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Tye‐Din JA. Evolution in coeliac disease diagnosis and management. JGH Open 2024; 8:e13107. [PMID: 38957478 PMCID: PMC11217771 DOI: 10.1002/jgh3.13107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 05/04/2024] [Accepted: 05/28/2024] [Indexed: 07/04/2024]
Abstract
The traditional gut-centric view of coeliac disease is evolving as immune and genetic insights underscore the central importance of a systemic, T cell immune response to gluten in disease pathogenesis. As the field increasingly recognize the limitations of small intestinal histology as the diagnostic standard, data supporting the accuracy of an immune (serologic) diagnosis of coeliac disease - well demonstrated in children - are growing for adults. Novel biomarkers such as interleukin-2 that identify the gluten-specific T cell demonstrate high sensitivity and specificity for coeliac disease and offer the potential for a diagnostic approach that avoids the need for gluten challenge. Asymptomatic disease and manifestations outside the gut pose considerable challenges for diagnosis using a case-finding strategy and enthusiasm for population screening is growing. The gluten-free diet remains a highly restrictive treatment and there is a paucity of controlled data to inform a safe gluten intake threshold. Ongoing symptoms and enteropathy are common and require systematic evaluation. Slowly-responsive disease is prevalent in the older patient diagnosed with coeliac disease, and super-sensitivity to gluten is an emerging concept that may explain many cases of nonresponsive disease. While there is great interest in developing novel therapies for coeliac disease, no drug has yet been registered. Efficacy studies are generally assessing drugs in patients with treated coeliac disease who undergo gluten challenge or in patients with nonresponsive disease; however, substantial questions remain around specific endpoints relevant for patients, clinicians and regulatory agencies and optimal trial design. Novel immune tools are providing informative readouts for clinical trials and are now shaping their design.
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Affiliation(s)
- Jason A Tye‐Din
- Immunology DivisionWalter and Eliza Hall InstituteParkvilleVictoriaAustralia
- Department of Medical BiologyUniversity of MelbourneParkvilleVictoriaAustralia
- Department of GastroenterologyThe Royal Melbourne HospitalParkvilleVictoriaAustralia
- Centre for Food & Allergy ResearchThe Murdoch Children's Research InstituteParkvilleVictoriaAustralia
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Rodríguez-Martín L, Vaquero Ayala LM, Hernando Martín M, Vivas Alegre S. Assessing mucosal recovery in celiac disease - Time to diagnosis and histological severity as determining factors. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024; 116:356-361. [PMID: 38205704 DOI: 10.17235/reed.2024.9968/2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
BACKGROUND AND OBJECTIVES there is a huge disparity in mucosal recovery among celiac patients on a gluten-free diet. We report a study to identify associated factors. METHODS celiac cases were collected that had positive celiac serology and villous atrophy at diagnosis, and had undergone a control biopsy after at least 12 months of follow-up. RESULTS seventy celiac patients were included and had experienced symptoms for 9.05 ± 9.48 years before being diagnosed. After follow-up for 2.93 ± 1.94 years, 34.3 % had complete mucosal recovery and 57.1 % had partial mucosal recovery. In the comparative analysis, there was no relationship between mucosal recovery and sex, age, clinical manifestations or follow-up time from diagnosis to the second biopsy. Time with clinical manifestations before diagnosis was associated with a worse outcome: 2.64 years in patients with full recovery, 4.61 years in patients with partial recovery, and 14.26 years in patients with persistent villous atrophy. Higher transglutaminase antibody titers both at diagnosis and during follow-up were associated with poorer histologic outcomes. We observed higher mucosal recovery rates in patients with mild atrophy versus severe atrophy at diagnosis. CONCLUSIONS in spite of a gluten-free diet, a significant proportion of patients have persistent histologic changes. Time with clinical manifestations before diagnosis is key for histological severity and recovery.
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Abadie V, Han AS, Jabri B, Sollid LM. New Insights on Genes, Gluten, and Immunopathogenesis of Celiac Disease. Gastroenterology 2024; 167:4-22. [PMID: 38670280 PMCID: PMC11283582 DOI: 10.1053/j.gastro.2024.03.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 03/10/2024] [Accepted: 03/11/2024] [Indexed: 04/28/2024]
Abstract
Celiac disease (CeD) is a gluten-induced enteropathy that develops in genetically susceptible individuals upon consumption of cereal gluten proteins. It is a unique and complex immune disorder to study as the driving antigen is known and the tissue targeted by the immune reaction can be interrogated. This review integrates findings gained from genetic, biochemical, and immunologic studies, which together have revealed mechanisms of gluten peptide modification and HLA binding, thereby enabling a maladapted anti-gluten immune response. Observations in human samples combined with experimental mouse models have revealed that the gluten-induced immune response involves CD4+ T cells, cytotoxic CD8+ T cells, and B cells; their cross-talks are critical for the tissue-damaging response. The emergence of high-throughput technologies is increasing our understanding of the phenotype, location, and presumably function of the gluten-specific cells, which are all required to identify novel therapeutic targets and strategies for CeD.
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Affiliation(s)
- Valérie Abadie
- Department of Medicine, University of Chicago, Chicago, Illinois; Section of Gastroenterology, Nutrition and Hepatology, University of Chicago, Chicago, Illinois; Committee on Immunology, University of Chicago, Chicago, Illinois.
| | - Arnold S Han
- Columbia Center for Translational Immunology, Columbia University, New York, New York; Department of Microbiology and Immunology, Columbia University, New York, New York; Department of Medicine, Digestive and Liver Diseases, Columbia University, New York, New York
| | - Bana Jabri
- Department of Medicine, University of Chicago, Chicago, Illinois; Section of Gastroenterology, Nutrition and Hepatology, University of Chicago, Chicago, Illinois; Committee on Immunology, University of Chicago, Chicago, Illinois; Department of Pathology, University of Chicago, Chicago, Illinois; Department of Pediatrics, University of Chicago, Chicago, Illinois
| | - Ludvig M Sollid
- Norwegian Coeliac Disease Research Centre, Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Immunology, Oslo University Hospital-Rikshospitalet, Oslo, Norway
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Elli L, Leffler D, Cellier C, Lebwohl B, Ciacci C, Schumann M, Lundin KEA, Chetcuti Zammit S, Sidhu R, Roncoroni L, Bai JC, Lee AR, Dennis M, Robert ME, Rostami K, Khater S, Comino I, Cebolla A, Branchi F, Verdu EF, Stefanolo JP, Wolf R, Bergman-Golden S, Trott N, Scudeller L, Zingone F, Scaramella L, Sanders DS. Guidelines for best practices in monitoring established coeliac disease in adult patients. Nat Rev Gastroenterol Hepatol 2024; 21:198-215. [PMID: 38110546 DOI: 10.1038/s41575-023-00872-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/09/2023] [Indexed: 12/20/2023]
Abstract
Coeliac disease (CeD) is an immunological disease triggered by the consumption of gluten contained in food in individuals with a genetic predisposition. Diagnosis is based on the presence of small bowel mucosal atrophy and circulating autoantibodies (anti-type 2 transglutaminase antibodies). After diagnosis, patients follow a strict, life-long gluten-free diet. Although the criteria for diagnosis of this disease are well defined, the monitoring phase has been studied less and there is a lack of specific guidelines for this phase. To develop a set of clinical guidelines for CeD monitoring, we followed the Grading of Recommendations Assessment, Development and Evaluation methodology. Statements and recommendations with the level of evidence were developed and approved by the working group, which comprised gastroenterologists, pathologists, dieticians and biostatisticians. The proposed guidelines, endorsed by the North American and European coeliac disease scientific societies, make recommendations for best practices in monitoring patients with CeD based on the available evidence. The evidence level is low for many topics, suggesting that further research in specific aspects of CeD would be valuable. In conclusion, the present guidelines support clinicians in improving CeD treatment and follow-up and highlight novel issues that should be considered in future studies.
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Affiliation(s)
- Luca Elli
- Center for Prevention and Diagnosis of Celiac Disease-Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Daniel Leffler
- Celiac Center, Beth Israel Deaconess Medical Center (BIDMC), Harvard Medical School, Boston, MA, USA
| | - Christophe Cellier
- Department of Gastroenterology and Endoscopy, CELAC network, AP-HP Centre, Hôpital Européen Georges Pompidou, Université de Paris, Cité and Institut National du Cancer, Paris, France
| | - Benjamin Lebwohl
- Celiac Disease Center, Department of Medicine, Columbia University Irving Medical Center, Columbia University, New York, NY, USA
| | - Carolina Ciacci
- Center for Celiac Disease, Gastrointestinal Unit, AOU San Giovanni di Dio e Ruggi D'Aragona and Department of Medicine Surgery Dentistry, Scuola Medica Salernitana, University of Salerno, Salerno, Italy
| | - Michael Schumann
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Berlin, Germany
| | - Knut E A Lundin
- K.G. Jebsen Coeliac Disease Research Centre, University of Oslo, Oslo, Norway
- Department of Gastroenterology, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | | | - Reena Sidhu
- Department of Infection, Immunity and Cardiovascular Diseases, Royal Hallamshire Hospital, University of Sheffield, Sheffield, UK
| | - Leda Roncoroni
- Center for Prevention and Diagnosis of Celiac Disease-Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Julio C Bai
- Department of Medicine, Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires, Argentina
| | - Anne R Lee
- Celiac Disease Center, Department of Medicine, Columbia University Irving Medical Center, Columbia University, New York, NY, USA
| | - Melinda Dennis
- Celiac Center, Beth Israel Deaconess Medical Center (BIDMC), Harvard Medical School, Boston, MA, USA
| | - Marie E Robert
- Department of Pathology and Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Kamran Rostami
- Department of Gastroenterology, Palmerston North District Health Board (DHB), Palmerston North, New Zealand
| | - Sherine Khater
- Department of Gastroenterology and Endoscopy, CELAC network, AP-HP Centre, Hôpital Européen Georges Pompidou, Université de Paris, Cité and Institut National du Cancer, Paris, France
| | - Isabel Comino
- Department of Microbiology and Parasitology, Faculty of Pharmacy, University of Seville, Seville, Spain
| | | | - Federica Branchi
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Berlin, Germany
| | - Elena F Verdu
- Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Juan Pablo Stefanolo
- Department of Medicine, Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires, Argentina
| | - Randi Wolf
- Program in Nutrition, Department of Health Studies & Applied Educational Psychology, Teachers College, Columbia University, New York, NY, USA
| | - Sheba Bergman-Golden
- Program in Nutrition, Department of Health Studies & Applied Educational Psychology, Teachers College, Columbia University, New York, NY, USA
| | - Nick Trott
- Department of Infection, Immunity and Cardiovascular Diseases, Royal Hallamshire Hospital, University of Sheffield, Sheffield, UK
| | - Luigia Scudeller
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Fabiana Zingone
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
- Gastroenterology Unit, Azienda Ospedale-Università Padova, Padua, Italy
| | - Lucia Scaramella
- Center for Prevention and Diagnosis of Celiac Disease-Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - David S Sanders
- Department of Infection, Immunity and Cardiovascular Diseases, Royal Hallamshire Hospital, University of Sheffield, Sheffield, UK
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Schiepatti A, Maimaris S, Raju SA, Green OL, Mantica G, Therrien A, Flores-Marin D, Linden J, Fernández-Bañares F, Esteve M, Leffler D, Biagi F, Sanders DS. Persistent villous atrophy predicts development of complications and mortality in adult patients with coeliac disease: a multicentre longitudinal cohort study and development of a score to identify high-risk patients. Gut 2023; 72:2095-2102. [PMID: 37364982 PMCID: PMC10579485 DOI: 10.1136/gutjnl-2023-329751] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 06/01/2023] [Indexed: 06/28/2023]
Abstract
OBJECTIVE Persistent villous atrophy (pVA) in coeliac disease (CD) despite a gluten-free diet (GFD) has unclear meaning. We aimed to (i) study the relationship between pVA and long-term outcomes and (ii) develop a score to identify patients at risk of pVA. DESIGN This is a multicentre retrospective-prospective study consisting of a study cohort (cohort 1) and an external validation cohort (cohort 2) of patients with biopsy-proven CD diagnosed between 2000 and 2021. Cohort 1 was used to (i) compare long-term outcomes between patients with and without pVA (Marsh ≥3a) at follow-up biopsy and (ii) to develop a score to evaluate the risk of pVA, which was validated in cohort 2. RESULTS Of 2211 patients, 694 (31%) underwent follow-up duodenal biopsy and were included in the study cohort (491F, 44±16 years). 157/694 (23%) had pVA. Risk of complications (HR 9.53, 95% CI 4.77 to 19.04, p<0.001) and mortality (HR 2.93, 95% CI 1.43 to 6.02, p<0.01) were increased in patients with pVA. A 5-point score was developed and externally validated (receiver operating characteristic area under the curve 0.78, 95% CI 0.68 to 0.89) to stratify patients by risk of pVA: low (0-1 points, 5% pVA), intermediate (2 points, 16% pVA) and high (3-5 points, 73% pVA). Predictors for pVA used in the score were age at diagnosis ≥45 years (OR 2.01, 95% CI 1.21 to 3.34, p<0.01), classical pattern of CD (OR 2.14, 95% CI 1.28 to 3.58, p<0.01), lack of clinical response to GFD (OR 2.40, 95% CI 1.43 to 4.01, p<0.001) and poor GFD adherence (OR 48.9, 95% CI 26.1 to 91.8, p<0.001). CONCLUSIONS Risk of complications and mortality were increased in patients with pVA. We developed a score to identify patients at risk of pVA and in need of histological reassessment and closer follow-up.
