Screening for celiac disease in diabetic children from Iran

Role of HLA-DQ typing and antitissue transglutaminase antibody titres in diagnosing coeliac disease among Sudanese children with type 1 diabetes mellitus

Objective

The aim of the study was to determine the prevalence of coeliac disease (CD) and to recognise Human leukocyte antigen (HLA)-associated hereditary susceptibility to Sudanese CD patients with type 1 diabetes mellitus (DM1).

Design

Antitissue transglutaminase IgA (anti-TG IgA) was measured in the serum of 373 children affected with DM1 aged 1–19-year old and in 100 serum samples from non-diabetic control children. Histological examination was performed in 19 children seropositive for anti-TG IgA (17 DMI and 2 controls). Additionally, PCR-based analysis of Major histocompatibility complex, class II, DQ beta 1 (HLA-DQB1) genotyping was implemented in three study population groups as follows: group 1 (n=25) (+ve DM1 and +ve CD), group 2 (n=63) (-ve DM1 and +ve CD) and control group 3 (n=2) (+ve CD).

Results

Twenty-six Sudanese children with DM1 out of 373 (6.97%) were seropositive for anti-TG IgA. Duodenal biopsy revealed Marsh 2 and 3 in 13 out of 17 (76.47%) seropositive anti-TG IgA patients with DM1. Significant association (p<0.05) was detected between the level of anti-TG IgA autoantibodies (IU/mL) and Marsh stage. HLA DQ2 and DQ8 were found in 88% (22/25) and 8% (2/25) of examined patients with CD with DM1, respectively.

Conclusions

Anti-TG IgA titre of greater than 10 times upper limit of normal (≥10× ULN) can be useful for detecting CD in children with type 1 diabetes without duodenal biopsy. HLA testing in children with DM1 appears to provide little added benefit given the high prevalence (96%) of HLA DQ2/DQ8 in children with DM1.

Prevalence of celiac disease in Iranian patients with type 1 diabetes: A systematic review and meta-analysis

Patients with type 1 diabetes mellitus (T1DM) are at high risk for celiac disease (CD) due to the common genetic background and interaction between environmental and immunological factors. The purpose of this systematic review and meta-analysis was to estimate the prevalence of CD among Iranian patients with type 1 diabetes. The search for articles was conducted using the following keywords: "celiac disease," "celiac," "coeliac disease," "diabetes," "Iran," and all other possible combinations of these terms. The following databases were searched from inception to June 2019: Scientific Information Database (SID), MagIran, Web of Science, PubMed, and Scopus. Meta-analysis was performed using the random-effects models, and the heterogeneity of results across the studies was assessed using the Cochran's Q test and quantified by the I² statistic. Data analysis was performed by Stata version 14. A total of 14 papers were included in the meta-analysis, involving 2030 Iranian patients with T1DM. The pooled prevalence of CD in patients with T1DM was 5% (95% CI 3-7). The prevalence of CD in Tehran (4%; 95% CI 1-6) was lower than in other provinces of the country (6%; 95% CI 4-8). Meta-regression analysis showed that, with increasing sample size, the prevalence of  CD was significantly reduced (p = 0.018).Given the adverse effects of CD , such as osteoporosis and malignancy (especially lymphoma), patients with T1DM must be screened for CD .

Celiac disease in Iran: a systematic review and meta-analysis

Introduction

Celiac disease (CD) is a chronic autoimmune-mediated disorder with both intestinal and systemic manifestations. The aim of this study was to determine the prevalence of celiac disease in Iran.

Methods

We conducted a systematic search on Embase, Pub Med, Web of Science, Google Scholar, MagIran, Scientific Information database (SID) and Iranmedex from 2003 through to November 2015. The Der-Simonian/Laird’s (DL), with a 95% confidence interval employed to estimate the overall pooled prevalence. Heterogeneity was investigated by using subgroup analysis based on sample size and time of study.

