general understanding of food allergy, and facilitate clearer understanding of the critical immunological and epidemiological factors needed to allow the adoptive transfer of a food-specific allergic disease from one individual to another.

Developments in the field of allergy in 2016 through the eyes of Clinical and Experimental Allergy

In this article, we described the development in the field of allergy as described by Clinical and Experimental Allergy in 2016. Experimental models of allergic disease, basic mechanisms, clinical mechanisms, allergens, asthma and rhinitis, and clinical allergy are all covered.

B cells establish, but do not maintain, long-lived murine anti-peanut IgE(a)

BACKGROUND

Peanut allergy (PNA) has been reported to be transferred to tolerant recipients through organ and bone marrow (BM) transplantation. The roles T and B cells play in establishing, and the roles B cell subsets play in maintaining lifelong anti-peanut IgE levels are unknown.

OBJECTIVES

To determine the cellular requirements for the transfer of murine PNA and to determine the role CD20(+) cells play in maintaining long-lived anti-peanut IgE levels.

METHODS

We developed a novel adoptive transfer model to investigate the cellular requirements for transferring murine PNA. We also treated peanut-allergic (PA) mice with anti-CD20 antibody and measured IgE levels throughout treatment.

RESULTS

Purified B220(+) cells from PA splenocytes and purified CD4(+) cells from naïve (NA) splenocytes are the minimal requirements for the adoptive transfer of PNA. Prolonged treatment of allergic mice with anti-CD20 antibody results in significant depletion of B cell subsets but does not affect anti-peanut IgE levels, symptoms, or numbers of IgE antibody secreting cells (ASCs) in the BM. Adoptive transfer of BM and spleen cells from allergic donors treated with anti-CD20 antibody does not result in the transfer of PNA in NA recipients, demonstrating that anti-CD20 antibody treatment depletes B cells capable of differentiating into peanut-specific IgE ASCs.

CONCLUSIONS AND CLINICAL RELEVANCE

Peanut allergy can be established in a NA hosts with B220(+) cells from PA donors and CD4(+) cells from peanut-NA donors. However, long-term depletion of B220(+) cells with anti-CD20 antibody does not affect anti-peanut IgE levels. These results highlight a novel role for B cells in the development of PNA and provide evidence that long-lived anti-peanut IgE levels may be maintained by long-lived ASCs.

Food allergies developing after solid organ transplant

The development of food allergy is an increasingly recognized form of morbidity after solid organ transplant. It occurs more commonly in liver transplant recipients, although it has also been reported in heart, lung, kidney, and intestinal transplants. Pediatric transplant recipients are more likely to develop symptoms compared to adults, and reports of frequency vary widely from 5% to 38% in pediatric liver transplant recipients. Multiple mechanisms have been proposed in the literature, although no single mechanism can yet account for all reported observations. As food allergy can have at worst potentially fatal consequences, and at best require lifestyle adjustment through food avoidance, it is important for recipients to be aware of the donor's food allergies and particularly in pediatrics, the possibility of completely de novo allergies. This review explores the recent reports surrounding food allergy after solid organ transplant, including epidemiology, proposed mechanisms, and implications for practice.

Transfer of peanut IgE sensitisation after combined pancreas-kidney transplant

BACKGROUND

The transfer of peanut allergy has been reported following solid organ transplantation.

OBJECTIVE

Present a case of peanut sensitization following combined pancreas-and-kidney transplantation.

METHODS

Circulating specific IgE against peanut were measured in serum samples collected from the transplant recipient 1 month before transplantation, and 1, 3 and 6 months after transplantation. Skin tests were performed 1, 3 and 6 months following transplant.

RESULTS

The organ recipient's pre-transplant peanut IgE levels were negative. At 1 month post-transplant, the patient had a 6 mm skin test to peanut and had serum IgE to peanut Arah1 of 0.79 kU/L. At 3 months, skin test size and IgE to peanut Arah1 decreased to 4 mm, and 0.69 kU/L respectively. At 6 months, the patient's skin test and IgE to peanuts were negative. At that time, the patient underwent a peanut food challenge without a clinical reaction to suggest allergy.