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Affiliation(s)
- Annalisa Schiepatti
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
- Gastroenterology Unit of Pavia Institute, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Stiliano Maimaris
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
- Gastroenterology Unit of Pavia Institute, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Suneil A Raju
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Olivia L Green
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Giulia Mantica
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Amelie Therrien
- Celiac Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - David Flores-Marin
- Celiac Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Justin Linden
- Celiac Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Fernando Fernández-Bañares
- Department of Gastroenterology, Hospital Universitari Mutua Terrassa, Terrassa, Spain
- Centro de Investigación biomédica en red de enfermedades hepáticas y digestivas (CIBEREHD), Madrid, Spain
| | - Maria Esteve
- Department of Gastroenterology, Hospital Universitari Mutua Terrassa, Terrassa, Spain
- Centro de Investigación biomédica en red de enfermedades hepáticas y digestivas (CIBEREHD), Madrid, Spain
| | - Daniel Leffler
- Celiac Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Federico Biagi
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
- Gastroenterology Unit of Pavia Institute, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - David S Sanders
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
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Galli G, Carabotti M, Conti L, Scalamonti S, Annibale B, Lahner E. Comparison of Clinical, Biochemical and Histological Features between Adult Celiac Patients with High and Low Anti-Transglutaminase IgA Titer at Diagnosis and Follow-Up. Nutrients 2023; 15:2151. [PMID: 37432272 DOI: 10.3390/nu15092151] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 04/24/2023] [Accepted: 04/28/2023] [Indexed: 07/12/2023] Open
Abstract
In adults, celiac disease (CD) diagnosis is based on specific serology (anti-transglutaminase IgA-anti-tTG) and duodenal histology. Evidence is raising the possibility of perform CD diagnosis based only on high anti-tTG titer in children. We aimed to evaluate clinical, histological and biochemical differences between adult patients with high tTG IgA titer (HT) and those with low titer (LT) at CD diagnosis and follow-up. This retrospective study included consecutive adult CD patients divided into two groups: HT (anti-tTG > 10 × ULN) and LT (anti-tTG < 10 × ULN). Clinical, biochemical and histological features were compared between groups at CD diagnosis and at follow-up. A total of 291 patients were included (HT: 47.1%; LT: 52.9%). At CD diagnosis, HT patients showed a non 'classical' presentation (p = 0.04), Marsh 3C (p = 0.005), hypoferritinaemia (p = 0.006) and osteopenia/osteoporosis (p = 0.04) more frequently than LT patients. A total of 216 patients (HT: 48.6%; LT: 51.4%) performed a follow-up after a median Gluten-free diet of 14 months; HT patients had persistent antibodies positivity (p = 0.001) more frequently and GI symptoms (p = 0.04) less frequently than LT patients. In conclusion, HT patients presented severe histological damage more frequently at diagnosis, recovering similarly to LT patients after the start of the Gluten-free diet. At follow-up, anti-tTG persisted positive in HT more frequently compared to LT patients, without differences regarding histological recovery and clinical improvement.
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Affiliation(s)
- Gloria Galli
- Department of Medical-Surgical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea Hospital, 00189 Rome, Italy
| | - Marilia Carabotti
- Department of Medical-Surgical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea Hospital, 00189 Rome, Italy
| | - Laura Conti
- Department of Medical-Surgical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea Hospital, 00189 Rome, Italy
| | - Silvia Scalamonti
- Department of Medical-Surgical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea Hospital, 00189 Rome, Italy
| | - Bruno Annibale
- Department of Medical-Surgical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea Hospital, 00189 Rome, Italy
| | - Edith Lahner
- Department of Medical-Surgical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea Hospital, 00189 Rome, Italy
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Evaluation of mucosal status in the follow-up of pediatric patients with celiac disease: the role of serology. Eur J Pediatr 2022; 181:3283-3289. [PMID: 35739293 DOI: 10.1007/s00431-022-04535-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 06/09/2022] [Accepted: 06/15/2022] [Indexed: 11/03/2022]
Abstract
UNLABELLED Recent guidelines suggest non-biopsy serology-based approach for the diagnosis of celiac disease; however, there is no evidence-based data regarding noninvasive follow-up of mucosal healing. The aim of this study is to investigate the efficacy of serology in reflecting mucosal status in the follow-up of pediatric patients with celiac disease. This is a validation study conducted at a university hospital. Patients who had biopsy proven celiac disease (Marsh III) at diagnosis, and had been followed-up for at least 12 months, were prospectively evaluated with duodenal biopsies. tTG-IgA and EMA tests were performed on the day of endoscopy. One hundred four patients with a mean age of 7.4 ± 4.02 years were included in the study. The sensitivity and specificity of tTG-IgA were 85.2% and 61% respectively, with a high negative predictive value (NPV) of 92.2% but a very low positive predictive value (PPV) of 43.4%. We found that a cutoff value of 68.5 U/mL for tTG-IgA had a sensitivity, specificity of 85.2% and 85.7% respectively. The AUC was 0.891. The sensitivity and specificity of EMA was 77.8% and 87% respectively, with a high NPV of 91.8% but low PPV of 67.7%. CONCLUSION This study suggests that negative tTG-IgA and/or EMA can be used as an indicator of mucosal improvement in the follow-up of pediatric patients with celiac disease. However, positive serology (i.e., < 10 × ULN) may be misleading in reflecting mucosal status in the follow-up of pediatric patients with celiac disease. WHAT IS KNOWN • The tissue transglutaminase IgA (tTG-IgA) and endomysium IgA (EMA) tests are widely used, sensitive and reliable diagnostic tests, but their role in monitoring adherence to dietary treatment in celiac patients has not yet been demonstrated. • There is still no reliable and non-invasive marker of persistent villous atrophy or mucosal recovery. WHAT IS NEW • Negative celiac serology detected in the follow-up of pediatric patients with celiac disease was successful in demonstrating histopathological mucosal healing. • Positive celiac serology, which is highly reliable in the diagnosis of celiac disease, has not been successful in reflecting mucosal status when used in the follow-up of pediatric patients with celiac disease.
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Tye‐Din JA. Review article: Follow-up of coeliac disease. Aliment Pharmacol Ther 2022; 56 Suppl 1:S49-S63. [PMID: 35815829 PMCID: PMC9542881 DOI: 10.1111/apt.16847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 02/12/2022] [Accepted: 02/13/2022] [Indexed: 12/09/2022]
Abstract
Coeliac disease is a lifelong immune-mediated enteropathy with systemic features associated with increased morbidity and modestly increased mortality. Treatment with a strict gluten-free diet improves symptoms and mucosal damage but is not curative and low-level gluten intake is common despite strict attempts at adherence. Regular follow-up after diagnosis is considered best-practice however this is executed poorly in the community with the problem compounded by the paucity of data informing optimal approaches. The aim of dietary treatment is to resolve symptoms, reduce complication risk and improve quality of life. It follows that the goals of monitoring are to assess dietary adherence, monitor disease activity, assess symptoms and screen for complications. Mucosal disease remission is regarded a key measure of treatment success as healing is associated with positive health outcomes. However, persistent villous atrophy is common, even after many years of a gluten-free diet. As the clinical significance of asymptomatic enteropathy is uncertain the role for routine follow-up biopsies remains contentious. Symptomatic non-responsive coeliac disease is common and with systematic follow-up a cause is usually found. Effective models of care involving the gastroenterologist, dietitian and primary care doctor will improve the consistency of long-term management and likely translate into better patient outcomes. Identifying suitable treatment targets linked to long-term health is an important goal.
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Affiliation(s)
- J. A. Tye‐Din
- Immunology DivisionThe Walter and Eliza Hall InstituteParkvilleVictoriaAustralia,Department of Medical BiologyUniversity of MelbourneParkvilleVictoriaAustralia,Department of GastroenterologyThe Royal Melbourne HospitalParkvilleVictoriaAustralia,Centre for Food & Allergy ResearchMurdoch Children’s Research InstituteParkvilleVictoriaAustralia
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Anderson RP. Review article: Diagnosis of coeliac disease: a perspective on current and future approaches. Aliment Pharmacol Ther 2022; 56 Suppl 1:S18-S37. [PMID: 35815826 DOI: 10.1111/apt.16840] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 02/08/2022] [Accepted: 02/08/2022] [Indexed: 12/09/2022]
Abstract
Diagnostics will play a central role in addressing the ongoing dramatic rise in global prevalence of coeliac disease, and in deploying new non-dietary therapeutics. Clearer understanding of the immunopathogenesis of coeliac disease and the utility of serology has led to partial acceptance of non-biopsy diagnosis in selected cases. Non-biopsy diagnosis may expand further because research methods for measuring gluten-specific CD4+ T cells and the acute recall response to gluten ingestion in patients is now relatively straightforward. This perspective on diagnosis in the context of the immunopathogenesis of coeliac disease sets out to highlight current consensus, limitations of current practices, gluten food challenge for diagnosis and the potential for diagnostics that measure the underlying cause for coeliac disease, gluten-specific immunity.
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Kaliciak I, Drogowski K, Garczyk A, Kopeć S, Horwat P, Bogdański P, Stelmach-Mardas M, Mardas M. Influence of Gluten-Free Diet on Gut Microbiota Composition in Patients with Coeliac Disease: A Systematic Review. Nutrients 2022; 14:nu14102083. [PMID: 35631222 PMCID: PMC9147811 DOI: 10.3390/nu14102083] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 05/10/2022] [Accepted: 05/13/2022] [Indexed: 02/06/2023] Open
Abstract
The aim of this study was to assess the changes in microbiota composition during a gluten-free diet (GFD) in coeliac disease (CD) patients. The systematic search followed databases such as PUBMED (MEDLINE), SCOPUS, WEB OF SCIENCE and EMBASE. Out of 843 initially screened papers, a total number of 13 research papers were included. A total of 212 patients with CD on GFD, in comparison to 174 healthy individuals and 176 untreated patients with CD, were examined. Analysis of the microbial community based primarily on faecal samples and duodenal biopsies. Bifidobacterium was noticed to be less abundant in the study group than in both control groups, while the abundance of Bacteroides was more numerous in the group of CD patients on GFD. Staphylococcaceae prevailed in untreated CD patients. Despite the fact that the GFD was not able to fully restore commensal microorganism abundance, the treatment was associated with the greater abundance of selected beneficial bacteria and lower presence of pathogenic bacteria associated with worsening of CD symptoms.
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Affiliation(s)
- Iwona Kaliciak
- Department of Treatment of Obesity, Metabolic Disorders and Clinical Dietetics, Poznan University of Medical Sciences, 60-569 Poznan, Poland; (I.K.); (K.D.); (A.G.); (S.K.); (P.H.); (P.B.)
| | - Konstanty Drogowski
- Department of Treatment of Obesity, Metabolic Disorders and Clinical Dietetics, Poznan University of Medical Sciences, 60-569 Poznan, Poland; (I.K.); (K.D.); (A.G.); (S.K.); (P.H.); (P.B.)
| | - Aleksandra Garczyk
- Department of Treatment of Obesity, Metabolic Disorders and Clinical Dietetics, Poznan University of Medical Sciences, 60-569 Poznan, Poland; (I.K.); (K.D.); (A.G.); (S.K.); (P.H.); (P.B.)
| | - Stanisław Kopeć
- Department of Treatment of Obesity, Metabolic Disorders and Clinical Dietetics, Poznan University of Medical Sciences, 60-569 Poznan, Poland; (I.K.); (K.D.); (A.G.); (S.K.); (P.H.); (P.B.)
| | - Paulina Horwat
- Department of Treatment of Obesity, Metabolic Disorders and Clinical Dietetics, Poznan University of Medical Sciences, 60-569 Poznan, Poland; (I.K.); (K.D.); (A.G.); (S.K.); (P.H.); (P.B.)
| | - Paweł Bogdański
- Department of Treatment of Obesity, Metabolic Disorders and Clinical Dietetics, Poznan University of Medical Sciences, 60-569 Poznan, Poland; (I.K.); (K.D.); (A.G.); (S.K.); (P.H.); (P.B.)
| | - Marta Stelmach-Mardas
- Department of Treatment of Obesity, Metabolic Disorders and Clinical Dietetics, Poznan University of Medical Sciences, 60-569 Poznan, Poland; (I.K.); (K.D.); (A.G.); (S.K.); (P.H.); (P.B.)
- Correspondence: ; Tel.: +48-697-424-245
| | - Marcin Mardas
- Department of Gynecological Oncology, Institute of Oncology, Poznan University of Medical Sciences, 60-569 Poznan, Poland;
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11
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Ciacchi L, Reid HH, Rossjohn J. Structural bases of T cell antigen receptor recognition in celiac disease. Curr Opin Struct Biol 2022; 74:102349. [PMID: 35272251 DOI: 10.1016/j.sbi.2022.102349] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 01/15/2022] [Accepted: 01/30/2022] [Indexed: 12/16/2022]
Abstract
Celiac disease (CeD) is a human leukocyte antigen (HLA)-linked autoimmune-like disorder that is triggered by the ingestion of gluten or related storage proteins. The majority of CeD patients are HLA-DQ2.5+, with the remainder being either HLA-DQ8+ or HLA-DQ2.2+. Structural studies have shown how deamidation of gluten epitopes engenders binding to HLA-DQ2.5/8, which then triggers an aberrant CD4+ T cell response. HLA tetramer studies, combined with structural investigations, have demonstrated that repeated patterns of TCR usage underpins the immune response to some HLADQ2.5/8 restricted gluten epitopes, with distinct TCR motifs representing common landing pads atop the HLA-gluten complexes. Structural studies have provided insight into TCR specificity and cross-reactivity towards gluten epitopes, as well as cross-reactivity to bacterial homologues of gluten epitopes, suggesting that environmental factors may directly play a role in CeD pathogenesis. Collectively, structural immunology-based studies in the CeD axis may lead to new therapeutics/diagnostics to treat CeD, and also serve as an exemplar for other T cell mediated autoimmune diseases.
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Affiliation(s)
- Laura Ciacchi
- Infection and Immunity Program and Department of Biochemistry and Molecular Biology, Biomedicine Discovery Institute, Monash University, Clayton, Victoria, 3800, Australia
| | - Hugh H Reid
- Infection and Immunity Program and Department of Biochemistry and Molecular Biology, Biomedicine Discovery Institute, Monash University, Clayton, Victoria, 3800, Australia
| | - Jamie Rossjohn
- Infection and Immunity Program and Department of Biochemistry and Molecular Biology, Biomedicine Discovery Institute, Monash University, Clayton, Victoria, 3800, Australia; Institute of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, CF14 4XN, United Kingdom.
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12
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Farina E, Roncoroni L, Lombardo V, Scricciolo A, Vecchi M, Doneda L, Elli L. Clinical Value of Tissue Transglutaminase Antibodies in Celiac Patients over a Long Term Follow-Up. Nutrients 2021; 13:nu13093057. [PMID: 34578935 PMCID: PMC8465060 DOI: 10.3390/nu13093057] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 08/26/2021] [Accepted: 08/27/2021] [Indexed: 01/16/2023] Open
Abstract
Introduction & Aim: Anti-tissue transglutaminase antibody (tTGA) titer is used during the follow-up of celiac patients to evaluate gluten-free diet (GFD) responsiveness. However, no clear data are available on this issue. The aim of this study was to evaluate tTGA significance during celiac disease (CD) monitoring. Methods: From January 2017 to January 2020, consecutive CD patients on a GFD with persistent positive tTGA were enrolled. Antibody titres were evaluated on a yearly basis from CD diagnosis to the last follow-up. Urinary gluten detection tests, duodenal histology and capsule enteroscopy (CE) were performed. A tTGA-positive cohort was compared with a control group composed of 212 treated CD patients with negative tTGA. Results: 65 patients (12% males, median age at enrollment and CD diagnosis, 37 (14–86) and 31 (1–76), respectively, median follow up 4 (1–26) years) presented with positive tTGA during follow-up. Overall, the tTGA titres were 3 (1–79) fold increased (ULN). Three different tTGA trends were recognized: (I) 36 (55%) patients with a progressive titres decrease; (II) 16 (25%) patients with a fluctuating behavior; (III) 13 (20%) patients with a steady state or increased titres. tTGA+ patients did not present with different clinical and demographic parameters. Duodenal atrophy was present in 10% vs. 36% of the tTGA positive vs. negative group (p < 0.005), respectively. Gluten detection results were positive in 3 (8%) cases, all in the III group. In tTGA+ patients, CE did not identify any CD-related complications. Conclusions: tTGA positivity during CD follow up did not present a relevant clinical significance without association with autoimmune comorbidities and mucosal damage.