Results

Sixty-three studies with 36,833 participants met inclusion criteria for analysis. The overall prevalence of celiac disease in 63 studies that had used serological tests for the diagnosis was observed as 3% (95% CI: 0.03–0.03) and the overall prevalence of celiac disease in studies that had used biopsy method for diagnosis was observed as 2% (95% CI: 0.01–0.02).

Conclusion

The prevalence of celiac disease in Iran was similar or even higher than world-wide reported.

Prevalence and clinical profile of celiac disease in children with type 1 diabetes mellitus

OBJECTIVE

To determine the prevalence of celiac disease (CD) in children with type 1 diabetes mellitus (TIDM) in follow-up in a Tertiary Care Referral Centre in Western India and to describe the clinical features indicative of CD in screened patients of TIDM.

STUDY DESIGN

In this single center observational cross-sectional study, 71 children who were diagnosed with TIDM were subjected to screening for CD with tissue transglutaminase antibody testing. Those who tested positive were offered intestinal biopsy for the confirmation of diagnosis. Clinical profiles of both groups of patients were compared and manifestations of CD were delineated.

RESULTS

The study revealed the prevalence of CD (based on serology) in children with Type 1 diabetes as 15.49%. The prevalence of biopsy-confirmed CD was 7.04%. Of the diagnosed CD patients, one-third were symptomatic at the time of screening while the majority was asymptomatic. The major clinical features indicative of CD were intestinal symptoms, anemia, rickets, and short stature. Autoimmune thyroid disease was prevalent in 29.6% of the patients with TIDM followed by CD.

CONCLUSIONS

The high prevalence of CD in children with Type 1 diabetes emphasizes the need for routine screening programs to be in place for these high-risk populations. The clinical profile of patients with CD further elaborates the indicators of CD and the need to screen for them.

Looking for coeliac disease in children with type 1 diabetes mellitus

AIM

To establish how clinicians in New Zealand (NZ) approach screening for and management of coeliac disease (CD) in type 1 diabetes mellitus (T1DM) in their paediatric patients.

METHODS

All clinicians caring for children under 15 years with T1DM in NZ in 2010 were asked to complete an online survey detailing their personal and departmental approach to diagnosing and managing patients with CD and T1DM.

RESULTS

Thirty-four from 37 clinicians responded to the survey. Most clinicians in NZ have a protocol for screening for CD in T1DM, and 25/34 respondents will screen for CD at diagnosis of T1DM. Those who do not screen will use symptoms, growth and hypoglycaemia as indicators to test. All use anti-tissue transglutaminase to screen for CD, and 32/34 use biopsy-proven CD as a criterion for commencing gluten-free diet (GFD). Nearly all consultants will still advise a GFD in symptom-free CD and will try to encourage the patients to adopt a GFD if they initially decline.

CONCLUSIONS

Most clinicians in NZ screen for CD, but there is a wide variation in practice.

Type 1 diabetes and celiac disease: clinical overlap and new insights into disease pathogenesis

Type 1 diabetes (T1D) and celiac disease (CD) are autoimmune diseases with clinical and pathogenic overlap. The mean prevalence of CD in patients with T1D is about 8 %. Classic intestinal symptoms of CD may not be present in T1D leading to the recommendation for active case finding in this higher risk group. Screening is done with sensitive and specific serologies including tissue transglutaminase (tTG) IgA and deaminated gliadin peptide (DGP) IgA and IgG. Positive serologies are confirmed by the presence of villous atrophy and increased intraepithelial lymphocytes on duodenal biopsy. A strict gluten free diet is recommended, although this can pose challenges for T1D patients who already have dietary restrictions. In aggregate, it appears as if the gluten free diet may help T1D management. T1D and CD have overlapping genetic and environmental risk factors. Among these, non-HLA genetic factors and the gut microbiome are among recent developments that will be discussed in this review.

Coexistence of coeliac disease and type 1 diabetes

There is a selective review of the literature concerning the coexistence of coeliac disease and type 1 diabetes mellitus. This review focuses on the principles of serological tests towards coeliac disease in patients with type 1 diabetes mellitus and metabolic control measures as a result of a gluten-free diet.

