Determination of autofluorescence of red blood cells (RbCs) in uremic patients as a marker of oxidative damage

AIM

It is suggested that the red blood cells (RBCs) of uremic patients have increased oxidative damage. The activities of different antioxidant enzymes and the levels of several antioxidants or lipid peroxidation products in RBCs are usually determined to estimate the oxidative stress in uremia. The autofluorescence of RBCs as measured by flow cytometry is caused by the formation of conjugated Schiff base compounds from aldehydes derived from lipid peroxidation and amino groups of phospholipids or cell proteins, and has been proposed as a marker of oxidative stress. The aim of this study was to evaluate if this method is suitable for estimation of oxidative stress in the RBCs of patients with different degrees of renal insufficiency.

PATIENTS AND METHODS

To determine the oxidative damage in RBCs in uremia, the autofluorescence of RBCs was measured by flow cytometry in the following 3 groups of patients: group A: 16 patients with chronic renal failure (CRF); group B: 16 hemodialysis (HD) patients; group C: 16 patients with a well-functioning renal allograft. Twenty-four healthy volunteers served as controls. The basal value of RBC autofluorescence and the autofluorescence of RBCs after oxidative damage by treatment with 0.1 mM hydrogen peroxide (H2O2)/0.7 mM sodium azide were determined.

RESULTS

In basal RBC autofluorescence values, no differences were found between the 3 groups and the controls. However, there was a significant correlation between the increase of serum creatinine and RBC autofluorescence in the group of patients with CRF (r = 0.521; p = 0.038). After H2O2 treatment, the RBC autofluorescence rose markedly in all individuals. This increase in RBC autofluorescence was significantly higher in the patients with CRF (p = 0.003) and in the HD patients (p = 0.001) compared to the controls. In contrast, there was no difference in RBC autofluorescence between the patients with renal allograft and the controls after H2O2 treatment.

CONCLUSIONS

In conclusion, flow cytometry is a useful tool for determining oxidative damage in RBCs. The RBCs of uremic patients are more susceptible to oxidative damage induced by H2O2, likely caused by diminished antioxidant defense in the RBC membrane. Successful renal transplantation leads to a normal autofluorescence response in the RBCs after H2O2 treatment.

[Diagnosis and therapy of celiac disease in adolescence and adulthood]

The incidence of celiac disease has increased considerably during the last two decades. Celiac Disease is now diagnosed in adults at least as frequently as in children. A prevalence of about 1:200 seems reasonable in central Europe. Besides the typical symptomatic presentation, silent, latent and potential celiac disease are found. Oligo- to asymptomatic courses (silent celiac disease) are increasingly found in all age groups. Endomysial antibodies and tissue-transglutaminase antibodies are sensitive and specific for about 95% of celiac patients. However, the final diagnosis is only done by a - mostly endoscopical - biopsy from the distal part of the duodenum, demonstrating hyperplastic villous atrophy of the mucosa with increased numbers of intraepithelial lymphocytes. The biopsies should be classified histologically according to the modified Marsh criteria. Increased prevalence in family members (10 to 15%) and in associated diseases (e.g. diabetes mellitus) lead to the recommendation of active screening in populations at risk. Although the clinical symptoms are rather variable and different, the response to a lifelong strict gluten free diet is nearly 100%. So-called refractory celiac disease is very rare. There are numerous associated diseases as dermatitis herpetiformis, diabetes mellitus type I, thyroid and neurologic diseases. The most frequent complications are retardation of growth in childhood, early onset osteoporosis, and an increased risk of abortions. The most severe complication is intestinal lymphoma. Especially patients with late diagnosis and bad dietary adherence are at risk. A regular follow-up of patients, rather with antibody tests than with duodenal biopsies is recommended to test and secure dietary compliance.

In vivo and in vitro permeability in coeliac disease

BACKGROUND

An increased permeability to sugars is found in the intestine of untreated patients with coeliac disease after oral ingestion.

AIM

To test whether in vitro permeability resembles in vivo permeability tests and whether an in vitro gliadin gluten challenge could be performed by an in vitro permeability test.

METHODS

We measured in vivo (urinary excretion after sucrose-lactulose-mannitol ingestion) and in vitro permeability (by mini-Ussing chambers) in 25 healthy controls, 12 relatives of coeliac disease patients, 19 treated, eight partly treated and 16 untreated patients with coeliac disease.

RESULTS

In vivo sugar permeability was increased in nearly all coeliac patients. Additionally, in vitro permeability to lactulose (P=0.0007), mannitol (P=0.004) and sucrose (P=0.042) was higher in untreated patients with coeliac disease. It correlated with in vivo permeability (sucrose tau=0.61, P=0.006; lactulose tau=0.41, P < 0.0001; mannitol tau=- 0.56, P=0.62) and was dependent on mucosal damage. An in vitro gliadin challenge over 24 h could not significantly change in vitro permeability in treated patients with coeliac disease.