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Affiliation(s)
- Elisa Farina
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy; (E.F.); (M.V.)
- Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico—Center for Prevention and Diagnosis of Celiac Disease and Division of Gastroenterology and Endoscopy, Via F. Sforza 35, 20122 Milan, Italy; (L.R.); (V.L.); (A.S.)
| | - Leda Roncoroni
- Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico—Center for Prevention and Diagnosis of Celiac Disease and Division of Gastroenterology and Endoscopy, Via F. Sforza 35, 20122 Milan, Italy; (L.R.); (V.L.); (A.S.)
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, 20133 Milan, Italy;
| | - Vincenza Lombardo
- Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico—Center for Prevention and Diagnosis of Celiac Disease and Division of Gastroenterology and Endoscopy, Via F. Sforza 35, 20122 Milan, Italy; (L.R.); (V.L.); (A.S.)
| | - Alice Scricciolo
- Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico—Center for Prevention and Diagnosis of Celiac Disease and Division of Gastroenterology and Endoscopy, Via F. Sforza 35, 20122 Milan, Italy; (L.R.); (V.L.); (A.S.)
| | - Maurizio Vecchi
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy; (E.F.); (M.V.)
- Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico—Center for Prevention and Diagnosis of Celiac Disease and Division of Gastroenterology and Endoscopy, Via F. Sforza 35, 20122 Milan, Italy; (L.R.); (V.L.); (A.S.)
| | - Luisa Doneda
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, 20133 Milan, Italy;
| | - Luca Elli
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy; (E.F.); (M.V.)
- Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico—Center for Prevention and Diagnosis of Celiac Disease and Division of Gastroenterology and Endoscopy, Via F. Sforza 35, 20122 Milan, Italy; (L.R.); (V.L.); (A.S.)
- Correspondence:
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13
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Villanacci V, Ciacci C, Salviato T, Leoncini G, Bonetti LR, Ragazzini T, Limarzi F, Saragoni L. Histopathology of Celiac Disease. Position Statements of the Italian Group of Gastrointestinal Pathologists (GIPAD-SIAPEC). TRANSLATIONAL MEDICINE AT UNISA 2021. [PMID: 33457319 PMCID: PMC8370535 DOI: 10.37825/2239-9747.1005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Celiac Disease (CeD) is an immune-mediated inflammatory disorder of the small intestine, affecting genetically susceptible individuals when exposed to gluten. Small intestinal biopsy interpretation has been the “gold standard” for celiac disease (CeD) for over 50 years. Despite today’s availability of sensitive and specific serological tests, the histopathological features from mucosal biopsy play a key role in diagnosing when CeD is suspected. Such a diagnostic approach requires a multidisciplinary team to optimize both tissue sampling and interpretation via the interaction between the pathologist and the gastroenterologist. Pathologists of the Italian Group of Gastrointestinal Pathology (GIPAD-SIAPEC), together with a member (TR) of the Italian Society of Technicians (AITIC) and an expert gastroenterologist (CC), provide position statements as a practical tool for reading and interpreting the report. Moreover, a position statement was formulated about the recently described condition known as Non-Celiac Gluten Sensitivity (NCGS). Within such a diagnostic setting, both the architectural abnormalities of the duodenal mucosa, namely glandular hyperplasia, and villous atrophy and the number of intraepithelial T-lymphocytes should be well highlighted. Ancillary tests such as anti-CD3 stain are useful for an accurate count of the intraepithelial T lymphocytes when CeD or NCGS is suspected. Moreover, anti-CD3 and anti-CD8 stains are recommended in patients not responding to the gluten-free diet (GFD) to confirm a diagnosis of Refractory Celiac Disease (RCeD). Diagnostic clues about the differential diagnosis of both CeD and RCeD have also been rendered.
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Affiliation(s)
- V Villanacci
- Institute of Pathology ASST-Spedali Civili, Brescia, Italy
| | - C Ciacci
- Celiac Center, AOU San Giovanni di Dio e Ruggi di Aragona, University of Salerno, Department of Medicine, Surgery, and Dentistry Scuola Medica Salernitana, Salerno, Italy
| | - T Salviato
- Department of Diagnostic, Clinic and Public Health Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - G Leoncini
- Pathology Unit, ASST del Garda, Desenzano del Garda, Brescia, Italy
| | - L Reggiani Bonetti
- Department of Diagnostic, Clinic and Public Health Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - T Ragazzini
- Department of Pathology, University of Bologna, Italy
| | - F Limarzi
- Department of Pathological Anatomy, AUSL Romagna, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - L Saragoni
- Department of Pathological Anatomy, AUSL Romagna, Morgagni-Pierantoni Hospital, Forlì, Italy
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14
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Krauthammer A, Guz-Mark A, Zevit N, Marderfeld L, Waisbourd-Zinman O, Silbermintz A, Mozer-Glassberg Y, Nachmias Friedler V, Rozenfeld Bar Lev M, Matar M, Assa A, Shamir R. Age-Dependent Trends in the Celiac Disease: A Tertiary Center Experience. J Pediatr Gastroenterol Nutr 2021; 72:894-899. [PMID: 33908739 DOI: 10.1097/mpg.0000000000003130] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Celiac disease (CD) is a common intestinal autoimmune disorder with diverse presenting features. We aimed to determine age-dependent patterns in CD presentation, diagnosis and management at a large tertiary referral center. METHODS A retrospective review of electronic medical records of pediatric patients diagnosed with CD between January 1999 and December 2018 at Schneider Children's Medical Center of Israel. We compared demographics, clinical and laboratory parameters between four age groups at CD presentation. RESULTS A cohort of 932 children was divided into four groups by age (in years) at diagnosis: 0-3 (17.9%), 3-6 (31.8%), 6-12 (34.5%), 12-18 (15.8%). The youngest age group presented more frequently with diarrhea, weight loss, abdominal distention, vomiting and lower weight z scores, P < 0.01. Hypoalbuminemia and zinc deficiency were also more frequent in this age group, compared to older patients (P < 0.05, each). Rates of anemia were higher in younger age groups (0-3 and 3-6 years), compared to older age groups, P < 0.05. Patients in the younger age groups (0-3 and 3-6 years) presented more frequently with tissue transglutaminase (TTG) levels above 10 times the upper limit of normal (ULN; P < 0.05), and more often normalized their CD serologies by 24 months of gluten-free diets (GFD) compared to older age groups (P < 0.05). CONCLUSION There is an age-dependent variation in CD presentation during childhood. Younger patients present more often with malabsorptive features, and higher TTG levels, yet normalize TTG while on GFD more rapidly than older patients. Clinicians should be aware of the diversity in CD presentation and course at the various presentation age.
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Affiliation(s)
- Alexander Krauthammer
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Anat Guz-Mark
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Noam Zevit
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Luba Marderfeld
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel
- Nutrition and Dietetics Department, Schneider Children's Medical Center, Petach Tikva
| | - Orith Waisbourd-Zinman
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Ari Silbermintz
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel
| | - Yael Mozer-Glassberg
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel
| | - Vered Nachmias Friedler
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel
| | - Michal Rozenfeld Bar Lev
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel
| | - Manar Matar
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel
| | - Amit Assa
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Raanan Shamir
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Israel
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15
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Persistent Villous Atrophy in De Novo Adult Patients With Celiac Disease and Strict Control of Gluten-Free Diet Adherence: A Multicenter Prospective Study (CADER Study). Am J Gastroenterol 2021; 116:1036-1043. [PMID: 33491958 DOI: 10.14309/ajg.0000000000001139] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 12/16/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION A substantial proportion of adult patients with celiac disease on a gluten-free diet exhibit persistent villous atrophy, and inadvertent gluten exposure may be one of the causes. The aim of the present study was to evaluate villous atrophy persistence after 2 years on a gluten-free diet in de novo adult patients with celiac disease with strict control of gluten exposure. METHODS Symptomatic de novo adult patients with celiac disease were prospectively included. Clinical visits and dietary surveillance were scheduled every 6 months during a 2-year follow-up period. At each visit, fecal samples were collected and stored at -20 °C until analysis for gluten immunogenic peptides (f-GIPs). A follow-up duodenal biopsy was performed at 2 years. We evaluated the variables associated with persistent villous atrophy. RESULTS Seventy-six patients completed the study (36.5 ± 1.6 years, 73% women); persistent villous atrophy was observed in 40 (53%), whereas 72.5% were asymptomatic and 75% had negative serology. Detectable f-GIP >0.08 μg/g in at least 1 fecal sample was seen in 69% of patients. There were no significant differences in the median f-GIP at each visit and median area under the curve over the serial measurements between patients with persistent villous atrophy and those who recovered. On multivariate analysis, only older age was associated with persistent villous atrophy (32% for 16-30 years; 67% for >30 years; P = 0.016). DISCUSSION The rate of persistent villous atrophy after 2 years was high in adult patients with celiac disease on an intentionally strict gluten-free diet. Low-level ongoing inadvertent gluten exposure could be a contributing factor to persistent villous atrophy.
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16
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Galli G, Carabotti M, Pilozzi E, Lahner E, Annibale B, Conti L. Relationship between Persistent Gastrointestinal Symptoms and Duodenal Histological Findings after Adequate Gluten-Free Diet: A Gray Area of Celiac Disease Management in Adult Patients. Nutrients 2021; 13:nu13020600. [PMID: 33673062 PMCID: PMC7918091 DOI: 10.3390/nu13020600] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/27/2021] [Accepted: 02/09/2021] [Indexed: 02/05/2023] Open
Abstract
A gluten-free diet (GFD) leads to a rapid improvement in gastrointestinal (GI) symptoms, biochemical alterations and duodenal histological damage in the majority of celiac disease (CD) patients. This study aimed to assess the frequency and factors associated with the persistence of GI symptoms/malabsorption signs and their relationship with duodenal histological findings among CD patients on an adequate GFD (mean duration 16 months, range 12-28 months). This longitudinal cohort study included 102 adult CD patients (median age 38.5 years, range 18-76 years, F = 71.6%) diagnosed between 2012 and 2018. A total of 36.3% of the included patients had persistent GI symptoms and/or malabsorption signs (Group 1), while the remaining patients had complete GI well-being without malabsorption signs (Group 2) at the time of histological re-evaluation. The persistence of GI symptoms/signs was associated with a long duration of symptoms/signs before CD diagnosis (≥5 years) (OR 5.3; 95% CI 1.3-21.8) and the presence of constipation at the time of CD diagnosis (OR 7.5; 95% CI 1.3-42) while for other variables, including age at CD diagnosis, sex, duration of GFD, comorbidities, CD serology positivity and severity of duodenal damage at histological re-evaluation, no association was found. According to our results, the persistence of symptoms/signs is not associated with histological findings, and their relationship could be a gray area in CD management.
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Affiliation(s)
- Gloria Galli
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, Sant’Andrea Hospital, Sapienza University of Rome, 00189 Roma, Italy; (M.C.); (E.L.); (B.A.); (L.C.)
- Correspondence:
| | - Marilia Carabotti
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, Sant’Andrea Hospital, Sapienza University of Rome, 00189 Roma, Italy; (M.C.); (E.L.); (B.A.); (L.C.)
| | - Emanuela Pilozzi
- Department of Clinical and Molecular Medicine, Sant’Andrea Hospital, Sapienza University of Rome, 00185 Roma, Italy;
| | - Edith Lahner
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, Sant’Andrea Hospital, Sapienza University of Rome, 00189 Roma, Italy; (M.C.); (E.L.); (B.A.); (L.C.)
| | - Bruno Annibale
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, Sant’Andrea Hospital, Sapienza University of Rome, 00189 Roma, Italy; (M.C.); (E.L.); (B.A.); (L.C.)
| | - Laura Conti
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, Sant’Andrea Hospital, Sapienza University of Rome, 00189 Roma, Italy; (M.C.); (E.L.); (B.A.); (L.C.)
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17
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Brown I, Bettington M, Rosty C. The role of histopathology in the diagnosis and management of coeliac disease and other malabsorptive conditions. Histopathology 2020; 78:88-105. [PMID: 33382496 DOI: 10.1111/his.14262] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/16/2020] [Accepted: 09/20/2020] [Indexed: 12/17/2022]
Abstract
Most absorption of nutrients takes place in the proximal small intestine, and the most common disorders leading to malabsorption are associated with a morphological abnormality in the duodenal mucosa that is appreciable in histological sections of biopsy specimens. Coeliac disease is the most well-known example, causing intraepithelial lymphocytosis, inflammation and villous atrophy in the duodenum. Remarkably similar inflammatory changes can be induced by other processes, including medications, e.g. angiotensin II receptor blockers and immune checkpoint inhibitors, immune dysregulation disorders, e.g. common variable immunodeficiency and autoimmune enteropathy, infections, collagenous sprue, and tropical sprue. However, there are often subtle histological differences from coeliac disease in the type of inflammatory infiltrate, the presence of crypt apoptosis, and the extent and type of inflammation beyond the duodenum. The clinical setting and serological investigation usually allow diagnostic separation, but some cases remain challenging. Histopathology is also important in assessing the response to treatment, such as the change in villous architecture caused by a gluten-free diet, or the response to cessation of a potentially causative medication. This review examines the practical role that histopathology of duodenal biopsy specimens plays in the assessment and management of inflammatory malabsorptive processes of the proximal small intestine, with a particular emphasis on coeliac disease.