Prevalence of celiac disease in omani children with type 1 diabetes mellitus: a cross sectional study

OBJECTIVE

Published studies on the prevalence of celiac disease in type 1 diabetes mellitus from the Arab World are scant. We aim to report the prevalence of celiac disease in Omani children with type 1 diabetes mellitus.

METHODS

Children with type 1 diabetes mellitus were prospectively screened for celiac disease, at Sultan Qaboos University Hospital, Muscat, Oman over a period of one year (June 2011 - May 2012). Serum anti tissue transglutaminase IgA, endomysial IgA antibodies and total IgA were measured for screening of celiac disease. Children with positive anti-tissue transglutaminase and/or endomysial IgA antibodies underwent endoscopy.

RESULTS

A total of 103 children with type 1 diabetes mellitus were initially included. Ten patients were lost to follow up. Ninety-three patients aged 2-17 years underwent screening for celiac disease. Sixteen patients had positive anti-tissue transglutaminase (17%). Fourteen patients underwent endoscopy with duodenal biopsies, while two were lost to follow-up. Five patients with positive anti-tissue transglutaminase had intestinal biopsy proven celiac disease. The prevalence of celiac disease is 5.5% in our cohort of children and adolescents with type 1 diabetes mellitus.

CONCLUSIONS

The prevalence of celiac disease in Omani children and adolescents with type 1 diabetes mellitus is similar to the World's reported prevalence, but is less than that reported for Middle Eastern Arab children. To our knowledge, this is the first reported study on the prevalence of celiac disease in Omani children with type 1 diabetes mellitus.

Systematic review: worldwide variation in the frequency of coeliac disease and changes over time

BACKGROUND

Coeliac disease (CD), originally thought to be largely confined to Northern Europe and Australasia and uncommon in North America and the Middle East, is now recognised to be equally common in all these countries. It is still thought to be rare in the Orient and Sub-Saharan Africa.

AIM

To assess geographical differences and time trends in the frequency of CD.

METHODS

Medline and Embase searches were conducted on 10 November 2012, from 1946 and 1980 respectively, using the key words: coeliac disease or celiac disease + prevalence or incidence or frequency.

RESULTS

There were significant intra- and inter-country differences in the prevalence and incidence of CD. Only 24 ethnic Chinese and Japanese patients have been reported in the English literature. Of CD-associated HLA DQ antigens, DQ2 occurs in 5-10% of Chinese and sub-Saharan Africans, compared to 5-20% in Western Europe. DQ8 occurs in 5-10% of English, Tunisians and Iranians, but in <5% of Eastern Europeans, Americans and Asians. The prevalence and incidence of both clinically and serologically diagnosed CD increased in recent years. These geographical and temporal differences seem genuine, although variable indices of suspicion and availability of diagnostic facilities are confounding factors.

CONCLUSIONS

Coeliac disease is increasing in frequency, with significant geographical differences. Although few cases have been described to date in the Orient and Sub-Saharan Africa, there is a significant prevalence of HLA DQ2 and wheat consumption is of the same order as that in Western Europe. CD may therefore become more common in the future in these countries.

High prevalence of celiac disease among Saudi children with type 1 diabetes: a prospective cross-sectional study

Background

There is lack of data on prevalence of celiac disease (CD) in children with type 1 diabetes (T1D) in Arabs in the Middle East. The present investigation aims to study the prevalence rate and clinical characteristics of CD among Saudi children with T1D using a combination of the most sensitive and specific screening serologic tests (anti- tissue transglutaminase antibodies IgA [anti-TTG] and ednomyseal antibodies [EMA]) and to determine the lower cut-off value of anti- anti-TTG level that best predicts CD in children with T1D.

