Pediatr Transplantation 2014: 18: 733–739
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Pediatric Transplantation DOI: 10.1111/petr.12342
Increase in de novo food allergies after pediatric liver transplantation: Tacrolimus vs. cyclosporine immunosuppression Lebel M-J, Chapdelaine H, Paradis L, Roches AD, Alvarez F. (2014) Increase in de novo food allergies after pediatric liver transplantation: Tacrolimus vs. cyclosporine immunosuppression. Pediatr Transplant, 18: 733–739. DOI: 10.1111/petr.12342. Abstract: Post-TAFA is an uncommon but serious complication of organ transplantation. This study aimed to compare the incidence of FA in CsA and tacrolimus-treated children following OLT and identify risk factors. The medical charts of all patients who underwent OLT at our institution were reviewed. Between 1985 and 2010, 218 OLTs were performed on 188 pediatric recipients, of which 154 were included in the study. Three patients (3%) of the 102 receiving CsA developed FA, compared with nine (17%) in the 52 tacrolimus-treated patients, the latter exceeding general population reported FA prevalence (RR 5.88; 95% CI: 1.66–20.81). All TAFA cases underwent transplantation before the age of three with an incidence of 29% (9/31) in the tacrolimus-treated children in comparison with 7% (3/41) in the CsA group (RR 3.97; 95% CI: 1.17–13.45). Eosinophilia was present in 81% of children receiving tacrolimus compared with 54% in the CsA group (p = 0.002). We observed a statistically significant increase incidence of FA in tacrolimus-treated children following an OLT and those under the age of three are particularly vulnerable. The underlying process is still unknown and probably multifactorial.
For more than a decade, new onset FA is an increasingly recognized complication of solid organ transplantation and has been associated with CNI, particularly tacrolimus (1–11). It is known primarily post-orthotopic liver transplant (OLT), but a few cases have also been described after intestine (12) and heart transplantation (1, 13). Post-TAFA attributed to the immunosuppressive protocol seems to affect exclusively the pediatric population. In adults, post-transplant food allergy has been primarily attributed to the presence of donor lymphocytes and is a transient phenomenon for most cases (14, 15). The patho-
Abbreviations: BA, biliary atresia; CI, confidence interval; CNI, calcineurin inhibitor; CsA, cyclosporine-A; EGE, eosinophilic gastroenteritis; FA, food allergy; GI, gastrointestinal; IgE, immunoglobulin E; NNH, number needed to harm; OLT, orthotopic liver transplantation; RR, relative risk; TAFA, transplant acquired food allergy.
Marie-Jeanne Lebel, Hugo Chapdelaine, Louis Paradis, Anne Des Roches and Fernando Alvarez Centre Hospitalier Universitaire Mere-enfant SainteJustine, Universite de Montreal, Montreal, Quebec, Canada
Key words: children – food allergy – liver transplantation – tacrolimus – cyclosporine – immunosuppression Marie-Jeanne Lebel, MD, Department of Pediatrics, CHU Sainte-Justine, 3175 Chemin de la C^ote-SainteCatherine, Montreal, Quebec, Canada H3T 1C5 Tel.: 514 345 4931 Fax: 514 345 4741 E-mail: [email protected] Accepted for publication 23 July 2014
genesis of TAFA in children is poorly understood and probably multifactorial. Recognition and awareness of FA in tacrolimus-treated patients following an OLT is essential to avoid potential life threatening events. Furthermore, it is important to consider that FA could act has a potential mimicker of common symptoms seen in those complex patients. This study was undertaken to compare the incidence of FA in CsA- and tacrolimus-treated children post-OLT, in a tertiary care center. We also recorded clinical features trying to identify risk factors that could influence TAFA development. Patients and methods We conducted a retrospective cohort study by reviewing the medical records of all patients who underwent liver transplantation at our institution (CHU Sainte-Justine, Montreal, Canada) from 1985 to 2010. Data collected included age at transplant, underlying disease, immunosuppressive
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Lebel et al. protocol at the time of the transplant and at the first allergic reaction, the presence of FA before and post-OLT, onset and types of symptoms, maximum eosinophil count, and total and specific IgE. Exclusion criteria included patients who died