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Affiliation(s)
- Ian Brown
- Envoi Specialist Pathologists, University of Queensland, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Mark Bettington
- Envoi Specialist Pathologists, University of Queensland, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Christophe Rosty
- Envoi Specialist Pathologists, University of Queensland, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
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18
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Optimising the follow-up of adult coeliac disease with a clinical-based score to identify patients in need of a histological reassessment: a retrospective single centre study. Br J Nutr 2020; 123:1159-1164. [PMID: 32077407 DOI: 10.1017/s0007114520000537] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Follow-up modalities for adult coeliac patients remain controversial. Non-invasive markers to identify coeliac patients on a gluten-free diet (GFD) with persistence of villous atrophy (VA) are still lacking. We aim to develop a score to stratify coeliac patients on a GFD according to their risk of having persistent VA and to tailor follow-up modalities accordingly. The clinical notes of over 700 coeliac patients attending our unit (September 1999-November 2018) were retrospectively examined. A total of 273 patients on a GFD with a histological follow-up performed 12-24 months after diagnosis were selected. We developed a bivariable model based on diet adherence and clinical response evaluated by previously validated methods. A four-level score (0·5, 1·5, 3, 4) was obtained. Patients on a strict GFD and with good clinical conditions (score 4) have a very low risk of persistence of VA (2 (95 % CI 1, 5) %). Conversely, the risk is very high (46 (95 % CI 25, 68) %) in patients with poor adherence to a GFD and unsatisfactory clinical response (score 0·5). A score of 1·5 (poor GFD adherence and persistent well-being) is linked with a high risk (23 (95 % CI 14, 36) %). Risk is intermediate (6 (95 % CI 3, 10) %) in patients scoring 3 (strict GFD and no/partial clinical improvement). Three patients who developed complications belonged to this scenario. Patients at low risk of persistent VA can be followed-up non-invasively, whereas a biopsy should be repeated in those at high/very high risk. Case-by-case evaluation is needed in patients at intermediate risk. Studies on a larger sample size are required to confirm these data.
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19
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Kreutz JM, Adriaanse MPM, van der Ploeg EMC, Vreugdenhil ACE. Narrative Review: Nutrient Deficiencies in Adults and Children with Treated and Untreated Celiac Disease. Nutrients 2020; 12:nu12020500. [PMID: 32075276 PMCID: PMC7071237 DOI: 10.3390/nu12020500] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 02/05/2020] [Accepted: 02/13/2020] [Indexed: 12/16/2022] Open
Abstract
Nutrient deficiencies are well recognized as secondary consequences of celiac disease (CD) and closely related to the clinical presentation of affected patients. Despite their clinical significance, consensus is lacking on the pattern and frequency of nutrient deficiencies in CD, the usefulness of their assessment at the time of diagnosis and during follow-up. This review aims to provide an overview of nutrient deficiencies among pediatric and adult CD patients at diagnosis and on a gluten-free diet (GFD), and their potential causes in CD. Secondly, we review their impact on CD management strategies including the potential of nutrient supplementation. A search of Medline, Pubmed and Embase until January 2019 was performed. Despite a high variability between the reported deficiencies, we noted that nutrient deficiencies occur frequently in children and adults with CD at diagnosis and during treatment with a GFD. Both inadequate dietary intake and/or diminished uptake due to intestinal dysfunction contribute to nutrient deficiencies. Most deficiencies can be restored with (long-term) treatment with a GFD and/or supplementation. However, some of them persist while others may become even more prominent during GFD. Our results indicate a lack of comprehensive evidence on the clinical efficacy of nutrient supplementation in CD management highlighting the need for further studies.
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Affiliation(s)
- Johanna M. Kreutz
- Department of Paediatrics and NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands; (J.M.K.); (M.P.M.A.)
| | - Marlou P. M. Adriaanse
- Department of Paediatrics and NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands; (J.M.K.); (M.P.M.A.)
| | | | - Anita C. E. Vreugdenhil
- Department of Paediatrics and NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands; (J.M.K.); (M.P.M.A.)
- Correspondence: ; Tel.: +31-433875284
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20
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Szakács Z, Gede N, Gyöngyi Z, Solymár M, Csupor D, Erőss B, Vincze Á, Mikó A, Vasas A, Szapáry L, Dobszai D, Balikó V, Hágendorn R, Hegyi P, Bajor J. A Call for Research on the Prognostic Role of Follow-Up Histology in Celiac Disease: A Systematic Review. Front Physiol 2019; 10:1408. [PMID: 31803064 PMCID: PMC6877721 DOI: 10.3389/fphys.2019.01408] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 10/31/2019] [Indexed: 12/12/2022] Open
Abstract
Background: Convincing evidence is lacking on the benefit of follow-up biopsy in celiac disease. Regardless, achieving mucosal recovery (MR) has remained a desirable goal of therapy. We aimed to conduct a systematic review to determine whether MR is a protective factor and persisting villous atrophy (PVA) has negative consequences on long-term outcomes of celiac disease. Methods: Seven databases were searched for articles discussing celiac patients subjected to a gluten-free diet who had a follow-up biopsy, and clinical and laboratory characteristics were reported by follow-up histology (MR vs. PVA). Outcomes included clinical symptoms, mortality, malignant tumors, nutritional parameters, and metabolic bone disease. Comparative and descriptive studies were included. Since data proved to be ineligible for meta-analysis, the evidence was synthesized in a systematic review. Results: Altogether, 31 studies were eligible for systematic review. Persisting symptoms were more frequently associated with PVA than with MR, although a lot of symptom-free patients had PVA and a lot of symptomatic patients achieved MR. PVA might be a risk factor of lymphomas, but mortality and the overall rate of malignant tumors seemed independent of follow-up histology. Patients with PVA tended to develop metabolic bone disease more often, although fracture risk remained similar in the groups except in hip fractures of which PVA was a risk factor. Reports on nutritional markers are only anecdotal. Conclusions: The limited evidence calls for high-quality prospective cohort studies to be arranged to clarify the exact role of follow-up histology in celiac disease.
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Affiliation(s)
- Zsolt Szakács
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary
| | - Noémi Gede
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Zoltán Gyöngyi
- Department of Public Health Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Margit Solymár
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Dezső Csupor
- Department of Pharmacognosy, University of Szeged, Szeged, Hungary
| | - Bálint Erőss
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary
| | - Áron Vincze
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Alexandra Mikó
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Andrea Vasas
- Department of Public Health Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - László Szapáry
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Department of Interventional Cardiology, Heart Institute, University of Pécs, Pécs, Hungary
| | - Dalma Dobszai
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Viktória Balikó
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Roland Hágendorn
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary
| | - Judit Bajor
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
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Abstract
Celiac disease is a gluten-triggered immune-mediated disorder, characterized by inflammation of the enteric mucosa following lymphocytic infiltration and eventually resulting in villous blunting. There have been many developments in refining diagnostic laboratory tests for celiac disease in the last decade. Biopsy-sparing diagnostic guidelines have been proposed and validated in a few recent prospective studies. However, despite these developments, histologic evaluation of duodenal mucosa remains one of the most essential diagnostic tools as it helps in the diagnosis of celiac disease in individuals who do not fulfill the biopsy-sparing diagnostic criteria and in those not responding to a gluten-free diet. Histologic evaluation also allows for the assessment of mucosal recovery after treatment and in the identification of concurrent intestinal diseases. Therefore, pathologists should be familiar with the histologic spectrum of celiac disease and need to be aware of other disorders with similar symptoms and histopathology that may mimic celiac disease. This review aims to provide pathologists with updates on celiac laboratory testing, biopsy-sparing diagnostic criteria, histopathology, complications, and differential diagnoses of celiac disease.
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Webster J, Vajravelu ME, Choi C, Zemel B, Verma R. Prevalence of and Risk Factors for Low Bone Mineral Density in Children With Celiac Disease. Clin Gastroenterol Hepatol 2019; 17:1509-1514. [PMID: 31230659 PMCID: PMC7779076 DOI: 10.1016/j.cgh.2018.10.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 10/08/2018] [Accepted: 10/21/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Celiac disease can reduce bone mineral density. We sought to determine the prevalence and risk factors for low areal bone mineral density (aBMD) in children with celiac disease. METHODS We performed a retrospective cohort study of 673 children with celiac disease (63% female; median age at diagnosis, 10.6 y; interquartile range, 7.8-13.9) who underwent dual x-ray absorptiometry (DXA) from 2009 through 2016 at the Children's Hospital of Philadelphia. We collected demographic, clinical, and laboratory data from medical records. We performed logistic regression analysis to identify factors associated with low (Z less than -2) lumbar spine aBMD Z (aBMD-Z) scores at initial and subsequent tests. RESULTS The time between diagnosis of celiac disease and first DXA was 0 days (interquartile range, -11 to 31 d). The mean aBMD-Z score at the children's initial scan was -0.4 ± 1.2; 46 children had aBMD-Z scores less than -2 (6.8%; 95% CI, 5.2%-9.0%). Those who had a second DXA analysis (n = 108; 16.0%) had a significant increase in aBMD-Z score (mean change, 0.29; P = .0005). Higher body mass index (BMI) was associated with lower odds of a low aBMD-Z score at the initial DXA analysis (odds ratio, 0.46, 95% CI, 0.35-0.50). BMI-Z scores greater than -0.4 identified children with a low aBMD-Z at their initial DXA analysis with a 95% negative predictive value. CONCLUSIONS Approximately 7% of subjects with celiac disease had a low aBMD-Z score, determined by DXA, at the time of diagnosis; this value was nearly 3-fold higher than expected from a population of children of this age and sex distribution. BMI-Z scores could be used to identify children with celiac disease at risk for low BMD who should receive DXA screening.
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Affiliation(s)
- Jennifer Webster
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Mary Ellen Vajravelu
- The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Clare Choi
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Babette Zemel
- The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Ritu Verma
- The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Drabińska N, Jarocka-Cyrta E, Złotkowska D, Abramowicz P, Krupa-Kozak U. Daily oligofructose-enriched inulin intake impacts bone turnover markers but not the cytokine profile in pediatric patients with celiac disease on a gluten-free diet: Results of a randomised, placebo-controlled pilot study. Bone 2019; 122:184-192. [PMID: 30840918 DOI: 10.1016/j.bone.2019.03.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 02/17/2019] [Accepted: 03/02/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Bone metabolism disturbances are commonly observed in patients with newly diagnosed celiac disease (CD). The only available treatment for CD-the intake of a gluten-free diet (GFD)-has been found to be insufficient in effectively improving bone health in some patients. Therefore, there is an urgent need to modify the GFD so as to allow for the provision of all the necessary nutrients and improved absorption. Prebiotics intake reportedly improves the absorption of bone-related vitamin D and calcium as well as bone metabolism. The effect of prebiotic intake on bone health in CD patients has not been studied yet. This study aimed to evaluate the effect of oligofructose-enriched inulin intake on bone metabolism and immune response in children with CD on a GFD. METHODS A total of 34 children with CD were randomised into two groups receiving 10 g of oligofructose-enriched inulin (Synergy 1) or a placebo (maltodextrin) for three months, together with a strict GFD. The children's bone metabolism marker levels and cytokine profiles were analysed before and after the intervention. RESULTS After supplementation, the concentration of osteocalcin increased significantly in children receiving Synergy 1, while the concentration of bone alkaline phosphatase increased in both groups, independent of supplementation. After the intervention, the level of pyridinoline increased significantly in the placebo group, resulting in a concentration that was two times higher than that in the Synergy 1 group, in which it remained stable. Moreover, the plasma concentrations of N-terminal telopeptides of type I collagen decreased in both the groups, whereas the tartrate-resistant acid phosphatase 5b level increased particularly in the Synergy 1 group. The intervention did not lead to immunological response changes. CONCLUSIONS The proposed supplementation beneficially altered bone metabolism, through increased bone formation rates and decreased bone resorption process rates. Supplementation of GFD with prebiotic oligofructose-enriched inulin may be a promising auxiliary therapy for bone metabolism improvements in children with CD.
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Affiliation(s)
- Natalia Drabińska
- Department of Chemistry and Biodynamics of Food, Institute of Animal Reproduction and Food Research of Polish Academy of Sciences, Tuwima 10 Str., 10-748 Olsztyn, Poland.
| | - Elżbieta Jarocka-Cyrta
- Department of Pediatrics, Gastroenterology and Nutrition Collegium Medicum School of Medicine University of Warmia and Masuria, Żołnierska 18A Str., 10-561 Olsztyn, Poland.
| | - Dagmara Złotkowska
- Department of Immunology and Food Microbiology, Institute of Animal Reproduction and Food Research of Polish Academy of Sciences, Tuwima 10 Str., 10-748 Olsztyn, Poland.
| | - Paweł Abramowicz
- Department of Pediatrics, Rheumatology, Immunology and Metabolic Bone Diseases, Medical University of Bialystok, Bialystok, Poland.
| | - Urszula Krupa-Kozak
- Department of Chemistry and Biodynamics of Food, Institute of Animal Reproduction and Food Research of Polish Academy of Sciences, Tuwima 10 Str., 10-748 Olsztyn, Poland.
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Drabińska N, Jarocka-Cyrta E, Ratcliffe NM, Krupa-Kozak U. The Profile of Urinary Headspace Volatile Organic Compounds After 12-Week Intake of Oligofructose-Enriched Inulin by Children and Adolescents with Celiac Disease on a Gluten-Free Diet: Results of a Pilot, Randomized, Placebo-Controlled Clinical Trial. Molecules 2019; 24:E1341. [PMID: 30959740 PMCID: PMC6479364 DOI: 10.3390/molecules24071341] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 04/01/2019] [Accepted: 04/04/2019] [Indexed: 12/26/2022] Open
Abstract
The concentration of volatile organic compounds (VOCs) can inform about the metabolic condition of the body. In the small intestine of untreated persons with celiac disease (CD), chronic inflammation can occur, leading to nutritional deficiencies, and consequently to functional impairments of the whole body. Metabolomic studies showed differences in the profile of VOCs in biological fluids of patients with CD in comparison to healthy persons; however, there is scarce quantitative and nutritional intervention information. The aim of this study was to evaluate the effect of the supplementation of a gluten-free diet (GFD) with prebiotic oligofructose-enriched inulin (Synergy 1) on the concentration of VOCs in the urine of children and adolescents with CD. Twenty-three participants were randomized to the group receiving Synergy 1 (10 g per day) or placebo for 12 weeks. Urinary VOCs were analyzed using solid-phase microextraction and gas chromatography⁻mass spectrometry. Sixteen compounds were identified and quantified in urine samples. The supplementation of GFD with Synergy 1 resulted in an average concentration drop (36%) of benzaldehyde in urine samples. In summary, Synergy 1, applied as a supplement of GFD for 12 weeks had a moderate impact on the VOC concentrations in the urine of children with CD.
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Affiliation(s)
- Natalia Drabińska
- Department of Chemistry and Biodynamics of Food, Institute of Animal Reproduction and Food Research of Polish Academy of Sciences, Tuwima 10 Str., 10-748 Olsztyn, Poland.
| | - Elżbieta Jarocka-Cyrta
- Department of Pediatrics, Gastroenterology, and Nutrition, Collegium Medicum, University of Warmia & Mazury, Oczapowskiego 2 Str., 10-719 Olsztyn, Poland.
| | - Norman Mark Ratcliffe
- Institute of Biosensor Technology, the University of the West of England, University of the West of England, Coldharbour Lane, Frenchay, Bristol BS16 1QY, UK.
| | - Urszula Krupa-Kozak
- Department of Chemistry and Biodynamics of Food, Institute of Animal Reproduction and Food Research of Polish Academy of Sciences, Tuwima 10 Str., 10-748 Olsztyn, Poland.
