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Walnut Threshold Dose Distribution and Safe Dose in Allergic Patients (Nut CRACKER Study).

Liat Nachshon1, W Marty Blom2, Sabina Bijlsma2

  • 1Institute of Allergy, Immunology and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Beer Yaakov, Israel; Department of Medicine, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

The Journal of Allergy and Clinical Immunology. in Practice
|June 1, 2025
PubMed
Summary

This study determined the reaction eliciting doses (EDs) for walnut allergy in a large population. Findings provide crucial data for allergen risk assessment and labeling, improving quality of life for allergic individuals.

Keywords:
Eliciting doseOral immunotherapySafe doseThresholdWalnut allergy

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Area of Science:

  • Food allergy research
  • Immunology
  • Clinical nutrition

Background:

  • Walnut allergy is a significant global health concern.
  • Limited data on population reaction thresholds hinders risk assessment and labeling.
  • This impacts patient quality of life.

Purpose of the Study:

  • To determine reaction eliciting doses (EDs) in a large cohort of walnut-allergic individuals.
  • To provide data for improved allergen risk assessment and management.
  • To address an evidence gap in global food allergen guidelines.

Main Methods:

  • Retrospective cohort study of 415 walnut oral food challenges (OFCs) from July 2014 to May 2023.
  • Inclusion of diagnostic OFCs and oral immunotherapy initiation OFCs.
  • Analysis of objective signs as stopping criteria and confirmatory safe-dose OFCs.

Main Results:

  • Estimated ED01 (1% population) at 0.8 mg (discrete) and 1.2 mg (cumulative).
  • Estimated ED05 (5% population) at 3.8 mg (discrete) and 5.9 mg (cumulative).
  • Younger age, oral immunotherapy, and pecan coallergy were associated with lower reaction thresholds.

Conclusions:

  • This study presents the largest dataset on walnut EDs, enhancing certainty with safe-dose OFCs.
  • Data supports evidence-based allergen risk assessment for walnuts.
  • Findings contribute to global Codex efforts for food safety standards.