CONCLUSION AND CLINICAL RELEVANCE

We report the development of IgE peanut sensitization in a recipient of a combined pancreas and kidney transplantation. Increasing awareness of this allergen sensitization following transplantation may help prevent serious allergic reactions in transplant recipients.

Food allergy: a practice parameter update-2014

This parameter was developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma & Immunology (AAAAI); the American College of Allergy, Asthma & Immunology (ACAAI); and the Joint Council of Allergy, Asthma & Immunology (JCAAI). The AAAAI and the ACAAI have jointly accepted responsibility for establishing "Food Allergy: A practice parameter update-2014." This is a complete and comprehensive document at the current time. The medical environment is a changing one, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, ACAAI, and JCAAI. These parameters are not designed for use by pharmaceutical companies in drug promotion.

New developments in transplant-acquired allergies

Transplant-acquired allergy (TAA) was firstly described as transplant-acquired food allergy (TAFA) after bone marrow transplantations and mostly observed in a transient form. The picture is complicated by numerous case reports of TAFA after the receipt of liver grafts from donors with no documented history of food allergy. The estimated prevalence of TAFA among young children in the literature has been documented in various studies ranging from 6% to 57%. Although TAA is mostly found to be associated with liver transplantation; it has been recently reported to be related with heart, intestinal, lung and even renal transplantations in adults. Previous reviews of published cases of liver TAA misleadingly emphasized the predominance of children and the absence of TAA in cardiac, pulmonary, and renal transplant recipients. In different studies, the male/female ratio is equal. Literature data suggest that children with TAFA typically present within the first year after surgery and are typically allergic to multiple foods. The pathogenesis of TAA is not still completely understood. Most of the studies support the concept that the functioning liver itself, and not only tacrolimus immunosuppression, is one of the main contributors to TAA in these patients. In the light of recent findings, other possible mechanisms can be summarized as following: (1) the recovery of delayed type hypersensitivity; (2) late manifestation of food allergy; (3) intestinal injury as well as inhibition of cellular energy production by tacrolimus; and (4) transfer of food-specific IgE or lymphocytes. Thus, interplay between hematopoietic cells from the transplanted organ and recipient specific factors (e.g., younger age and atopic background) seem to underlie the development of TAA. Most patients will have symptomatic improvement following reduced immunosuppression and an appropriately restricted diet. Nevertheless, some studies suggest that atopic diseases occur in some of pediatric liver transplant recipients, with manifestations including food allergy, eczema, allergic rhinitis, and asthma. More studies would be needed including greater number of patients to determine whether TAA is transient or not in pediatric/adult solid organ recipients.

De novo food sensitization and eosinophilic gastrointestinal disease in children post-liver transplantation

BACKGROUND

Children have increased prevalence of food allergy (FA) and eosinophilic gastrointestinal disease (EGID) following liver transplantation. The aim of this study was to identify related risk factors.

METHODS

Chart review of pediatric liver transplant (LT) recipients with de novo FA and/or EGID post-LT and non-allergic controls.

RESULTS

We identified 30 (8.5%) children with FA and/or EGID among 352 pediatric LT recipients. Median age at transplant was 0.9 inter-quartile range (IQR 0.6-2.0) years. FA developed at a median 1.0 (IQR 0.5-8.2) yr post-LT and manifested with gastrointestinal symptoms (53%) or urticaria/angioedema (40%). Commonly avoided foods included milk (60%), egg (57%), and peanut (47%). Of the 15 children with FA who underwent endoscopy, 11 had eosinophilic infiltrates in multiple segments of the esophagus alone or in combination with other bowel segments. FA and EGID were linked to transplantation at a younger age (median, 0.9 vs. 5.5 yr), higher frequency of blood eosinophilia, and prior history of rhinitis and atopic dermatitis. Tacrolimus use and tacrolimus serum levels were similar between allergic subjects and controls.

CONCLUSIONS

Findings suggest that exposure to tacrolimus alone post-LT is insufficient to initiate de novo allergic disease in LT recipients; rather, younger age and underlying predisposition to atopic disease may play larger roles.