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25
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Feruś K, Drabińska N, Krupa-Kozak U, Jarocka-Cyrta E. A Randomized, Placebo-Controlled, Pilot Clinical Trial to Evaluate the Effect of Supplementation with Prebiotic Synergy 1 on Iron Homeostasis in Children and Adolescents with Celiac Disease Treated with a Gluten-Free Diet. Nutrients 2018; 10:nu10111818. [PMID: 30469412 PMCID: PMC6266607 DOI: 10.3390/nu10111818] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 10/31/2018] [Accepted: 11/16/2018] [Indexed: 12/13/2022] Open
Abstract
Iron deficiency anemia (IDA) occurs in 15–46% of patients with celiac disease (CD), and in some cases, it may be its only manifestation. Studies in animal models have shown that prebiotics, including inulin, may help to increase intestinal absorption of iron. The aim of this study was to evaluate the effect of a prebiotic, oligofructose-enriched inulin (Synergy 1), on iron homeostasis in non-anemic children and adolescents with celiac disease (CD) in association with a gluten-free diet (GFD). Thirty-four CD patients (4–18 years old) were randomized into two groups receiving Synergy 1 (10 g/day) or a placebo (maltodextrin) for three months. Before and after intervention, blood samples were collected from all patients for assessment of blood morphology, biochemical parameters and serum hepcidin concentration. We found that serum hepcidin concentration after the intervention was significantly decreased by 60.9% (p = 0.046) in the Synergy 1 group, whereas no significant difference was observed in the placebo group. No differences in morphological and biochemical blood parameters (including ferritin, hemoglobin and C-reactive protein (CRP)) were observed after intervention in either group. Given that hepcidin decrease may improve intestinal iron absorption, these results warrant further investigation in a larger cohort and especially in patients with IDA.
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Affiliation(s)
- Klaudia Feruś
- Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum Faculty of Medicine, University of Warmia & Mazury, Oczapowskiego 2 Str., 10-719 Olsztyn, Poland.
| | - Natalia Drabińska
- Department of Chemistry and Biodynamics of Food, Institute of Animal Reproduction and Food Research of Polish Academy of Sciences, Tuwima 10 Str., 10-748 Olsztyn, Poland.
| | - Urszula Krupa-Kozak
- Department of Chemistry and Biodynamics of Food, Institute of Animal Reproduction and Food Research of Polish Academy of Sciences, Tuwima 10 Str., 10-748 Olsztyn, Poland.
| | - Elżbieta Jarocka-Cyrta
- Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum Faculty of Medicine, University of Warmia & Mazury, Oczapowskiego 2 Str., 10-719 Olsztyn, Poland.
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Pekki H, Kaukinen K, Ilus T, Mäki M, Huhtala H, Laurila K, Kurppa K. Long-term follow-up in adults with coeliac disease: Predictors and effect on health outcomes. Dig Liver Dis 2018; 50:1189-1194. [PMID: 30025706 DOI: 10.1016/j.dld.2018.05.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 05/04/2018] [Accepted: 05/22/2018] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Guidelines recommend regular follow-up in coeliac disease, but effect of this on long-term outcomes remains unclear. AIMS To evaluate predictors and significance of long-term follow-up. METHODS 677 previously diagnosed coeliac patients were recruited for a nationwide health survey. Medical data were gathered through interviews and patient records. Current symptoms and quality of life were assessed by validated questionnaires and blood samples were drawn for serology. All variables were compared between patients with and without long-term (>2 years) follow-up. RESULTS 15% had long-term follow-up, median duration 10 years. Predictors (p < 0.05) for the follow-up were immunological (35% vs. 24%) and circulatory (20% vs. 12%) comorbidities, whereas it was less common in subjects with musculoskeletal (23% vs. 34%) comorbidity and those not belonging to any at-risk group (16% vs. 27%). Patients with or without follow-up had comparable age, adherence and ability to manage a gluten-free diet and frequency of seropositivity. Also questionnaire scores paralleled, but those without follow-up reported more overall symptoms (16% vs. 26%). Most patients wished for follow-up. CONCLUSION Only a minority of patients had regular follow-up. However, patients with and without the follow-up were comparable in most long-term outcomes, indicating that it might not be always necessary. The results call for more personalized follow-up policies in coeliac disease.
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Affiliation(s)
- Henna Pekki
- Celiac Disease Research Centre, University of Tampere and Tampere University Hospital, Tampere, Finland; Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - Katri Kaukinen
- Celiac Disease Research Centre, University of Tampere and Tampere University Hospital, Tampere, Finland; Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland; Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Tuire Ilus
- Celiac Disease Research Centre, University of Tampere and Tampere University Hospital, Tampere, Finland; Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - Markku Mäki
- Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, University of Tampere, Tampere, Finland
| | - Kaija Laurila
- Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - Kalle Kurppa
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland; Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland.
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A Review on the Gluten-Free Diet: Technological and Nutritional Challenges. Nutrients 2018; 10:nu10101410. [PMID: 30279384 PMCID: PMC6213115 DOI: 10.3390/nu10101410] [Citation(s) in RCA: 114] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 09/24/2018] [Accepted: 09/25/2018] [Indexed: 12/21/2022] Open
Abstract
Consumers, food manufacturers and health professionals are uniquely influenced by the growing popularity of the gluten-free diet. Consumer expectations have urged the food industry to continuously adjust and improve the formulations and processing techniques used in gluten-free product manufacturing. Health experts have been interested in the nutritional adequacy of the diet, as well as its effectiveness in managing gluten-related disorders and other conditions. In this review, we aim to provide a clear picture of the current motivations behind the use of gluten-free diets, as well as the technological and nutritional challenges of the diet as a whole. Alternative starches and flours, hydrocolloids, and fiber sources were found to play a complex role in mimicking the functional and sensory effects of gluten in gluten-free products. However, the quality of gluten-free alternatives is often still inferior to the gluten-containing products. Furthermore, the gluten-free diet has demonstrated benefits in managing some gluten-related disorders, though nutritional imbalances have been reported. As there is limited evidence supporting the use of the gluten-free diet beyond its role in managing gluten-related disorders, consumers are urged to be mindful of the sensorial limitations and nutritional inadequacies of the diet despite ongoing strategies to improve them.
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Celiac Disease 30 Years After Diagnosis: Struggling With Gluten-free Adherence or Gaining Gluten Tolerance? J Pediatr Gastroenterol Nutr 2018; 67:361-366. [PMID: 29620596 DOI: 10.1097/mpg.0000000000001995] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Studies investigating patients with coeliac disease (CD) on very long-term follow-up are limited. We aimed to evaluate the characteristics of patients with CD diagnosed more than 30 years ago. METHODS Clinical, histologic, genetic, and demographic data of patients with CD diagnosis made before 1985 were collected and their standardised mortality ratio calculated. According to the gluten-free diet (GFD) status, CD patients were divided into 3 groups and a specific questionnaire on GFD awareness and gluten-free products was administered to patients and caregivers. RESULTS A total of 337 CD patients were included in the study. The standardised mortality ratio was 0.37 (confidence interval 0.10 to 0.94) compared with a matched population. A total of 197 patients were grouped according to GFD compliance, with 35 CD patients reporting chronic voluntary gluten ingestion. No significant differences were found between groups regarding family history of CD, symptoms and histology at diagnosis, autoimmune disorders. Follow-up histology was performed in 63 patients. Twenty patients had normal histology on gluten-containing diet (GCD). Questionnaire scores were lower in patients on GCD. Caregivers scores were not correlated with patients' gluten consumption. CONCLUSIONS Although poor adherence to GFD is the major predictor of persistence of mucosal lesions at follow-up histology, a proportion of patients did not show a relapse of villous atrophy in spite chronic voluntary gluten ingestion, nor increase in mortality. Moreover, GFD knowledge and adherence could be partly lost during the transition between childhood and adulthood.
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29
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Moretti S, Mrakic-Sposta S, Roncoroni L, Vezzoli A, Dellanoce C, Monguzzi E, Branchi F, Ferretti F, Lombardo V, Doneda L, Scricciolo A, Elli L. Oxidative stress as a biomarker for monitoring treated celiac disease. Clin Transl Gastroenterol 2018; 9:157. [PMID: 29880904 PMCID: PMC5992147 DOI: 10.1038/s41424-018-0031-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 04/11/2018] [Accepted: 05/07/2018] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION High levels of reactive oxygen species (ROS) and impaired antioxidant defense systems lead to oxidative stress (OxS) and tissue injury in different intestinal and extra intestinal conditions, including celiac disease (CD). The aim of the present study was to investigate the role and potential use of ROS and other biomarkers of OxS in the clinical management of CD. METHODS We collected duodenal specimens and blood samples from naïve patients (N-CD), patients on a gluten free diet (GFD) including responders (CD-GFD) and non-responders (NRCD). We measured plasmatic ROS production (electron paramagnetic resonance, EPR), lipid peroxidation (thiobarbituric acid-reactive substances, TBARS), protein oxidation (protein carbonyl, PC), total antioxidant capacity (TAC), nitric oxides and glutathione (GSH) in erythrocytes. RESULTS Fifty-four patients affected by CD were enrolled (17 N-CD, 18 CD-GFD and 19 NRCD; 44 F; age 44 ± 13 years). A significant increase of plasmatic OxS biomarkers (ROS, peroxidated lipids, oxidized proteins, and nitrate concentrations) and decrease of antioxidant species (TAC and GSH levels) were found in NRCD and N-CD compared to CD-GFD. Comparably, a significant direct relationship between the severity of duodenal atrophy, ROS production rates and TBARS was found; conversely, TAC and GSH presented an inverse correlation. DISCUSSION OxS is involved in CD tissue damage and correlates with the degree of duodenal atrophy. These findings suggest the possible role of OxS biomarkers as indicators of CD activity during the clinical follow-up.
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Affiliation(s)
- Sarah Moretti
- Institute of Bioimaging and Molecular Physiology, National Research Council (CNR), Via Fratelli Cervi 93, 20090, Segrate, Italy
| | - Simona Mrakic-Sposta
- Institute of Bioimaging and Molecular Physiology, National Research Council (CNR), Via Fratelli Cervi 93, 20090, Segrate, Italy
| | - Leda Roncoroni
- Center for Prevention and Diagnosis of Celiac Disease- Div. of Gastroenterology and Endoscopy, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milano, Italy
- Department of Biomedical, Surgical and Dental Sciences, Università degli Studi di Milano, Via Festa del Perdono, 20122, Milano, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Via Festa del Perdono, 20122, Milano, Italy
| | - Alessandra Vezzoli
- Institute of Bioimaging and Molecular Physiology, National Research Council (CNR), Via Fratelli Cervi 93, 20090, Segrate, Italy
| | - Cinzia Dellanoce
- Institute of Clinical Physiology, National Research Council (CNR), Niguarda Ca' Granda Hospital, Via G. Moruzzi 1, 56124, Pisa, Italy
| | - Erika Monguzzi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Via Festa del Perdono, 20122, Milano, Italy
| | - Federica Branchi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Via Festa del Perdono, 20122, Milano, Italy
| | - Francesca Ferretti
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Via Festa del Perdono, 20122, Milano, Italy
| | - Vincenza Lombardo
- Center for Prevention and Diagnosis of Celiac Disease- Div. of Gastroenterology and Endoscopy, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milano, Italy
| | - Luisa Doneda
- Department of Biomedical, Surgical and Dental Sciences, Università degli Studi di Milano, Via Festa del Perdono, 20122, Milano, Italy
| | - Alice Scricciolo
- Center for Prevention and Diagnosis of Celiac Disease- Div. of Gastroenterology and Endoscopy, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milano, Italy
| | - Luca Elli
- Center for Prevention and Diagnosis of Celiac Disease- Div. of Gastroenterology and Endoscopy, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milano, Italy.
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Haridy J, Lewis D, Newnham ED. Investigational drug therapies for coeliac disease - where to from here? Expert Opin Investig Drugs 2018; 27:225-233. [PMID: 29411655 DOI: 10.1080/13543784.2018.1438407] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Despite decades of research and a detailed knowledge of the immunopathological basis of coeliac disease (CD), adherence to a lifelong gluten-free diet (GFD) remains the single proven and available treatment. The increasing prevalence of CD combined with variable adherence to the GFD in a significant proportion of patients demands new therapeutic strategies. AREAS COVERED Trial registries, clinicaltrials.gov, pharmaceutical company website searches as well as published data from PubMed and conference proceedings were used to extract the most recent outcomes for CD therapeutics. This article aims to review the available therapies from a pathophysiological approach, and propose future directions in this interesting yet largely unfulfilled area of research. EXPERT OPINION Increasingly, the GFD is being challenged by its availability, palatability, practicality and now even efficacy in some populations. Whilst the causative antigens have been well described, it is clear that treatment based on the removal of these immunostimulatory peptides from the diet is far more complex than early experience in CD treatment implied. Despite burgeoning interest and research in experimental therapies for CD over the past twenty years, the only therapy showing promise as a true alternative to a GFD is that of the induction of tolerance via a vaccine.
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Affiliation(s)
- James Haridy
- a Department of Gastroenterology and Hepatology , Monash University, Eastern Health Clinical School , Melbourne , Australia
| | - Diana Lewis
- a Department of Gastroenterology and Hepatology , Monash University, Eastern Health Clinical School , Melbourne , Australia
| | - Evan D Newnham
- a Department of Gastroenterology and Hepatology , Monash University, Eastern Health Clinical School , Melbourne , Australia
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31
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Tye-Din JA, Galipeau HJ, Agardh D. Celiac Disease: A Review of Current Concepts in Pathogenesis, Prevention, and Novel Therapies. Front Pediatr 2018; 6:350. [PMID: 30519552 PMCID: PMC6258800 DOI: 10.3389/fped.2018.00350] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 10/29/2018] [Indexed: 12/14/2022] Open
Abstract
Our understanding of celiac disease and how it develops has evolved significantly over the last half century. Although traditionally viewed as a pediatric illness characterized by malabsorption, it is now better seen as an immune illness with systemic manifestations affecting all ages. Population studies reveal this global disease is common and, in many countries, increasing in prevalence. These studies underscore the importance of specific HLA susceptibility genes and gluten consumption in disease development and suggest that other genetic and environmental factors could also play a role. The emerging data on viral and bacterial microbe-host interactions and their alterations in celiac disease provides a plausible mechanism linking environmental risk and disease development. Although the inflammatory lesion of celiac disease is complex, the strong HLA association highlights a central role for pathogenic T cells responding to select gluten peptides that have now been defined for the most common genetic form of celiac disease. What remains less understood is how loss of tolerance to gluten occurs. New insights into celiac disease are now providing opportunities to intervene in its development, course, diagnosis, and treatment.
