Management of allergy transfer upon solid organ transplantation

Abstract

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.

Keywords: IgE; allergy; allergy transfer; anaphylaxis; business/management; clinical decision-making; clinical research/practice; diagnostic techniques and imaging; guidelines; immunoglobulin E; immunosuppression; immunosuppression/immune modulation; management; organ transplantation in general; patient safety; solid organ transplantation.

Figure 1

Allergy transfer analysis in donor and recipients. A, Overview of 3 series of donors who died because of fatal anaphylaxis. Green charts show patients with IgE transfer and red charts patients without detectable IgE transfer. Dashed lines highlight recipients with positive oral challenge. § shows atopic recipients. Atopic status was assessed by the presence of specific IgE against, pollen, animal dander, or house dust mites using commercial protein microarray bearing recombinant allergenic molecules (ISAC). B, Donors sera analysis with ISAC. Green recombinant IgE highlights those who were transferred into recipients (left Y axis). Yellow bars (right Y axis) represent the tryptase (ng/mL) measured in donors during their hospitalization. C, IgE follow‐up over time in recipients (liver recipient 1 [LiverR1], liver recipient 2 [LiverSplitR2], lung recipient [LungR3]) of series 1 compared to donor. D, Percentage of atopic recipients with or without IgE transfer. E, Absolute number of sensitizations before and 6 months after transplantation in all atopic recipients (series 1‐3) [Color figure can be viewed at http://www.wileyonlinelibrary.com]

Figure 2

Allergy persistence in 5 symptomatic atopic patients. A, Immunosuppression protocol of the 5 recipients over time. B, Representative skin prick test results 7 days after transplantation in 1 of the recipients. C, Areas in mm² of the positive skin prick tests the day before transplantation 7 and 90 days after transplantation. D, Level of total IgE over time (day before transplantation, 7 and 90 days after transplantation). E, Level of recombinant IgE over time (day before transplantation, 7 and 90 days after transplantation). F, Rhinoconjunctivitis symptoms score before and 90 days after transplantation [Color figure can be viewed at http://www.wileyonlinelibrary.com]

Figure 3

Mechanisms for allergy transfer. IgE, immunoglobulin E; MC, mastocyte; IgE‐Bcs, IgE‐producing B cells; Th, T helper cells; IgG1‐MBcs, IgG1 memory B cells

Figure 4

Recommendation for patient management in case of solid organ transplantation from donors who died because of fatal anaphylaxis. IgE, immunoglobulin E