Development of transient peanut allergy following lung transplantation: a case report

A 47-year-old woman underwent bilateral lung transplantation for nonspecific interstitial pneumonitis and received donor lungs from a 12-year-old patient with a known peanut allergy. Post-transplant, the patient experienced four anaphylaxis-like reactions. A skin prick test to peanut was initially positive; however, it steadily declined over serial assessments and reverted to negative one year post-transplant. The patient subsequently had a negative oral peanut challenge. Transfer of food allergy post-transplantation is theorized to occur via transfer of donor B lymphocytes producing peanut-specific immunoglobulin E into the circulation of the recipient. An alternate mechanism proposes passive transfer of immunoglobulin E-sensitized mast cells and⁄or basophils within the transplanted tissue that subsequently migrate into recipient tissues. The gradual decline in the magnitude of the peanut skin prick test and its return to negative over the course of one year supports the gradual depletion of sensitized cells in the recipient (B lymphocytes and, possibly, mast cells), and supports the initial passive transfer of sensitized cells from donor tissue during transplantation. This should be considered when donor organs are obtained from allergic individuals.

Presentation of atopic disease in a large cohort of pediatric liver transplant recipients

Atopic disease occurs in solid organ transplant recipients with an increasingly recognized frequency. The time course for the development of these atopic diseases in liver transplantation has not been described. The objective was to characterize the atopic manifestations of children receiving chronic immunosuppression after orthotopic liver transplantation (OLT). Chart review and follow-up questionnaire were utilized for 176 OLT pediatric recipients at a single institution for manifestations of allergic disease. Atopic disease was present in 25 (14.2%) patients. Median age at transplant was 16 months with a median follow-up of 63 months. Food allergy and non-food related atopic symptoms presented at a median of 11.5 (IQR, 6-28) and 19 (IQR, 5-41) months post-transplantation, respectively. The median age at transplant of the non-atopic children was 72 months, higher than patients with atopy (p < 0.001). Food allergy and atopic skin disease symptoms were present in 40% and 56% of cases, respectively. Asthma, allergic rhinitis, or both were found in 66% of cases. The onset of symptoms of food allergy and eczema (median, 12 months post-transplantation) preceded symptoms of allergic rhinitis and asthma. (median of 27 and 30 months post-transplantation, respectively). Atopy occurs in ∼14% of pediatric liver transplant recipients, with manifestations including food allergy, eczema, allergic rhinitis, and asthma.

Transfer of peanut allergy following lung transplantation: a case report

This case study describes a patient who developed peanut allergy following lung transplantation. A 54-year-old woman underwent bilateral lung transplantation on June 2009 owing to severe chronic obstructive pulmonary disease. She had no history of food allergy before transplantation. The donor, however, was a 20-year-old man who was fatally injured during an automobile accident; he was allergic to peanuts. At 3 months after transplantation, the lung recipient presented with acute dyspnea and urticaria 15 minutes after consuming food containing peanut derivatives. Pre- and posttransplantation recipient blood samples analyzed for the presence of IgE antibodies specific for peanut allergens confirmed that the allergy had been passively transfered as a consequence of transplantation. Food allergy following solid organ transplantation is thought to be rare, mostly occurring in children. Two mechanisms may explain the observations described for the patient reported in this study: de novo development of peanut allergies after transplantation, or passive transfer of peanut allergies from a peanut-sensitized organ donor. This case report documenting pre- and posttransplantation IgE status in a lung transplantation case suggested that the allergic status of organ donors should be thoroughly assessed before transplantation, and potential allergy transfer risks must be discussed with the transplant team and the patient.

Long term outcome of acquired food allergy in pediatric liver recipients: a single center experience

Food induced sensitization has been reported in pediatric liver recipients. However long term follow up has not been established so far.We report here our experience regarding 3 pediatric patients who developed acquired food allergy after liver transplantation. The first patient suffered from persistent diarrhea and eczema. The second one presented with abdominal pain with no signs of rejection, abdominal discomfort, vomiting when ingesting milk proteins and responded well to the elimination diet. The third patient presented with facial angioedema and hoarseness of voice. She had multiple food allergies and reacted to milk, egg and sesame. All the patients had elevated total Immunoglobulin E (IgE) and elevated specific IgE antibodies to the implicated food allergens. The first patient presented clinical manifestations of allergy when she was 19 months old. The second patient became allergic at the age of 16 and the third patient at the age of 3. The symptoms of food allergy persisted for 8 years in the first case and for 2 years in the other two cases. Low levels of specific IgE antibodies to the implicated food allergens and an enhanced T-helper 1 cell immune response toward interferon-gamma production were markers of tolerance acquisition. The long term prognosis in our cases was excellent. Food allergy resolved in all the patients. The long term prognosis of acquired food allergy after liver transplantation is currently obscure. More studies would be needed including greater number of patients to determine whether acquired food allergy is transient in pediatric liver recipients.