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Affiliation(s)
- Jason A Tye-Din
- Immunology Division, The Walter and Eliza Hall Institute, Parkville, VIC, Australia.,Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia.,Department of Gastroenterology, The Royal Melbourne Hospital, Parkville, VIC, Australia.,Centre for Food & Allergy Research, Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Heather J Galipeau
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Daniel Agardh
- The Diabetes and Celiac Disease Unit, Department of Clinical Sciences, Lund University, Malmö, Sweden.,Unit of Endocrinology and Gastroenterology, Department of Pediatrics, Skåne University Hospital, Malmö, Sweden
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The Role of an IgA/IgG-Deamidated Gliadin Peptide Point-of-Care Test in Predicting Persistent Villous Atrophy in Patients With Celiac Disease on a Gluten-Free Diet. Am J Gastroenterol 2017; 112:1859-1867. [PMID: 29016564 DOI: 10.1038/ajg.2017.357] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 08/05/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Mucosal healing is important in celiac disease (CD) for the prevention of complications. However, obtaining duodenal biopsies is invasive, and there is currently no reliable surrogate marker for histological remission in clinical practice. We aimed to assess the role of a point-of-care test (POCT) based on IgA/IgG-deamidated gliadin peptide, in detecting persistent villous atrophy (VA) in CD. METHODS We prospectively recruited patients with CD attending endoscopy for the assessment of histological remission. All patients had IgA-endomysial (EMA) antibodies, IgA-tissue transglutaminase (TTG) antibodies, and the POCT performed, and completed a validated dietary adherence questionnaire. A gastroscopy was performed in all patients, with four biopsies taken from the second part of the duodenum and one from the duodenal bulb. We compared the diagnostic performance of the surrogate markers against duodenal histology as the reference standard. RESULTS A total of 217 patients with CD (70% female, age range 16-83 years, median age 53 years) on a gluten-free diet (median duration 6 years) were recruited from 2013 to 2017. Eighty-five (39.2%) patients had persistent VA. The sensitivities of the POCT, TTG, EMA, and the adherence score in detecting VA were 67.1%, 44.7%, 37.7%, and 24.7% respectively (P=0.0005). The combination of the POCT and adherence score only marginally increased the sensitivity to 70.6% (59.7-80.0%). CONCLUSIONS The sensitivity of the POCT was higher than the other surrogate markers in predicting VA. A POCT may provide the additional advantage of an immediate objective assessment of mucosal healing at the time of an office-based follow-up consultation.
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Younger age at diagnosis predisposes to mucosal recovery in celiac disease on a gluten-free diet: A meta-analysis. PLoS One 2017; 12:e0187526. [PMID: 29095937 PMCID: PMC5695627 DOI: 10.1371/journal.pone.0187526] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 07/27/2017] [Indexed: 12/12/2022] Open
Abstract
Background and aims Persistent intestinal damage is associated with higher complication rates in celiac disease. We aimed to assess the potential modifiers of mucosal recovery. Materials and methods We screened databases (PubMed, Embase, Cochrane Trials, and Web of Science) for papers on celiac disease. Papers discussing (1) celiac patients (2) follow-up biopsy and (3) mucosal recovery after commencement of a gluten-free diet were included. The primary outcome was to produce a comprehensive analysis of complete mucosal recovery (i.e., Marsh 0 on follow-up). We compared children’s recovery ratios to those of adults. Patients following a strict gluten-free dietary regimen were included in a subgroup. Summary point estimates, 95% confidence intervals (CIs), and 95% predictive intervals (PIs) were calculated. Heterogeneity was tested with I2-statistic. The PROSPERO registration number is CRD42016053482. Results The overall complete mucosal recovery ratio, calculated from 37 observational studies, was 0.36 (CI: 0.28–0.44, PI: -0.12–0.84; I2: 98.4%, p<0.01). Children showed higher complete mucosal recovery ratio than adults (p<0.01): 0.65 (CI: 0.44–0.85, PI: -0.10–1.39; I2: 96.5%, p<0.01) as opposed to 0.24 (CI: 0.15–0.33, PI: -0.19–1.08; I2: 96.3%, p<0.01). In the strict dietary adherence subgroup, complete mucosal recovery ratio was 0.47 (CI: 0.24–0.70, PI: -0.47–1.41; I2: 98.8%, p<0.001). On meta-regression, diagnostic villous atrophy (Marsh 3) ratio (-8.97, p<0.01) and male ratio (+6.04, p<0.01) proved to be a significant determinant of complete mucosal recovery, unlike duration of gluten-free diet (+0.01, p = 0.62). The correlation between complete mucosal recovery ratio and age on diagnosis is of borderline significance (-0.03, p = 0.05). Conclusions There is considerable heterogeneity across studies concerning complete mucosal recovery ratios achieved by a gluten-free diet in celiac disease. Several celiac patients fail to achieve complete mucosal recovery even if a strict dietary regimen is followed. Younger age on diagnosis, less severe initial histologic damage and male gender predispose for achieving mucosal recovery.
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Lerner A, Arleevskaya M, Schmiedl A, Matthias T. Microbes and Viruses Are Bugging the Gut in Celiac Disease. Are They Friends or Foes? Front Microbiol 2017; 8:1392. [PMID: 28824555 PMCID: PMC5539691 DOI: 10.3389/fmicb.2017.01392] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 07/10/2017] [Indexed: 12/17/2022] Open
Abstract
The links between microorganisms/viruses and autoimmunity are complex and multidirectional. A huge number of studies demonstrated the triggering impact of microbes and viruses as the major environmental factors on the autoimmune and inflammatory diseases. However, growing evidences suggest that infectious agents can also play a protective role or even abrogate these processes. This protective crosstalk between microbes/viruses and us might represent a mutual beneficial equilibrium relationship between two cohabiting ecosystems. The protective pathways might involve post-translational modification of proteins, decreased intestinal permeability, Th1 to Th2 immune shift, induction of apoptosis, auto-aggressive cells relocation from the target organ, immunosuppressive extracellular vesicles and down regulation of auto-reactive cells by the microbial derived proteins. Our analysis demonstrates that the interaction of the microorganisms/viruses and celiac disease (CD) is always a set of multidirectional processes. A deeper inquiry into the CD interplay with Herpes viruses and Helicobacter pylori demonstrates that the role of these infections, suggested to be potential CD protectors, is not as controversial as for the other infectious agents. The outcome of these interactions might be due to a balance between these multidirectional processes.
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Affiliation(s)
- Aaron Lerner
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion Israel Institute of TechnologyHaifa, Israel.,Department of Research, AESKU.KIPP InstituteWendelsheim, Germany
| | - Marina Arleevskaya
- Central Research Laboratory, Kazan State Medical Academy KazanKazan, Russia
| | - Andreas Schmiedl
- Department of Research, AESKU.KIPP InstituteWendelsheim, Germany
| | - Torsten Matthias
- Department of Research, AESKU.KIPP InstituteWendelsheim, Germany
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Mahadev S, Murray JA, Wu TT, Chandan VS, Torbenson MS, Kelly CP, Maki M, Green PHR, Adelman D, Lebwohl B. Factors associated with villus atrophy in symptomatic coeliac disease patients on a gluten-free diet. Aliment Pharmacol Ther 2017; 45:1084-1093. [PMID: 28220520 DOI: 10.1111/apt.13988] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 10/25/2016] [Accepted: 01/23/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Duodenal injury persists in some coeliac disease patients despite gluten-free diet, and is associated with adverse outcomes. AIM To determine the prevalence and clinical risk factors for persistent villus atrophy among symptomatic coeliac disease patients. METHODS A nested cross-sectional analysis was performed on coeliac disease patients with self-reported moderate or severe symptoms while following a gluten-free diet, who underwent protocol-mandated duodenal biopsy upon enrolment in the CeliAction clinical trial. Demographic factors, symptom type, medication use, and serology were examined to determine predictors of persistent villus atrophy. RESULTS Of 1345 symptomatic patients, 511 (38%, 95% CI, 35-41%) were found to have active coeliac disease with persistent villus atrophy, defined as average villus height to crypt depth ratio ≤2.0. On multivariable analysis, older age (OR, 5.1 for ≥70 vs. 18-29 years, 95% CI, 2.5-10.4) was a risk factor while longer duration on gluten-free diet was protective (OR, 0.37, 95% CI, 0.24-0.55 for 4-5.9 vs. 1-1.9 years). Villus atrophy was associated with use of proton-pump inhibitors (PPIs; OR, 1.6, 95% CI, 1.1-2.3), non-steroidal anti-inflammatory drugs (NSAIDs; OR, 1.64, 95% CI, 1.2-2.2), and selective serotonin reuptake inhibitors (SSRIs; OR, 1.74, 95% CI, 1.2-2.5). Symptoms were not associated with villus atrophy after adjusting for covariates. Conclusions A majority of symptomatic coeliac disease patients did not have active disease on follow-up histology. Symptoms were poorly predictive of persistent mucosal injury. The impact of NSAIDs, PPIs, and SSRIs on mucosal healing in coeliac disease warrants further study.
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Affiliation(s)
- S Mahadev
- Celiac Disease Center, Columbia University College of Physicians and Surgeons, New York, USA
| | - J A Murray
- Division of Gastroenterology and Hepatology, The Mayo Clinic, Rochester, MN, USA
| | - T-T Wu
- Department of Laboratory Medicine and Pathology, The Mayo Clinic, Rochester, MN, USA
| | - V S Chandan
- Department of Laboratory Medicine and Pathology, The Mayo Clinic, Rochester, MN, USA
| | - M S Torbenson
- Department of Laboratory Medicine and Pathology, The Mayo Clinic, Rochester, MN, USA
| | - C P Kelly
- Celiac Center, Beth Israel Deaconess Medical Center and Celiac Research Program, Harvard Medical School, Boston, MA, USA
| | - M Maki
- Tampere Center for Child Health Research, School of Medicine, University of Tampere and Tampere University Hospital, Finland, Europe
| | - P H R Green
- Celiac Disease Center, Columbia University College of Physicians and Surgeons, New York, USA
| | - D Adelman
- Division of Allergy/Immunology, Department of Medicine, University of California, San Francisco, CA, USA
| | - B Lebwohl
- Celiac Disease Center, Columbia University College of Physicians and Surgeons, New York, USA
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Murray JA, Kelly CP, Green PHR, Marcantonio A, Wu TT, Mäki M, Adelman DC. No Difference Between Latiglutenase and Placebo in Reducing Villous Atrophy or Improving Symptoms in Patients With Symptomatic Celiac Disease. Gastroenterology 2017; 152:787-798.e2. [PMID: 27864127 DOI: 10.1053/j.gastro.2016.11.004] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 11/04/2016] [Accepted: 11/09/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Gluten ingestion leads to symptoms and small intestinal mucosal injury in patients with celiac disease. The only option is the strict lifelong exclusion of dietary gluten, which is difficult to accomplish. Many patients following a gluten-free diet continue to have symptoms and have small intestinal mucosal injury. Nondietary therapies are needed. We performed a phase 2 study of the ability of latiglutenase, an orally administered mixture of 2 recombinant gluten-targeting proteases, to reduce mucosal morphometric measures in biopsy specimens from patients with celiac disease. METHODS We performed a double-blind, placebo-controlled, dose-ranging study to assess the efficacy and safety of latiglutenase in 494 patients with celiac disease (with moderate or severe symptoms) in North America and Europe, from August 2013 until December 2014. Participants reported following a gluten-free diet for at least 1 year before the study began. Patients with documented moderate or severe symptoms and villous atrophy (villous height:crypt depth ratio of ≤2.0) were assigned randomly to groups given placebo or 100, 300, 450, 600, or 900 mg latiglutenase daily for 12 or 24 weeks. Subjects completed the Celiac Disease Symptom Diary each day for 28 days and underwent an upper gastrointestinal endoscopy with duodenal biopsy of the distal duodenum at baseline and at weeks 12 and 24. The primary end point was a change in the villous height:crypt depth ratio. Secondary end points included numbers of intraepithelial lymphocytes, serology test results (for levels of antibodies against tissue transglutaminase-2 and deamidated gliadin peptide), symptom frequencies, and safety. RESULTS In a modified intent-to-treat population, there were no differences between latiglutenase and placebo groups in change from baseline in villous height:crypt depth ratio, numbers of intraepithelial lymphocytes, or serologic markers of celiac disease. All groups had significant improvements in histologic and symptom scores. CONCLUSIONS In a phase 2 study of patients with symptomatic celiac disease and histologic evidence of significant duodenal mucosal injury, latiglutenase did not improve histologic and symptom scores when compared with placebo. There were no significant differences in change from baseline between groups. ClinicalTrials.gov no: NCT01917630.
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Affiliation(s)
- Joseph A Murray
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
| | - Ciarán P Kelly
- Celiac Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Peter H R Green
- Columbia University College of Physicians and Surgeons, New York, New York
| | | | - Tsung-Teh Wu
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Markku Mäki
- School of Medicine, University of Tampere and Tampere University Hospital, Tampere, Finland
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Moreno MDL, Rodríguez-Herrera A, Sousa C, Comino I. Biomarkers to Monitor Gluten-Free Diet Compliance in Celiac Patients. Nutrients 2017; 9:nu9010046. [PMID: 28067823 PMCID: PMC5295090 DOI: 10.3390/nu9010046] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 11/29/2016] [Accepted: 12/27/2016] [Indexed: 12/11/2022] Open
Abstract
Gluten-free diet (GFD) is the only treatment for celiac disease (CD). There is a general consensus that strict GFD adherence in CD patients leads to full clinical and histological remission accompanied by improvement in quality of life and reduced long-term complications. Despite the importance of monitoring the GFD, there are no clear guidelines for assessing the outcome or for exploring its adherence. Available methods are insufficiently accurate to identify occasional gluten exposure that may cause intestinal mucosal damage. Serological tests are highly sensitive and specific for diagnosis, but do not predict recovery and are not useful for follow-up. The use of serial endoscopies, it is invasive and impractical for frequent monitoring, and dietary interview can be subjective. Therefore, the detection of gluten immunogenic peptides (GIP) in feces and urine have been proposed as new non-invasive biomarkers to detect gluten intake and verify GFD compliance in CD patients. These simple immunoassays in human samples could overcome some key unresolved scientific and clinical problems in CD management. It is a significant advance that opens up new possibilities for the clinicians to evaluate the CD treatment, GFD compliance, and improvement in the quality of life of CD patients.