Methods

Children with T1D following in diabetic clinic have been prospectively screened for presence of CD, over a two-year period (2008–2010), by doing anti-TTG, EMA, and total IgA. Children with positive anti-TTG titres (>50 U/ml) and/or EMA and children with persistently low positive anti-TTG titres (two readings 20–50 U/ml; within 6 months intervals) had upper endoscopy and 6 duodenal biopsies.

Results

One hundred and six children with T1D have been screened for CD: age ranged between 8 months to 15.5 years (62 females). Nineteen children had positive anti-TTG and/or EMA, however only 12 children had biopsy proven CD (11.3%). Five of 12 had gastrointestinal symptoms (42%). Children with T1D and CD had significantly lower serum iron than children with T1D alone (8.5 μgm/L Vs 12.5 μgm/L; P = 0.014). The sensitivity and specificity of anti-TTG were 91.6% and 93.6%, with a positive and negative predictive value of 64.7% and 98.8%, respectively. Receiver operated characteristics analysis for the best cut-off value of anti-TTG level for diagnosis of CD was 63 units (sensitivity 100% and specificity 98.8%).

Conclusion

CD is highly prevalent among Saudi children with T1D. Anti-TTG titres more than 3 times the upper limit of normal has very high sensitivity and specificity for diagnosis of CD in T1D children.

Evaluation of serum IgA levels in Iranian patients with type 1 diabetes mellitus

An increased prevalence of immunoglobulin (Ig) A deficiency has been documented in a number of autoimmune diseases; however, its association with type 1 diabetes mellitus (DM1) is a subject of debate. This study was performed to evaluate serum IgA levels in a group of pediatric patients with DM1. Three hundred patients with mean age of 12.6 ± 6.7 years were enrolled in this study. Serum IgA and other immunoglobulins levels were measured using enzyme-linked immunosorbant assay. Mean serum IgA level of patients was 271.0 ± 141.4 mg/dl. Only two patients had IgA deficiency (IgA < 10 mg/dl), who were two boys with ages of 9 and 10 years. Although associated autoimmune disorders were found in a number of patients with DM1, no other autoimmune disorder was detected in these two patients with IgA deficiency. Serum levels of all other immunoglobulins were normal. Serum IgA levels did not significantly differ by grouping the patients according to age variation, sex distribution, disease duration, and associated disorders. There was no significant correlation between IgA levels and hemoglobin A1c. This study showed the prevalence of IgA deficiency in Iranian patients with DM1 as 0.7% (1:150), which is much higher than reported prevalences in general populations. Further studies are needed for better understanding the possible etiologies of increased IgA deficiency in DM1 and its effects on diabetes control.

Anti-cardiolipin and anti-beta 2-glycoprotein I antibodies in celiac disease

AIMS

To determine the frequency of anti-cardiolipin (aCL) and anti-β2-glycoprotein I antibodies (aβ2GPI) in celiac disease (CD) patients.

PATIENTS AND METHODS

Sixty-three untreated CD patients and 40 healthy blood donors (HBD) were studied. IgG, IgA and IgM aCL and aβ2GPI were detected by Elisa.

RESULTS

The frequency of antiphospholipid antibodies (aPL) (aCL and/or aβ2GPI) was significantly higher in CD patients (12 out of 63) than in HBD (two out of 40) (19% vs 5%, P=0.04). Six CD patients out of 63 (9.5%) and one HBD out of 40 (2.5%) had aCL. Ten CD patients (15.9%) and two HBD (5%) had aβ2GPI. Only aβ2GPI-IgA was significantly more frequent in CD patients than in HBD (14.3% vs 2.5%, P=0.048). In CD patients, aβ2GPI-IgA (nine out of 63) was significantly more frequent (14.3%) than aβ2GPI-IgG (1.6%) and IgM (1.6%) (P=0.008). In CD patients, the frequency of aCL-IgA and IgM was 6.3% (four out of 63) and aCL-IgG were not detected. Simultaneous presence of positive antibodies was found in four CD patients: one patient had four aPL, one had three aPL and two had two aPL. The four patients who had aCL-IgA had also aβ2GPI-IgA and three of them had a titer higher than 50 units. Among nine patients with aβ2GPI-IgA, four had a titer higher than 100 units. The highest titers were found in adults.