Passive transient transfer of peanut allergy by liver transplantation

We report a case of transient symptomatic transferred IgE-mediated peanut allergy after elective blood-group compatible liver transplantation. We show that the allergy was transient and therefore passive, authorizing further uneventful peanut consumption. Skin tests with commercial peanut extract and native peanut were performed in the recipient. Circulating specific IgE against peanut and recombinant peanut allergens (rArah1, rArah2, rArah3) was measured in stored serum samples collected from the recipient between 6 months before and 8 months after liver transplantation. Specific IgE levels in the donor were measured at the time of multiorgan donation. In the recipient, diagnosis of IgE-mediated peanut anaphylaxis was based on the clinical history and detection of specific IgE against peanut and recombinant major peanut allergens (rArah1, rArah2 and rArah3). Skin tests were negative and specific IgE undetectable 6 months after the clinical reaction. Oral peanut challenge was negative excluding persistent peanut allergy. This case confirms that IgE-mediated peanut allergy can be transferred by liver transplantation and shows that it may be transient and therefore passively acquired.

Allergic sensitization in kidney-transplanted patients prevails under tacrolimus treatment

BACKGROUND

Type I allergies have repeatedly been reported after solid organ transplantation despite T cell-targeted immunosuppressive therapy. A causal relationship with tacrolimus has been proposed.

OBJECTIVE

The present study directly compared the occurrence of allergic sensitization and disease under tacrolimus- vs. cyclosporin A-based immunosuppressive therapy.

METHODS

The prevalences of IgE-mediated sensitization and allergy were assessed in a cross-sectional study of kidney-transplanted adults receiving tacrolimus (n = 100) or cyclosporin A (n = 100).

METHODS

included a standardized questionnaire, skin prick test and measurement of total and specific IgE against common nutritive and inhalant allergens. Results The prevalence of sensitization was significantly higher in the tacrolimus- than in the cyclosporin A-treated group (34%, n = 34, vs. 20%, n = 20; P = 0.026). The rate of clinically relevant allergy in patients receiving tacrolimus was twice that in patients receiving cyclosporin A (15%, n = 15, vs. 8%, n = 8; P = 0.12). No other factor (age, serum drug level, concomitant immunosuppressive medication, time since transplantation, underlying disease) was found to have an influence on sensitization or allergy prevalence (logistic regression).

CONCLUSION AND CLINICAL RELEVANCE

Our results suggest that post-transplant immunosuppression with tacrolimus is associated with an increased occurrence of IgE-mediated sensitization and probably manifestation of allergic disease, which has to be treated specifically despite immunosuppressive therapy.

Food allergy: transfused and transplanted

The inadvertent transfer of food allergy from an allergic donor to an unsuspecting recipient by transfusion or organ donation is a relatively rare but intriguing event with potentially catastrophic consequences. Additionally, the development of food allergy in the recipient of a transplant from a donor who was not food allergic poses questions about why this occurs, why it is observed more frequently in some situations than others, and the mechanisms that may be involved. In this review, the transfer of food allergy by transfusion, bone marrow transplantation, and the transplantation of different solid organs is explored, and potential mechanisms in addition to the importance of careful monitoring are discussed.

New-onset post-transplantation food allergy in children--is it attributable only to the immunosuppressive protocol?