CONCLUSIONS

An in vitro permeability test capable of measuring elevated permeability in coeliac mucosa was described, but this test cannot replace oral gluten challenge by in vitro gliadin incubation.

Extracorporeal photochemotherapy in patients with steroid-dependent Crohn's disease: a prospective pilot study

BACKGROUND

Extracorporeal photochemotherapy has been proven effective in selected T-cell mediated diseases.

AIM

To evaluate the safety and efficacy of extracorporeal photochemotherapy in patients with steroid-dependent Crohn's disease by an open, monocentric trial in three phases of 24 weeks each.

METHODS

In phase 1 standardized steroid tapering was initiated in patients with a history of steroid-dependent Crohn's disease. Those with a prospectively evaluated maintenance dose of at least 10 mg/day prednisolone continued steroid-withdrawal under the application of extracorporeal photochemotherapy in phase 2. The duration of remission or response was followed during phase 3. Colonic tissue bioptically obtained before and after extracorporeal photochemotherapy was studied by immunofluorescence microscopy for the presence of photoadduct positive cells.

RESULTS

Out of 24 patients included in phase 1, 10 entered phase 2 for extracorporeal photochemotherapy. Four subjects achieved remission and four others response. Significant reductions in serum C-reactive protein levels and intestinal permeability were measured, as well as increases in quality of life and plasma adrenocorticotropic hormone levels. No major side-effects were observed. Remission remained stable in three out of four patients during phase 3. In three patients, positive nuclear stainings of photoadducts were detected in colonic mononuclear cells after extracorporeal photochemotherapy.

CONCLUSIONS

Extracorporeal photochemotherapy represents a safe steroid-sparing approach in patients with Crohn's disease and is associated with intestinal homing of photopheresed cells.

Impact of different therapeutic regimens on the outcome of patients with Crohn's disease of the upper gastrointestinal tract

BACKGROUND

To follow-up clinical and biochemical features in patients with Crohn's disease (CD) of the upper gastrointestinal (GI) tract and to evaluate the impact of different therapeutics on the outcome of these patients.

METHODS

32 CD patients with endoscopically and histologically proven CD of the upper GI tract were included into this retrospective study. Gastroduodenal and intestinal permeability tests, inflammatory parameters, Crohn's Disease Activity Index (CDAI), and upper gastrointestinal complaint profile were sequentially assessed. These parameters were assessed at the beginning and followed up during therapies with antisecretory drugs, mesalamine, prednisolone, and azathioprine.

RESULTS

Symptoms responded to antisecretory drugs. Gastroduodenal permeability increased under mesalamine. Gastroduodenal and intestinal permeability as well as CDAI decreased under prednisolone. Under azathioprine, gastroduodenal and intestinal permeability, CDAI, and C-reactive protein decreased.

Diagnostic duodenal bulb biopsy in celiac disease

BACKGROUND AND STUDY AIMS

Duodenal or jejunal biopsies are needed to establish the diagnosis of celiac disease. It is widely advocated that these biopsies be taken from the distal duodenum.

PATIENTS AND METHODS

After finding two index cases with diagnostic biopsies taken from the duodenal bulb, we retrospectively analyzed biopsies from the descending duodenum and the duodenal bulb of 51 patients with suspected or diagnosed celiac disease. The diagnosis of celiac disease and classification of the histological changes were performed by one pathologist.

RESULTS

In the two index cases the diagnosis of celiac disease could only be established by taking the biopsies from the duodenal bulb, and not from the descending duodenum. In the retrospective analysis the number of intraepithelial lymphocytes was on average higher, but not significantly, in the descending part of the duodenum.

CONCLUSIONS

Most patients with celiac disease show similar mucosal changes in biopsies taken from the descending part of the duodenum and from the duodenal bulb. But in patients who have already been on a gluten-free diet in childhood and later abandoned their diet, an additional duodenal bulb biopsy should be done.

Is mycophenolate mofetil an effective alternative in azathioprine-intolerant patients with chronic active Crohn's disease?

OBJECTIVES

Up to 50% of patients with Crohn's disease (CD) develop steroid-dependent or refractory disease requiring immunosuppression. Azathioprine (AZA) is usually used for this purpose but must be withdrawn in up to 10% of patients because of adverse events. Mycophenolate mofetil (MMF) is of proven efficacy and safety in transplantation and in some autoimmune disorders. The aim of the present study was to investigate the effect of MMF, especially in AZA-intolerant patients with chronic active CD, in comparison to a matched control group treated with AZA.

METHODS

In a retrospective study, 15 patients treated with MMF and 30 randomly chosen, matched patients treated with AZA for chronic active CD were compared over a period of 1 yr. Intolerance to AZA was the indication for MMF. Crohn's Disease Activity Index (CDAI), steroid demand, extraintestinal manifestations, and hematological and biochemical parameters were assessed at the start of therapy and 1, 2, 3, 6, 9, and 12 months thereafter.