CONCLUSIONS

aPL and particularly aβ2GPI-IgA are frequent in CD. The significance of these antibodies has to be determined.

Clinical and immunological features of celiac disease in patients with Type 1 diabetes mellitus

Celiac disease (CD) is one of the most frequent autoimmune disorders occurring in Type 1 diabetes mellitus (T1DM). The prevalence of CD in T1DM varies from 3 to 16%, with a mean prevalence of 8%. The clinical presentation of CD in T1DM is classified as symptomless in approximately half of cases, but a more accurate analysis often discloses a wide array of symptoms suggestive of CD. Both T1DM and CD show the same genetic background and an abnormal small intestinal immune response with inflammation and a variable grade of enteropathy. Serological screening for CD should be performed in all T1DM patients by means of antibodies to tissue transglutaminase at T1DM onset. T1DM patients found to be celiacs must be treated by a gluten-free diet. Potential CD cases (especially when asymptomatic) should be kept on a gluten-containing diet with a careful clinical and antibody follow-up, since many of them will not develop villous atrophy.

Prevalence and clinical profile of celiac disease in type 1 diabetes mellitus in north India

BACKGROUND AND AIM

There is scanty data on the occurrence of celiac disease in patients with type 1 diabetes mellitus in South Asia. Our aim was to study the prevalence and clinical profile of celiac disease in patients with type 1 diabetes mellitus in a tertiary care referral centre in north India.

METHODS

Consecutive patients of type 1 diabetes mellitus attending the Endocrine clinic of our institute between January 2002 and December 2008 were screened using anti-tissue transglutaminase antibodies (tTGAb), and those positive were subjected to duodenal biopsy. Clinical profile of these patients was recorded.

RESULTS

Out of 189 patients of type 1 diabetes mellitus, 21 (11.1%) were diagnosed to have celiac disease on the basis of positive serology (tTGAb) and duodenal histology. The mean age at diagnosis of diabetes was 10.81 ± 7.3 years and that of celiac disease was 13.74 ± 5.71 years, with a difference of 5.18 ± 4.75 years between the two. Only 2/21 patients with celiac disease had been diagnosed before detection of diabetes mellitus. Short stature was the commonest (52.3%) manifestation of celiac disease, followed by anemia (47.3), weight loss (42.8%), diarrhea (28.6%) and abdominal pain (14.2%). After initiating gluten free diet, 14/16 symptomatic patients had reversal of anemia, weight loss and diarrhea. Growth rate velocity improved from 2.3 ± 1.0 cm/year to 5.5 ± 2.4 cm/year in those with short stature.

CONCLUSION

Celiac disease is highly prevalent in patients with type 1 diabetes mellitus (11.1%) and majority of them (90.5%) were diagnosed on screening. Routine screening is required for early diagnosis and combat associated co-morbidities.

Celiac disease and pediatric type 1 diabetes: diagnostic and treatment dilemmas

Despite the advent of sensitive and specific serologic testing, routine screening for celiac disease (CD) in diabetic populations may not be universal practice, and many clinicians struggle to find the optimal approach to managing CD in pediatric Type 1 diabetes (T1D) patients. While some clinicians advocate screening for CD in all patients with T1D, others are unsure whether this is warranted. The diagnosis of patients who present with symptomatic CD, including malabsorption and obvious pathology upon biopsy, remains straightforward, with improvements noted on a gluten-free diet. Many patients identified by screening, however, tend to be asymptomatic. Evidence is inconclusive as to whether the benefits of screening and potentially treating asymptomatic individuals outweigh the harms of managing a population already burdened with a serious illness. This review focuses on current knowledge of CD in children and youth with T1D, highlighting important elements of the disease's pathophysiology, epidemiology, clinical presentation, and diagnostic challenges.