New-onset post-transplantation food allergy has been described mainly after liver transplantation, and its pathogenesis was attributed to the immunomodulatory effects of tacrolimus therapy. The aim of the present study was to evaluate the association of food allergy with solid organ transplantation in our center. The medical records of children who underwent kidney transplantation and children who underwent liver or liver and kidney transplantation from 1986 to 2005 were reviewed. A total of 189 children (124 after kidney transplantation, 65 after liver or liver and kidney transplantation) received tacrolimus as part of the immunosuppressive regimen. New-onset post-transplantation food allergy was documented in four of them: two with liver transplants and two with combined kidney and liver transplants. The absence of new-onset food allergy in the children with isolated kidney transplants is compatible with other reports in the literature. This study supports the concept that the functioning liver itself, and not only tacrolimus immunosuppression, is a main contributor to food allergy in this patient population.

Transfer of peanut allergy from the donor to a lung transplant recipient

Among solid organs, transfer of peanut allergy from donor to recipient has been implicated after liver transplantation. We report the first case in which such transfer occurred after a lung transplant. A 42-year-old woman with history of sarcoidosis underwent a successful bilateral lung transplant from a donor who died from anaphylactic shock after eating peanut-related food. Seven months later, she ate a peanut butter cookie at a transplant support group meeting. Immediately thereafter, she developed an anaphylactic reaction, but survived with prompt treatment. During subsequent follow-up, she could recall three prior episodes of wheezing and difficulty breathing after eating peanut-related foods. The first episode occurred 4 days after the transplant. Prior to her transplant, she never had problems eating peanuts. Skin-prick testing confirmed peanut sensitization. She avoided peanuts and, although her skin-prick test became negative, she still manifested peanut allergy when formally challenged orally with the food. She was advised to continue abstaining from all peanut-related foods. This case emphasizes the importance of considering donor allergy transfer when caring for all solid-organ transplant recipients in order to avoid a life-threatening event.

A EuroPrevall review of factors affecting incidence of peanut allergy: priorities for research and policy

Peanuts are extensively cultivated around the world, providing a foodstuff that is both cheap to produce and nutritious. However, allergy to peanuts is of growing global concern, particularly given the severity of peanut-allergic reactions, which can include anaphylaxis and death. Consequently, it is important to understand the factors related to the prevalence of peanut allergy in order to inform efforts to ameliorate or pre-empt the condition. In this article we review evidence for the relevance of factors hypothesized to have some association with allergy prevalence, including both genetic and environmental factors. Although our analysis does indicate some empirical support for the importance of a number of factors, the key finding is that there are significant data gaps in the literature that undermine our ability to provide firm conclusions. We highlight these gaps, indicating questions that need to be addressed by future research.

Is allergic disease curable or transferable with allogeneic hematopoietic cell transplantation?

In the pathogenesis of allergic asthma/rhinitis, 2 main types of cells play a role: hematolymphatic cells (mast cells, eosinophils, T cells, B cells) and nonhematolymphatic cells (airway smooth muscle cells, epithelial cells). It is not known which one of the 2 cell types plays the primary role. Here we review the literature on allergic disease transfer and potential cure with allogeneic hematopoietic cell transplantation (HCT), as transferability and curability would support a primary role of hematolymphatic cells and have implications for donor selection for HCT and possible future treatment of severe allergic disease with HCT. A total of 18 nonallergic recipients were reported to develop allergic disease after transplantation; however, conclusive information for transfer was available for only 5 cases. Allergic disease was reported to abate in 3 allergic recipients; however, conclusive information for "cure" was available for only 2 cases. Problems in interpreting the reports include incomplete data on allergic disease in the donor or recipient before transplantation, not knowing the denominator, and the lack of controls. In summary, review of the literature generates the hypothesis that allergic disease is transferable and curable with HCT. A prospective study, including appropriate controls, is needed to evaluate this hypothesis.

Immunoglobulin E-Mediated Allergies in Lung-Transplanted Adults

BACKGROUND

Immunoglobulin E (IgE)-mediated allergy has repeatedly been reported after solid organ transplantation, apparently affecting approximately 10% of pediatric organ transplant recipients. Interestingly, type 1 allergy has not been described in transplanted adults, suggesting a particular propensity in childhood.

METHODS

The present cross-sectional study assessed the prevalence of type 1 allergy in 42 adult lung transplant recipients aged 25 to 50 years. Instruments included standardized interviews, skin prick tests, and serum IgE measurements.