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Affiliation(s)
- María de Lourdes Moreno
- Departamento de Microbiología y Parasitología, Facultad de Farmacia, Universidad de Sevilla, c/Profesor García González 2, 41012 Sevilla, Spain.
| | | | - Carolina Sousa
- Departamento de Microbiología y Parasitología, Facultad de Farmacia, Universidad de Sevilla, c/Profesor García González 2, 41012 Sevilla, Spain.
| | - Isabel Comino
- Departamento de Microbiología y Parasitología, Facultad de Farmacia, Universidad de Sevilla, c/Profesor García González 2, 41012 Sevilla, Spain.
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Hære P, Høie O, Schulz T, Schönhardt I, Raki M, Lundin KEA. Long-term mucosal recovery and healing in celiac disease is the rule - not the exception. Scand J Gastroenterol 2016; 51:1439-1446. [PMID: 27534885 DOI: 10.1080/00365521.2016.1218540] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The prevalence of persistent villous atrophy (VA) in patients with celiac disease (CD) on a gluten-free diet (GFD) varies greatly between studies. Most studies show a relatively high prevalence of mucosal atrophy and inflammation in treated patients, a finding which have led to a concept of non-responsive CD. Few studies have examined the prevalence of long-term mucosal healing. Our study aimed to determine the extent of mucosal healing in a cohort of Norwegian patients with CD treated with GFD for several years. MATERIALS AND METHODS Adult patients diagnosed with VA between 1989 and 2009 were included. We performed a follow-up gastroscopy with duodenal biopsies. Two pathologists evaluated the biopsies according to the Marsh-Oberhuber classification. Mucosal healing was defined as Marsh 0 while mucosal recovery was defined as Marsh 0-2. RESULTS Duodenal biopsies were obtained from 127 adult patients with established CD. After a follow-up time of 8.1 years (median, range 2.3-22.3), 103 (81%) of the patients showed mucosal healing, 120 patients (94%) showed mucosal recovery, and 7 patients (6%) showed persistent VA. In addition, 103 of the 127 patients (81%) had undergone a routine follow-up biopsy 12.6 months (median, range 5.2-28.8) after diagnosis. At the time of the routine follow-up, only 52 of these patients (50.5%) had achieved mucosal recovery. CONCLUSIONS Although half of the patients had persistent VA at the time of routine follow-up, both long-term mucosal recovery and healing is possible for the vast majority of adult patients with CD.
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Affiliation(s)
- Petter Hære
- a Department of Gastroenterology , Sørlandet Hospital HF , Arendal , Norway
| | - Ole Høie
- a Department of Gastroenterology , Sørlandet Hospital HF , Arendal , Norway
| | - Tom Schulz
- a Department of Gastroenterology , Sørlandet Hospital HF , Arendal , Norway
| | - Irina Schönhardt
- b Department of Pathology , Sørlandet Hospital HF , Kristiansand , Norway
| | - Melinda Raki
- c Department of Pathology , Oslo University Hospital , Oslo , Norway
| | - Knut E A Lundin
- d CIR - Centre for Immune Regulation in Oslo, Oslo University Hospital, University of Oslo , Oslo , Norway
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Zanini B, Marullo M, Villanacci V, Salemme M, Lanzarotto F, Ricci C, Lanzini A. Persistent Intraepithelial Lymphocytosis in Celiac Patients Adhering to Gluten-Free Diet Is Not Abolished Despite a Gluten Contamination Elimination Diet. Nutrients 2016; 8:nu8090525. [PMID: 27571100 PMCID: PMC5037512 DOI: 10.3390/nu8090525] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 08/04/2016] [Accepted: 08/16/2016] [Indexed: 02/06/2023] Open
Abstract
The gluten-free diet (GFD) is the only validated treatment for celiac disease (CD), but despite strict adherence, complete mucosal recovery is rarely obtained. The aim of our study was to assess whether complete restitutio ad integrum could be achieved by adopting a restrictive diet (Gluten Contamination Elimination Diet, GCED) or may depend on time of exposure to GFD. Two cohorts of CD patients, with persisting Marsh II/Grade A lesion at duodenal biopsy after 12–18 months of GFD (early control) were identified. Patients in Cohort A were re-biopsied after a three-month GCED (GCED control) and patients in Cohort B were re-biopsied after a minimum of two years on a standard GFD subsequent to early control (late control). Ten patients in Cohort A and 19 in Cohort B completed the study protocol. There was no change in the classification of duodenal biopsies in both cohorts. The number of intraepithelial lymphocytes, TCRγδ+ (T-Cell Receptor gamma delta) T cell and eosinophils significantly decreased at GCED control (Cohort A) and at late control (Cohort B), compared to early control. Duodenal intraepithelial lymphocytosis persisting in CD patients during GFD is not eliminated by a GCED and is independent of the length of GFD. [NCT 02711696]
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Affiliation(s)
- Barbara Zanini
- Gastroenterology Unit, University and Spedali Civili of Brescia, Piazzale Spedali Civili, Brescia I-25123, Italy.
| | - Monica Marullo
- Gastroenterology Unit, University and Spedali Civili of Brescia, Piazzale Spedali Civili, Brescia I-25123, Italy.
| | - Vincenzo Villanacci
- Histopathology Unit, University and Spedali Civili of Brescia, Piazzale Spedali Civili, Brescia I-25123, Italy.
| | - Marianna Salemme
- Histopathology Unit, University and Spedali Civili of Brescia, Piazzale Spedali Civili, Brescia I-25123, Italy.
| | - Francesco Lanzarotto
- Gastroenterology Unit, University and Spedali Civili of Brescia, Piazzale Spedali Civili, Brescia I-25123, Italy.
| | - Chiara Ricci
- Gastroenterology Unit, University and Spedali Civili of Brescia, Piazzale Spedali Civili, Brescia I-25123, Italy.
| | - Alberto Lanzini
- Gastroenterology Unit, University and Spedali Civili of Brescia, Piazzale Spedali Civili, Brescia I-25123, Italy.
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Newnham ED, Shepherd SJ, Strauss BJ, Hosking P, Gibson PR. Adherence to the gluten-free diet can achieve the therapeutic goals in almost all patients with coeliac disease: A 5-year longitudinal study from diagnosis. J Gastroenterol Hepatol 2016. [PMID: 26212198 DOI: 10.1111/jgh.13060] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Key aims of treatment of coeliac disease are to heal the intestinal mucosa and correct nutritional abnormalities. AIM We aim to determine prospectively the degree of success and time course of achieving those goals with a gluten-free diet. METHODS Ninety-nine patients were enrolled at diagnosis and taught the diet. The first 52 were reassessed at 1 year and 46 at 5 years, 25 being assessed at the three time points regarding dietary compliance (dietitian-assessed), coeliac serology, bone mineral density and body composition analysis by dual energy X-ray absorptiometry, and intestinal histology. RESULTS Mean age (range) was 40 (18-71) years and 48 (76%) were female. Dietary compliance was very good to excellent in all but one. Tissue transglutaminase IgA was persistently elevated in 44% at 1 year and 30% at 5 years and were poorly predictive of mucosal disease. Rates of mucosal remission (Marsh 0) and response (Marsh 0/1) were 37% and 54%, and 50% and 85% at 1 and 5 years, respectively. Fat mass increased significantly over the first year in those with normal/reduced body mass index. Lean body mass indices more slowly improved irrespective of status at diagnosis with significant improvement at 5 years. Bone mass increased only in those with osteopenia or osteoporosis, mostly in year 1. CONCLUSION Dietary compliance is associated with a high chance of healing the intestinal lesion and correction of specific body compositional abnormalities. The time course differed with body fat improving within 1 year, and correction of the mucosal lesion and improvement in lean mass and bone mass taking longer.
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Affiliation(s)
- Evan D Newnham
- Department of Gastroenterology and Hepatology, Eastern Health Clinical School
| | - Susan J Shepherd
- Department of Gastroenterology and Hepatology, Eastern Health Clinical School
| | | | | | - Peter R Gibson
- Department of Gastroenterology, Central Clinical School, Monash University, Alfred Hospital, Melbourne, Victoria, Australia
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Senger S, Sapone A, Fiorentino MR, Mazzarella G, Lauwers GY, Fasano A. Celiac Disease Histopathology Recapitulates Hedgehog Downregulation, Consistent with Wound Healing Processes Activation. PLoS One 2015; 10:e0144634. [PMID: 26649570 PMCID: PMC4674131 DOI: 10.1371/journal.pone.0144634] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 11/21/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND In celiac disease (CD), intestinal epithelium damage occurs secondary to an immune insult and is characterized by blunting of the villi and crypt hyperplasia. Similarities between Hedgehog (Hh)/BMP4 downregulation, as reported in a mouse model, and CD histopathology, suggest mechanistic involvement of Hh/BMP4/WNT pathways in proliferation and differentiation of immature epithelial cells in the context of human intestinal homeostasis and regeneration after damage. Herein we examined the nature of intestinal crypt hyperplasia and involvement of Hh/BMP4 in CD histopathology. METHODS AND FINDINGS Immunohistochemistry, qPCR and in situ hybridization were used to study a cohort of 24 healthy controls (HC) and 24 patients with diagnosed acute celiac disease (A-CD) intestinal biopsies. In A-CD we observed an increase in cells positive for Leucin-rich repeat-containing G protein-coupled receptor 5 (LGR5), an epithelial stem cell specific marker and expansion of WNT responding compartment. Further, we observed alteration in number and distribution of mesenchymal cells, predicted to be part of the intestinal stem cells niche. At the molecular level we found downregulation of indian hedgehog (IHH) and other components of the Hh pathway, but we did not observe a concurrent downregulation of BMP4. However, we observed upregulation of BMPs antagonists, gremlin 1 and gremlin 2. CONCLUSIONS Our data suggest that acute CD histopathology partially recapitulates the phenotype reported in Hh knockdown models. Specifically, Hh/BMP4 paradigm appears to be decoupled in CD, as the expansion of the immature cell population does not occur consequent to downregulation of BMP4. Instead, we provide evidence that upregulation of BMP antagonists play a key role in intestinal crypt hyperplasia. This study sheds light on the molecular mechanisms underlying CD histopathology and the limitations in the use of mouse models for celiac disease.
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Affiliation(s)
- Stefania Senger
- Center for Mucosal Immunology and Biology Research, Massachusetts General Hospital for Children and Celiac Program at Harvard Medical School, Charlestown, Massachusetts, United States of America
| | - Anna Sapone
- Center for Mucosal Immunology and Biology Research, Massachusetts General Hospital for Children and Celiac Program at Harvard Medical School, Charlestown, Massachusetts, United States of America
- Celiac Center, Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Maria Rosaria Fiorentino
- Center for Mucosal Immunology and Biology Research, Massachusetts General Hospital for Children and Celiac Program at Harvard Medical School, Charlestown, Massachusetts, United States of America
| | - Giuseppe Mazzarella
- Institute of Food Sciences, National Research Council (CNR), Avellino, 83100, Italy
| | - Gregory Y. Lauwers
- Department of Pathology, Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts, United States of America
| | - Alessio Fasano
- Center for Mucosal Immunology and Biology Research, Massachusetts General Hospital for Children and Celiac Program at Harvard Medical School, Charlestown, Massachusetts, United States of America
- * E-mail:
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Stadlmann V, Harant H, Korschineck I, Hermann M, Forster F, Missbichler A. Novel avian single-chain fragment variable (scFv) targets dietary gluten and related natural grain prolamins, toxic entities of celiac disease. BMC Biotechnol 2015; 15:109. [PMID: 26625857 PMCID: PMC4666168 DOI: 10.1186/s12896-015-0223-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 11/10/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Celiac disease (CD) is a chronic, small intestinal inflammatory disease mediated by dietary gluten and related prolamins. The only current therapeutic option is maintenance of a strict life-long gluten-free diet, which implies substantial burden for CD patients. Different treatment regimes might be feasible, including masking of toxic celiac peptides with blocking antibodies or fragments thereof. The objective of this study was therefore to select and produce a recombinant avian single-chain fragment variable (scFv) directed against peptic-tryptic digested gliadin (PT-Gliadin) and related celiac toxic entities. RESULTS Gluten-free raised chicken of same age were immunized with PT-Gliadin. Chicken splenic lymphocytes, selected with antigen-coated magnetic beads, served as RNA source for the generation of cDNA. Chicken VH and VL genes were amplified from the cDNA by PCR to generate full-length scFv constructs consisting of VH and VL fragments joined by a linker sequence. ScFv constructs were ligated in a prokaryotic expression vector, which provides a C-terminal hexahistidine tag. ScFvs from several bacterial clones were expressed in soluble form and crude cell lysates screened for binding to PT-Gliadin by ELISA. We identified an enriched scFv motif, which showed reactivity to PT-Gliadin. One selected scFv candidate was expressed and purified to homogeneity. Polyclonal anti-PT-Gliadin IgY, purified from egg yolk of immunized chicken, served as control. ScFv binds in a dose-dependent manner to PT-Gliadin, comparable to IgY. Furthermore, IgY competitively displaces scFv from PT-Gliadin and natural wheat flour digest, indicating a common epitope of scFv and IgY. ScFv was tested for reactivity to different gastric digested dietary grain flours. ScFv detects common and khorasan wheat comparably with binding affinities in the high nanomolar range, while rye is detected to a lesser extent. Notably, barley and cereals which are part of the gluten-free diet, like corn and rice, are not detected by scFv. Similarly, the pseudo-grain amaranth, used as gluten-free alternative, is not targeted by scFv. This data indicate that scFv specifically recognizes toxic cereal peptides relevant in CD. CONCLUSION ScFv can be of benefit for future CD treatment regimes.
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Affiliation(s)
| | | | | | - Marcela Hermann
- Department of Medical Biochemistry, Division of Molecular Genetics, Medical University of Vienna, Vienna, Austria
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Ciccocioppo R, Kruzliak P, Cangemi GC, Pohanka M, Betti E, Lauret E, Rodrigo L. The Spectrum of Differences between Childhood and Adulthood Celiac Disease. Nutrients 2015; 7:8733-51. [PMID: 26506381 PMCID: PMC4632446 DOI: 10.3390/nu7105426] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Revised: 10/06/2015] [Accepted: 10/12/2015] [Indexed: 02/06/2023] Open
Abstract
An old saying states that ''children are not little adults" and this certainly holds true for celiac disease, as there are many peculiar aspects regarding its epidemiology, diagnosis, clinical presentations, associated diseases, and response to treatment in pediatric compared to adult populations, to such an extent that it merits a description of its own. In fact, contrary to the past when it was thought that celiac disease was a disorder predominantly affecting childhood and characterized by a malabsorption syndrome, nowadays it is well recognized that it affects also adult and elderly people with an impressive variability of clinical presentation. In general, the clinical guidelines for diagnosis recommend starting with specific serologic testing in all suspected subjects, including those suffering from extraintestinal related conditions, and performing upper endoscopy with appropriate biopsy sampling of duodenal mucosa in case of positivity. The latter may be omitted in young patients showing high titers of anti-transglutaminase antibodies. The subsequent management of a celiac patient differs substantially depending on the age at diagnosis and should be based on the important consideration that this is a lifelong condition.
