*Purpose: Donor to recipient IgE-mediated food allergy transfer has been described in non-kidney solid organ transplant. Here, we report a novel case of an adult post-transplant kidney allergy transfer resulting in anaphylaxis.

*Methods: A 56-year-old man with ESRD secondary to PKD underwent a living donor transplant with thymoglobulin induction and maintenance tacrolimus, mycophenolate, and prednisone. Four weeks after transplant, he developed a de novo anaphylactic reaction, presenting with swollen throat and lips and hives after ingesting a collagen bar containing cashews. These symptoms progressed to hypotension, generalized rash, shortness of breath, and loss of consciousness requiring emergency treatment with epinephrine. The patient had no prior history of food allergy. Evaluation of the donor’s medical record revealed a history of allergies to pine nuts, hazelnuts, macadamia, and cashews. Further testing revealed positive skin testing for cashews and pistachio. In contrast, skin testing was negative for walnut, pecan, and brazil nut. Serum specific IgE testing was negative to walnut, pecan, hazelnut, pine nut, and macadamia nut. The oral challenge was negative for macadamia nut, pecan, and walnut. The patient was instructed to avoid ingestion of cashews and pistachio and received education on the use of Epi-pen in case of incidental exposures.

*Results: This is the first case of allergy transfer on an adult patient after receiving a kidney transplant. The other case described after a kidney transplant was on a 7-year-old patient. Although increased risk for atopic diseases occurs after transplantation, donor to recipient acquired food allergies have been described mostly on liver, lung, and combined pancreas-kidney transplants. Some of the possible mechanisms for posttransplant acquired allergy are binding of passively transferred IgE to recipient mastocytes and transfer of IgG-memory B cells, IgE-producing B cells, clone specific T cells, and tissue-resident mastocytes. Although it has been speculated that the kidneys contain a small amount of memory B cells explaining the low risk for posttransplant acquired allergies, this case suggests allergy transfer after kidney transplant is possible.

*Conclusions: Fatal anaphylactic reactions in non-kidney solid organ transplants have led to the development of protocols to identify patients at risk for severe donor-derived food allergies. Review of food allergies among living kidney donors prior to transplant may be a simple and effective tool to prevent this rare but life-threatening complication in kidney transplant recipients, as well.

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