RESULTS

Ten of 42 patients (23.8%) displayed elevated specific IgE levels or positive skin prick test results against one or more allergens. Five individuals (11.9%) additionally reported corresponding clinical symptoms of type 1 allergy. No statistically significant association of sensitization or allergy prevalence with patient age, kind of immunosuppressive therapy, and time since transplantation was found.

CONCLUSIONS

The phenomenon of transplantation-associated allergy is not age-restricted and thus should be assessed more thoroughly in all age groups.

Food allergy: nuts and tree nuts

Nuts are a well-defined cause of food allergy, which affect approximately 1 % of the general population in the UK and the USA. There do appear to be differences in the frequency of nut allergy between different countries because of different dietary habits and cooking procedures. For example, in the USA and France, peanuts are one of the most frequent causes of food allergy, but in other countries, it seems to be less common. Genetic factors, in particular, appear to play a role in the development of peanut allergy. While the majority of nut allergens are seed storage proteins, other nut allergens are profilins and pathogenesis-related protein homologues, considered as panallergens because of their widespread distribution in plants. The presence of specific IgE antibodies to several nuts is a common clinical finding, but the clinical relevance of this cross-reactivity is usually limited. Allergic reactions to nuts appear to be particularly severe, sometimes even life-threatening, and fatal reactions following their ingestion have been documented. Food allergy is diagnosed by identifying an underlying immunological mechanism (i.e. allergic testing), and establishing a causal relationship between food ingestion and symptoms (i.e. oral challenges). In natural history investigations carried out in peanut-allergic children, approximately 20 % of the cases outgrew their allergy or developed oral tolerance. The treatment of nut allergies should include patient and family education about avoiding all presentations of the food and the potential for a severe reaction caused by accidental ingestion. Patients and families should be instructed how to recognise early symptoms of an allergic reaction and how to treat severe anaphylaxis promptly.

Immunosuppressive therapy does not prevent the occurrence of immunoglobulin E-mediated allergies in children and adolescents with organ transplants

BACKGROUND

Allogeneic organ transplantation has become a common procedure in acute and chronic organ failure. The major limitation, rejection of the allograft by the host's immune system, can be limited by various immunosuppressive drugs that target the adaptive T-cell response. Most of these drugs are used in the treatment of allergic diseases as well, suggesting that transplant recipients under long-term immunosuppressive therapy should not develop any sensitizations or at least not show any clinical signs of allergy. Surprisingly, organ-transplanted children and adults do report symptoms of type 1 allergies, such as allergic rhinoconjunctivitis, bronchial asthma, and food allergies. Thus far, mainly case reports and series on the occurrence of allergy after orthotopic liver transplantation exist.

OBJECTIVE

Our purpose with this study was to evaluate in a cross-sectional design the prevalence of immunoglobulin E-mediated sensitizations and type 1 allergies in solid organ-transplanted children and adolescents and to identify risk factors.

METHODS

Seventy-eight organ-transplanted subjects (50 kidney, 9 lung, 19 liver; mean age: 14.06 +/- 5.94 years; range 1.42 to 24.25 years) were studied by standardized interviews (modified International Study of Asthma and Allergies in Childhood [ISAAC] criteria), skin-prick tests, and measurement of specific and total serum immunoglobulin E.

RESULTS

Nineteen patients (24.4%) were found to be sensitized to > or = 1 common inhalant or food allergens, as reflected by elevated specific immunoglobulin E levels and/or positive skin-prick test results, and 8 subjects (10.3%) additionally reported a corresponding present history of atopic diseases. No severe anaphylactic reactions were reported. No statistically significant associations with gender, kind of transplanted organ, distinct immunosuppressive therapies, and age at time of transplantation or age at investigation were found (chi2 test, Fisher's exact test, and Wilcoxon rank-sum test, respectively). Multiple logistic-regression analysis did not identify any independent risk factor either.

CONCLUSION

This study demonstrates that therapeutic immunosuppression does not control sensitizations and clinical manifestation of type 1 allergies in organ-transplanted children and adolescents.

Sesame allergy: a growing food allergy of global proportions?

OBJECTIVE

To present an up-to-date synopsis on the global prevalence, natural history, nature of allergens, and immune mechanisms of sesame allergy.

DATA SOURCES

We performed a literature search using the PubMed database. We obtained information on regulatory issues from the Web pages of respective agencies.

