Transfer and loss of allergen-specific responses via stem cell transplantation: A prospective observational study

Drug-induced liver injury due to granulocyte colony-stimulating factor in a healthy donor for allogeneic peripheral blood stem cell transplantation

BACKGROUND AND OBJECTIVES

Granulocyte-colony stimulating factor (G-CSF) is commonly used for peripheral blood stem cell harvesting (PBSCH). Although its well-documented adverse effects include thrombocytopaenia and bone pain, drug-induced liver injury (DILI) is rare.

MATERIALS AND METHODS

We present the case of a 40-year-old male donor who developed DILI 4 days after G-CSF administration for PBSCH.

RESULTS

Laboratory results indicated elevated hepatobiliary enzymes, with aspartate aminotransferase (AST) peaking at 171 U/L (×6 the upper limit of normal [ULN]) on Day 7 of G-CSF administration, alanine aminotransferase (ALT) at 244 U/L (×6 ULN) on Day 11, alkaline phosphatase (ALP) at 371 U/L (×3 ULN) on Day 5 and gamma-glutamyl transpeptidase (γ-GTP) 93 U/L (×1.5 ULN) on Day 9. The hepatobiliary dysfunction became evident after G-CSF administration had ended, despite other parameters-including white blood cell and platelet counts-remaining within acceptable ranges. DILI was confirmed by positive drug lymphocyte stimulation test results. The donor's liver function normalized within 1 month of supportive treatment, and the recipient achieved successful engraftment without G-CSF administration.

CONCLUSION

As G-CSF allergy screening is not mandatory in current Japanese protocols, DILI due to G-CSF could present a risk during PBSCH. This case emphasizes the importance of vigilant monitoring and comprehensive risk assessment to ensure the safety of healthy donors.

Transplant-acquired allergy in HCT-recipients: Reference for clinical management

Transplant-acquired allergy (TAA) is well known in pediatric patients undergoing liver transplantation. Regarding allogeneic hematopoietic cell transplantation (allo-HCT), the clinical characteristics of TAA have not been fully elucidated. Clinical manifestations of TAA include eczematous dermatitis, allergic rhinitis, and asthma. It is known that allergic diseases are transferable from allergic donors to non-allergic recipients via allo-HCT. The potential mechanism is the transfer of allergen-specific memory B cells resulting in Th2-skewed allergy-specific immune responses. Retrospective studies have suggested that cord blood transplantation (CBT) and the immunosuppressant tacrolimus have a significant impact on the development of TAA. The reported prevalence varies according to study design, diagnostic methods, and study population, and the suspected allergens vary widely among individuals. Prospective cohort studies and further mechanistic investigations are warranted to provide robust evidence on the prevalence and risk factors associated with TAA.

ABO incompatibility and component irradiation are independently associated with platelet transfusion reaction rate

BACKGROUND

Allocating incompatible platelet components to avoid product wastage must be balanced against the risk of reduced efficacy and adverse outcomes. The impact of platelet compatibility in association with product irradiation or pathogen reduction is unknown. This study aims to determine the combined and independent impact of platelet compatibility and component modification on transfusion reaction rate.

STUDY DESIGN AND METHODS

A retrospective review of all adult platelet transfusions from 2020 to 2022 was performed, including all reported reactions. Logistic regression was performed to evaluate the significance of ABO compatibility and unit modification for reaction rate.

RESULTS

Out of 21,330 transfusions to 3450 patients, 285 (1.33%) reactions were reported and 178 (0.83%) were diagnosed as related to transfusion, predominantly febrile nonhemolytic (n = 59) and allergic (n = 102). The compatibility of transfusion was 67.7% ABO identical, 13.8% ABO minor incompatible, 17.2% ABO major incompatible, and 1.4% ABO bidirectionally incompatible. Irradiated, unmodified, and pathogen-reduced single-donor platelets were transfused in 70.9%, 21.8%, and 7.3% of cases, respectively. Univariable regression demonstrated increased odds of reaction for major incompatibility vs. ABO identical (OR: 1.92; 95% CI: 1.36-2.71) and irradiated vs. unmodified (OR: 2.34; 95% CI: 1.45-3.91), which were confirmed by multivariable analysis. The effect of compatibility and unit modification were independent in all analyses.

CONCLUSIONS

The results demonstrate a trend of increasing reaction rate associated with major incompatibility and product irradiation. This study provides additional data to inform institutional policies guiding product selection for individual patients.

Shrimp allergy leading to severe transfusion reaction: A case report

Background

Transfusion reactions occur at an estimated incidence of 2 per 1.000 transfused products. Anaphylactic transfusion reactions are rarer, and seen in 1 per 10.000 transfusions, and are mostly related to platelet transfusions. Here, we describe a rare cause of a transfusion reaction.

Case presentation

A 19-year-old man underwent an allogeneic haematopoietic stem cell transplantation for sickle cell disease and developed an anaphylactic shock following a platelet transfusion, after excluding all common causes. The patient reported a shrimp allergy, and one of the blood/platelet donors had consumed shrimp the day before donation. Elevated levels of specific immunoglobulin E (IgE) directed against shrimp and tropomyosin allergens were found in the patient. Subsequent transfusions were performed with apheresis platelets from selected donors who were instructed to avoid shrimp consumption, and these transfusions were uneventfully.