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Pediatric Transplantation DOI: 10.1111/petr.12342
Increase in de novo food allergies after pediatric liver transplantation: Tacrolimus vs. cyclosporine immunosuppression Lebel M-J, Chapdelaine H, Paradis L, Roches AD, Alvarez F. (2014) Increase in de novo food allergies after pediatric liver transplantation: Tacrolimus vs. cyclosporine immunosuppression. Pediatr Transplant, 18: 733–739. DOI: 10.1111/petr.12342. Abstract: Post-TAFA is an uncommon but serious complication of organ transplantation. This study aimed to compare the incidence of FA in CsA and tacrolimus-treated children following OLT and identify risk factors. The medical charts of all patients who underwent OLT at our institution were reviewed. Between 1985 and 2010, 218 OLTs were performed on 188 pediatric recipients, of which 154 were included in the study. Three patients (3%) of the 102 receiving CsA developed FA, compared with nine (17%) in the 52 tacrolimus-treated patients, the latter exceeding general population reported FA prevalence (RR 5.88; 95% CI: 1.66–20.81). All TAFA cases underwent transplantation before the age of three with an incidence of 29% (9/31) in the tacrolimus-treated children in comparison with 7% (3/41) in the CsA group (RR 3.97; 95% CI: 1.17–13.45). Eosinophilia was present in 81% of children receiving tacrolimus compared with 54% in the CsA group (p = 0.002). We observed a statistically significant increase incidence of FA in tacrolimus-treated children following an OLT and those under the age of three are particularly vulnerable. The underlying process is still unknown and probably multifactorial.
For more than a decade, new onset FA is an increasingly recognized complication of solid organ transplantation and has been associated with CNI, particularly tacrolimus (1–11). It is known primarily post-orthotopic liver transplant (OLT), but a few cases have also been described after intestine (12) and heart transplantation (1, 13). Post-TAFA attributed to the immunosuppressive protocol seems to affect exclusively the pediatric population. In adults, post-transplant food allergy has been primarily attributed to the presence of donor lymphocytes and is a transient phenomenon for most cases (14, 15). The patho-
Abbreviations: BA, biliary atresia; CI, confidence interval; CNI, calcineurin inhibitor; CsA, cyclosporine-A; EGE, eosinophilic gastroenteritis; FA, food allergy; GI, gastrointestinal; IgE, immunoglobulin E; NNH, number needed to harm; OLT, orthotopic liver transplantation; RR, relative risk; TAFA, transplant acquired food allergy.
Marie-Jeanne Lebel, Hugo Chapdelaine, Louis Paradis, Anne Des Roches and Fernando Alvarez Centre Hospitalier Universitaire Mere-enfant SainteJustine, Universite de Montreal, Montreal, Quebec, Canada
Key words: children – food allergy – liver transplantation – tacrolimus – cyclosporine – immunosuppression Marie-Jeanne Lebel, MD, Department of Pediatrics, CHU Sainte-Justine, 3175 Chemin de la C^ote-SainteCatherine, Montreal, Quebec, Canada H3T 1C5 Tel.: 514 345 4931 Fax: 514 345 4741 E-mail: [email protected] Accepted for publication 23 July 2014
genesis of TAFA in children is poorly understood and probably multifactorial. Recognition and awareness of FA in tacrolimus-treated patients following an OLT is essential to avoid potential life threatening events. Furthermore, it is important to consider that FA could act has a potential mimicker of common symptoms seen in those complex patients. This study was undertaken to compare the incidence of FA in CsA- and tacrolimus-treated children post-OLT, in a tertiary care center. We also recorded clinical features trying to identify risk factors that could influence TAFA development. Patients and methods We conducted a retrospective cohort study by reviewing the medical records of all patients who underwent liver transplantation at our institution (CHU Sainte-Justine, Montreal, Canada) from 1985 to 2010. Data collected included age at transplant, underlying disease, immunosuppressive
733
Lebel et al. protocol at the time of the transplant and at the first allergic reaction, the presence of FA before and post-OLT, onset and types of symptoms, maximum eosinophil count, and total and specific IgE. Exclusion criteria included patients who died