STUDY SELECTION

The PubMed search was performed using the algorithm sesame AND allergy. Date restriction was not used, and only articles in English were considered. The articles obtained were screened for additional references to work not obtained in the initial search. Each article was analyzed, and a pooled source of published information was generated.

RESULTS

Evidence was found for increased reporting of sesame allergy during the past 5 decades, with reports mostly from developed countries. Clinically, most sesame allergy was presented in at least 2 major forms: (1) immediate hypersensitivity, often expressed as systemic anaphylaxis, associated with positive skin prick test and/or IgE antibody test results to sesame proteins with some cross-reactivity with other foods, and (2) delayed hypersensitivity to lignin-like compounds in sesame oil clinically expressed as contact allergic dermatitis. There were a few cases of immediate hypersensitivity to sesame with negative skin prick test and/or IgE antibody test results that were confirmed by oral challenge tests.

CONCLUSIONS

Sesame allergy is a significant, serious, and growing problem. Evidence exists of the ability of protein and oil components of sesame to trigger immediate hypersensitivity via IgE antibody and delayed hypersensitivity via cell-mediated immune responses, respectively.

Gastrointestinal food allergy: new insights into pathophysiology and clinical perspectives

Adverse reactions to food that result in gastrointestinal symptoms are common in the general population; while only a minority of such individuals will have symptoms due to immunologic reactions to foods, gastrointestinal food allergies do exist in both children and adults. These immune reactions are mediated by immunoglobulin E-dependent and -independent mechanisms involving mast cells, eosinophils, and other immune cells, but the complexity of the underlying mechanisms of pathogenesis have yet to be fully defined. Knowledge of the spectrum of adverse reactions to foods that affect the digestive system, including gastrointestinal food allergy, is essential to correctly diagnose and manage the subset of patients with immunologically mediated adverse reactions to foods. Potentially fatal reactions to food necessitate careful instruction and monitoring on the part of health care workers involved in the care of individuals at risk of anaphylaxis. New methods of diagnosis and novel strategies for treatment, including immunologic modulation and the development of hypoallergenic foods, are exciting developments in the field of food allergy.

The development of food allergy after liver transplantation

The acquisition of new food allergy after orthotopic liver transplantation is now a well described phenomenon, mainly reported in children. The etiology of this phenomenon is at present unclear, but has been ascribed by some to tacrolimus treatment. Here we report a case of liver transplant acquired food allergy (LTAFA) in a child who received a split liver graft. The case is remarkable for the absence of new food allergy in the adult recipient of the same graft. This suggests that host-specific factors play an important role in the development of food allergy after liver transplantation, and emphasizes the predisposition that children have toward this phenomenon. Possible mechanisms underlying the development of food allergy after liver transplantation are discussed. In conclusion, tacrolimus treatment alone cannot account for LTAFA. Host factors such as the maturity of immune regulatory mechanisms are likely to play a critical role in the development of new food allergy after a liver transplant.

Special considerations accompany the 'gift of life'

Patient safety practices for organ and tissue donors - as well as recipients - must be understood by health care providers to combat medical error.This article discusses how regulatory and accreditation bodies are doing their part to reassure the public that there are strict rules, criteria and provisions specific to organ donation and transplantation. Additionally, health care risk management concepts as they apply to emerging issues in the organ donation and transplant field are explained. The article also highlights strategies to address particular patient safety issues and concerns. Case studies illustrate risk management applications and lessons learned.

Nontumoral dermatologic problems after liver transplantation

The skin, easily accessible for medical examination, is affected in many ways by liver transplantation. Mucocutaneous manifestations of advanced liver disease and dermatologic conditions associated with specific hepatic diagnoses generally improve after liver transplantation. Vasculitic lesions due to cryoglobulinemia associated with hepatitis C, and photosensitivity due to porphyria are occasional exceptions. Dermatologic diseases complicating the posttransplantation course can be challenging. Their presentation is sometimes unusual and their course severe. Infections with rare organisms alone or in combination may occur. Our intent is to provide an overview of the current knowledge regarding nontumoral dermatologic problems associated with liver transplantation by summarizing the available information from all documented case reports.