Conclusion

When a severe transfusion reaction occurs in a patient with a known food allergy, an IgE-mediated (food-related) transfusion reaction should be considered after excluding other causes.

Transplant-Acquired Food Allergy in Children

BACKGROUND

Organ transplantation in children is a vital procedure for those with end-stage organ failure, but it has been linked to the development of post-transplant allergies, especially food allergies. This phenomenon, known as transplant-acquired food allergy (TAFA), is becoming increasingly recognized, though its mechanisms remain under investigation. Pediatric transplant recipients often require lifelong immunosuppressive therapy to prevent graft rejection, which can alter immune function and heighten the risk of allergic reactions. Our review aimed to gather the latest evidence on TAFA.

METHODS

We conducted a PubMed search from 25 June to 5 July 2024, using specific search terms, identifying 143 articles. After screening, 36 studies were included: 24 retrospective studies, 1 prospective study, 2 cross-sectional researches, and 9 case reports/series.

RESULTS

Most studies focused on liver transplants in children. The prevalence of food allergies ranged from 3.3% to 54.3%. Tacrolimus, alongside corticosteroids, was the most commonly used immunosuppressive therapy. In addition to food allergies, some patients developed atopic dermatitis, asthma, and rhinitis. Allergic symptoms typically emerged within a year post-transplant, with common allergens including milk, eggs, fish, nuts, soy, wheat, and shellfish. Both IgE-mediated and non-IgE-mediated reactions were observed, with treatment often involving the removal of offending foods and the use of adrenaline when necessary.

CONCLUSIONS

Consistent immunological monitoring, such as skin prick tests and IgE level assessments, is essential for early detection and management of allergies in these patients. Understanding the link between transplantation and allergy development is crucial for improving long-term outcomes for pediatric transplant recipients.

We are memory: B-cell responses in allergy and tolerance

The significance of B-cell memory in sustaining IgE-mediated allergies but also ensuring the development of long-term allergen tolerance has remained enigmatic. However, well-thought murine and human studies have begun to shed more light on this highly disputed subject. The present mini review highlights important aspects, like the involvement of IgG1 memory B cells, the meaning of low- or high-affinity IgE antibody production, the impact of allergen immunotherapy, or the relevance of local memory established by ectopic lymphoid structures. Based on recent findings, future investigations should lead to deeper knowledge and the development of improved therapies treating allergic individuals.

The Road Toward Transformative Treatments for Food Allergy

A series of landmark studies have provided conclusive evidence that the early administration of food allergens dramatically prevents the emergence of food allergy. One of the greatest remaining challenges is whether patients with established food allergy can return to health. This challenge is particularly pressing in the case of allergies against peanut, tree nuts, fish, and shellfish which are lifelong in most patients and may elicit severe reactions. The standard of care for food allergy is allergen avoidance and the timely administration of epinephrine upon accidental exposure. Epinephrine, and other therapeutic options like antihistamines provide acute symptom relief but do not target the underlying pathology of the disease. In principle, any transformative treatment for established food allergy would require the restoration of a homeostatic immunological state. This may be attained through either an active, non-harmful immune response (immunological tolerance) or a lack of a harmful immune response (e.g., anergy), such that subsequent exposures to the allergen do not elicit a clinical reaction. Importantly, such a state must persist beyond the course of the treatment and exert its protective effects permanently. In this review, we will discuss the immunological mechanisms that maintain lifelong food allergies and are, consequently, those which must be dismantled or reprogrammed to instate a clinically non-reactive state. Arguably, the restoration of such a state in the context of an established food allergy would require a reprogramming of the immune response against a given food allergen. We will discuss existing and experimental therapeutic strategies to eliminate IgE reactivity and, lastly, will propose outstanding questions to pave the road to the development of novel, transformative therapeutics in food allergy.

Post-transplant food anaphylaxis in an adult cord blood transplant recipient (Ms. No. IJHM-D-20-01037R1)

Transplant acquired food allergy (TAFA) is a well-known complication following pediatric liver transplantation, but post-cord blood transplantation (post-CBT) TAFA has rarely been reported. Here, we describe a case of new-onset food anaphylaxis after CBT in an adult patient that demonstrates that post-CBT allergen-challenge is not a risk for long-term allergic sensitization even in adult recipients. The patient was a 39-year-old Japanese man with aggressive NK cell leukemia. He had no previous history of allergies. After receiving CBT, the patient had an unbalanced diet with high preference for bread, bananas, miso-soup, cow's milk, cheese, egg, sesame and buckwheat soba noodles, and experienced repeated diarrhea. Six months later, he developed symptoms such as vomiting, epigastric pain, diarrhea, high fever and hypotension. The condition was initially diagnosed as enterocolitis, but symptoms recurred after consumption of buckwheat. Anaphylaxis induced by buckwheat was confirmed with serum radioallergosorbent tests (RAST), showing allergen-specific IgE for buckwheat (greater than 100 U/mL, Class 6) and egg ovomucoid (Class 4). Nineteen months after a buckwheat and egg-free diet, serum RAST for buckwheat and egg significantly improved. As a result, the patient acquired a tolerance and was able to consume buckwheat and egg without allergic symptoms.