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Affiliation(s)
- Rachele Ciccocioppo
- Rachele Ciccocioppo, Center for the Study and Cure of Celiac Disease, Clinica Medica I, Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation, University of Pavia, 19-27100 Pavia, Italy.
| | - Peter Kruzliak
- International Clinical Research Center, St. Anne's University Hospital and Masaryk University, 65691 Brno, Czech Republic.
| | - Giuseppina C Cangemi
- Rachele Ciccocioppo, Center for the Study and Cure of Celiac Disease, Clinica Medica I, Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation, University of Pavia, 19-27100 Pavia, Italy.
| | - Miroslav Pohanka
- Faculty of Military Health Sciences, University of Defence, Trebešská 1575-500 01 Hradec Kralove, Czech Republic.
- Department of Geology and Pedology, Faculty of Forestry and Wood Technology, Mendel University in Brno, 61300 Brno, Czech Republic.
| | - Elena Betti
- Rachele Ciccocioppo, Center for the Study and Cure of Celiac Disease, Clinica Medica I, Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation, University of Pavia, 19-27100 Pavia, Italy.
| | - Eugenia Lauret
- Gastroenterology Unit, Hospital Universitario Central de Asturias, 33000 Oviedo, Spain.
| | - Luis Rodrigo
- Gastroenterology Unit, Hospital Universitario Central de Asturias, 33000 Oviedo, Spain.
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Elli L, Zini E, Tomba C, Bardella MT, Bosari S, Conte D, Runza L, Roncoroni L, Ferrero S. Histological evaluation of duodenal biopsies from coeliac patients: the need for different grading criteria during follow-up. BMC Gastroenterol 2015; 15:133. [PMID: 26467310 PMCID: PMC4604755 DOI: 10.1186/s12876-015-0361-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Accepted: 10/01/2015] [Indexed: 12/12/2022] Open
Abstract
Background Coeliac disease is characterised by villous atrophy, which usually normalises after gluten withdrawal. Sometimes the revaluation of duodenal histology is required during follow-up, even if the methodology for comparing duodenal histology before and after introducing a gluten-free diet is not yet established. Our aim was to evaluate a novel criterion to compare duodenal histology in coeliac disease before and after gluten withdrawal. Methods Duodenal biopsies from coeliac patients were retrospectively reviewed to compare duodenal histology at diagnosis and after at least one year on a gluten-free diet. Two different methods were used: the first was represented by the classical Marsh-Oberhuber score, the second compared the areas covered by each Marsh-Oberhuber grade and expressed as percentages, the final grade being calculated from the analysis of ten power fields per duodenal biopsy. Results Sixty-nine patients (17 males 52 females, age at diagnosis 36 ± 15 years) who underwent duodenal biopsies, were considered. According to the classical Marsh-Oberhuber scale, 32 patients did not present atrophy during follow-up while 37 showed duodenal atrophy, among whom 26 improved the grade of severity and 11 retained the same one. Of these latter, according to the second method, eight patients were considered improved, two showed a worsened duodenal damage and only one remained unchanged; the evaluation changed in 91 % of cases. Conclusions The proposed semi-quantitative approach (i.e. the second method) for the evaluation of histology at follow-up provides additional information about the progression/regression of the mucosal damage. Electronic supplementary material The online version of this article (doi:10.1186/s12876-015-0361-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Luca Elli
- Center for the Prevention and Diagnosis of Coeliac Disease, Gastroenterology and Endoscopy Unit - Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 28, 20100, Milan, Italy.
| | - Enea Zini
- Pathology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 28, 20100, Milan, Italy.
| | - Carolina Tomba
- Center for the Prevention and Diagnosis of Coeliac Disease, Gastroenterology and Endoscopy Unit - Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 28, 20100, Milan, Italy. .,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Via Festa del Perdono 7, 20100, Milan, Italy.
| | - Maria Teresa Bardella
- Center for the Prevention and Diagnosis of Coeliac Disease, Gastroenterology and Endoscopy Unit - Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 28, 20100, Milan, Italy.
| | - Silvano Bosari
- Pathology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 28, 20100, Milan, Italy. .,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Via Festa del Perdono 7, 20100, Milan, Italy.
| | - Dario Conte
- Center for the Prevention and Diagnosis of Coeliac Disease, Gastroenterology and Endoscopy Unit - Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 28, 20100, Milan, Italy. .,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Via Festa del Perdono 7, 20100, Milan, Italy.
| | - Letterio Runza
- Pathology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 28, 20100, Milan, Italy.
| | - Leda Roncoroni
- Center for the Prevention and Diagnosis of Coeliac Disease, Gastroenterology and Endoscopy Unit - Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 28, 20100, Milan, Italy.
| | - Stefano Ferrero
- Pathology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 28, 20100, Milan, Italy. .,Department of Biomedical, Surgical and Dental Sciences, Università degli Studi di Milano, Via Festa del Perdono 7, 20100, Milan, Italy.
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Stein J, Schuppan D. Coeliac Disease - New Pathophysiological Findings and Their Implications for Therapy. VISZERALMEDIZIN 2015; 30:156-65. [PMID: 26288589 PMCID: PMC4513807 DOI: 10.1159/000365099] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Coeliac disease (CD) is one of the most common diseases worldwide, resulting from a combination of environmental (gluten) and genetic (human leucocyte antigen (HLA) and non-HLA genes) factors. Depending on the geographical location, the prevalence of CD has been estimated to approximate 0.5-1%. The only treatment currently available for CD is a gluten-free diet (GFD) excluding gluten-containing cereals such as wheat, rye, and barley, and other foodstuffs with natural or added gluten. However, adherence rates and patient acceptance are often poor. Moreover, even in fully adherent patients, the diet may fail to induce clinical or histological improvement. Hence, it is unsurprising that studies show CD patients to be highly interested in non-dietary alternatives. The following review focuses on current pathophysiological concepts of CD, spotlighting those pathways which may serve as new possible, non-dietary therapeutic targets in the treatment of CD.
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Affiliation(s)
- Jürgen Stein
- Department of Gastroenterology and Clinical Nutrition, Sachsenhausen Hospital, Teaching Hospital of the Goethe University Frankfurt, Germany ; Interdisciplinary Crohn Colitis Centre Rhein-Main, Frankfurt/M., Germany
| | - Detlef Schuppan
- Institute of Translational Immunology, University Medical Center, Hospital Mainz, Germany ; Division of Gastroenterology, Beth Israel deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Ciacci C, Ciclitira P, Hadjivassiliou M, Kaukinen K, Ludvigsson JF, McGough N, Sanders DS, Woodward J, Leonard JN, Swift GL. The gluten-free diet and its current application in coeliac disease and dermatitis herpetiformis. United European Gastroenterol J 2015; 3:121-35. [PMID: 25922672 PMCID: PMC4406897 DOI: 10.1177/2050640614559263] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 10/17/2014] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND A gluten-free diet (GFD) is currently the only available therapy for coeliac disease (CD). OBJECTIVES We aim to review the literature on the GFD, the gluten content in naturally gluten-free (GF) and commercially available GF food, standards and legislation concerning the gluten content of foods, and the vitamins and mineral content of a GFD. METHODS We carried out a PubMed search for the following terms: Gluten, GFD and food, education, vitamins, minerals, calcium, Codex wheat starch and oats. Relevant papers were reviewed and for each topic a consensus among the authors was obtained. CONCLUSION Patients with CD should avoid gluten and maintain a balanced diet to ensure an adequate intake of nutrients, vitamins, fibre and calcium. A GFD improves symptoms in most patients with CD. The practicalities of this however, are difficult, as (i) many processed foods are contaminated with gluten, (ii) staple GF foods are not widely available, and (iii) the GF substitutes are often expensive. Furthermore, (iv) the restrictions of the diet may adversely affect social interactions and quality of life. The inclusion of oats and wheat starch in the diet remains controversial.
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Affiliation(s)
- Carolina Ciacci
- Department of Medicine and Surgery, Gastroenterology, University of Salerno, Italy
| | - Paul Ciclitira
- Department of Gastroenterology, Division of Diabetes and Nutritional Sciences, Kings College London; The Rayne Institute, St Thomas Hospital, London, UK
| | - Marios Hadjivassiliou
- Academic Department of Neurosciences, Sheffield Teaching Hospitals NHS Trust; Royal Hallamshire Hospital, Sheffield, UK
| | - Katri Kaukinen
- School of Medicine, University of Tampere and Department of Internal Medicine, Tampere University Hospital and Department of Internal Medicine, Seinäjoki Central Hospital, Finland
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet and Department of Pediatrics, Örebro University Hospital, Sweden
| | | | - David S Sanders
- Gastroenterology and Liver Unit, Royal Hallamshire Hospital & University of Sheffield, Sheffield, UK
| | - Jeremy Woodward
- Cambridge Intestinal Unit, Addenbrooke’s Hospital, Cambridge, UK
| | - Jonathan N Leonard
- Department of Dermatology, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Gillian L Swift
- Department of Gastroenterology, University Hospital Llandough, Cardiff, UK
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Lebwohl B, Emilsson L, Fröbert O, Einstein AJ, Green PHR, Ludvigsson JF. Mucosal healing and the risk of ischemic heart disease or atrial fibrillation in patients with celiac disease; a population-based study. PLoS One 2015; 10:e0117529. [PMID: 25635403 PMCID: PMC4312018 DOI: 10.1371/journal.pone.0117529] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Accepted: 11/15/2014] [Indexed: 02/06/2023] Open
Abstract
Background Patients with celiac disease (CD), characterized histologically by villous atrophy (VA) of the small intestine, have an increased risk of ischemic heart disease (IHD) and atrial fibrillation (AF), risks that persist for years after commencing the gluten-free diet. It is unknown whether persistent VA on follow-up biopsy, rather than mucosal healing, affects the risk of IHD or AF. Methods We identified patients with histologic evidence of CD diagnosed at all 28 pathology departments in Sweden. Among patients who underwent a follow-up small intestinal biopsy, we compared patients with persistent VA to those who showed histologic improvement, with regard to the development of IHD (angina pectoris or myocardial infarction) or AF. Results Among patients with CD and a follow-up biopsy (n = 7,440), the median age at follow-up biopsy was 25 years, with 1,063 (14%) patients who were ≥60 years at the time of follow-up biopsy. Some 196 patients developed IHD and 205 patients developed AF. After adjusting for age, gender, duration of CD, calendar period, and educational attainment, there was no significant effect of persistent VA on IHD (adjusted HR 0.97; 95%CI 0.73–1.30). Adjusting for diabetes had a negligible effect (adjusted HR 0.98; 95%CI 0.73–1.31). There was no significant association between persistent VA and the risk of AF (adjusted HR 0.98; 95%CI 0.74–1.30). Conclusions In this population-based study of patients with CD, persistent VA on follow-up biopsy was not associated with an increased risk of IHD or AF. Failed mucosal healing does not influence the risk of these cardiac events.
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Affiliation(s)
- Benjamin Lebwohl
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, United States of America
- Department of Medical Epidemiology and Biostatistics, Karolinska University Hospital and Karolinska Institute, Stockholm, Swede0060045
| | - Louise Emilsson
- Primary care research unit, Vårdcentralen Värmlands Nysäter, Värmland County, and the Department of Medicine, Örebro University, Örebro, Sweden
| | - Ole Fröbert
- Department of Cardiology, Örebro University Hospital, Örebro, Sweden
| | - Andrew J. Einstein
- Division of Cardiology, Department of Medicine, and Department of Radiology, Columbia University College of Physicians and Surgeons and New York-Presbyterian Hospital, New York, New York, United States of America
| | - Peter H. R. Green
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, United States of America
| | - Jonas F. Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska University Hospital and Karolinska Institute, Stockholm, Swede0060045
- Department of Pediatrics, Örebro University Hospital, Örebro, Sweden
- * E-mail:
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Abstract
Interleukin-15 (IL-15) exerts many biological functions essential for the maintenance and function of multiple cell types. Although its expression is tightly regulated, IL-15 upregulation has been reported in many organ-specific autoimmune disorders. In celiac disease, an intestinal inflammatory disorder driven by gluten exposure, the upregulation of IL-15 expression in the intestinal mucosa has become a hallmark of the disease. Interestingly, because it is overexpressed both in the gut epithelium and in the lamina propria, IL-15 acts on distinct cell types and impacts distinct immune components and pathways to disrupt intestinal immune homeostasis. In this article, we review our current knowledge of the multifaceted roles of IL-15 with regard to the main immunological processes involved in the pathogenesis of celiac disease.
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Affiliation(s)
- Valérie Abadie
- Sainte-Justine Hospital Research Center, Department of Microbiology and Immunology, Faculty of Medicine, University of Montreal, Montreal, Canada
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Abstract
The advent of highly reliable noninvasive celiac diagnostic tests has transformed the field of celiac disease, from diagnosis, to evaluation of epidemiology, to clinical and translational research. Serologic tests in their modern forms are highly sensitive and specific for diagnosis, allowing for consideration of avoidance of diagnostic intestinal biopsy in some settings. On the other hand, as predictors of intestinal damage and for use in monitoring disease activity, currently available noninvasive tests have been disappointing. Serologic tests, while a measure of disease activity, do not correlate well with histology or symptomatology, and it is unclear if they predict long-term risk. Additionally, while the many clinically available tests have improved accessibility, they can have widely different cutoff levels and overall performance, making the comparison of levels in individual patients over time and across populations quite difficult. In the future, we can expect to see improvement in the currently available serologic tests including tissue transglutaminase and deamidated gliadin peptide with expansion of the dynamic range of the tests, and the celiac care community should push for a standardization of assays that would simplify research and patient care. Additionally, current serologic tests are measures of the adaptive immune response in celiac disease but do not directly measure intestinal inflammation. Promising work on intestinal fatty acid-binding protein and other assays which directly measure intestinal damage may complement traditional serologic tests and further improve our ability to noninvasively diagnose and monitor celiac disease. The coming years hold promise for the continuing evolution of serum-based tests in celiac disease with the possibility of substantial improvement of patient care and clinical research.
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Abadie V, Jabri B. Immunopathology of Celiac Disease. Mucosal Immunol 2015. [DOI: 10.1016/b978-0-12-415847-4.00080-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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