RESULTS

All patients who completed the 12 months of treatment (77% AZA, 60% MMF) achieved remission. Under MMF, the cumulative prednisolone dose could be reduced by 1 g in the first half year, whereas, under AZA, this reduction was possible only in the second half year. MMF patients had almost twice as many flare-ups (80% vs 47%). Adverse events prompted the withdrawal of AZA in five patients (17%) and of MMF in three (20%).

CONCLUSIONS

Both drugs are effective in inducing remission. AZA seems to be more effective in maintaining remission. The onset of therapeutic effect is delayed less under MMF. Both drugs have steroid sparing potential, which is delayed under AZA. It seems that AZA still is the immunouppressant of choice in chronic active CD, but MMF is a reasonable alternative in patients who do not tolerate AZA.

DHPLC mutation analysis of the hereditary nonpolyposis colon cancer (HNPCC) genes hMLH1 and hMSH2

Denaturing high-performance liquid chromatography (DHPLC) is an efficient method for detection of mutations involving a single or few numbers of nucleotides, and it has been successfully used for mutation detection in disease-related genes. Colorectal cancer is one of the most common cancers, and mutations in the genes for hereditary nonpolyposis colon cancer (HNPCC), hMLH1 and hMSH2, also involve mainly point mutations. Sequence analysis is supposed to be a screening method with high sensitivity; however, it is time-consuming and expensive. We therefore decided to test sensitivity and reproducibility of DHPLC for 71 sequence variants in hMLH1 and hMSH2 initially found by sequence analysis in DNA samples of German HNPCC patients. DHPLC conditions of the PCR products were based on the melting pattern of the wild-type sequence of the corresponding PCR fragments. All but one of the 71 mutations was detected using DHPLC (sensitivity of 97%). Running time per sample averaged only 7 min, and the system is highly automated. Thus DHPLC is a rapid and sensitive method for the detection of hMLH1 and hMSH2 sequence variants.

[Severe multiorgan failure caused by aspiration with laryngeal mask airway]

We report a case of a 77-year-old woman who developed severe multiple organ failure after aspiration with the LMA during ureteral splinting. Two hours after induction of anaesthesia the urologists decided for nephrostomy in prone position. Therefore the patient was intubated. During removal of the LMA bilious secretion was recognized inside the LMA and in the pharynx. Endotracheal suction and immediate bronchoscopy showed severe aspiration. After the operation the patient was submitted to the ICU. She developed a severe multiple organ failure within 12 hours. Recovery took 54 days. The discussion is focussed on risk factors for the use of the LMA, adequate intraoperative monitoring, possible disadvantages of the applied anaesthetic technique and initial treatment after aspiration.

[Therapy of active Crohn disease with Boswellia serrata extract H 15]

BACKGROUND

The purpose of this clinical trial was to compare efficacy and safety of the Boswellia serrata extract H15 with mesalazine for the treatment of active Crohn's disease.

PATIENTS AND METHODS

Randomised, double-blind, verum-controlled, parallel group comparison for which 102 Patients were randomised. The per protocol population included 44 patients treated with H15 and 39 patients treated with mesalazine. As primary outcome measure the change of the Crohn Disease Activity Index (CDAI) between the status of enrolment and end of therapy was chosen. H 15 was tested on non-inferiority compared to standard treatment with mesalazine.

RESULTS

The CDAI between the status of enrolment and end of therapy after treatment with H15 was reduced by 90 and after therapy with mesalazine by 53 scores in the mean. In this non-inferiority-trial the test hypothesis was confirmed by the statistical analysis. The difference between both treatments could not be proven to be statistically significant in favor to H15 for the primary outcome measure. The secondary efficacy endpoints confirm the assessment of the comparison of H15 and mesalazine. The proven tolerability of H15 completes the results of the shown clinical efficacy.

CONCLUSIONS

The study confirms that therapy with H15 is not inferior to mesalazine. This can be interpreted as evidence for the efficacy of H15 according to the state of art in the treatment of active Crohn's disease with Boswellia serrata extract, since the efficacy of mesalazine for this indication has been approved by the health authorities. Considering both safety and efficacy of Boswellia serrata extract H15 it appears to be superior over mesalazine in terms of a benefit-risk-evaluation.

Surface membrane antigen alteration on blood basophils in patients with Hymenoptera venom allergy under immunotherapy

BACKGROUND

Venom immunotherapy (VIT) provides widespread protection against systemic anaphylactic reactions after a sting of the respective insect. This effect is attributed to a shift from T(H)2 to T(H)1. However, because basophils also produce and release cytokines, such as IL-4 and IL-13, they may be part of the cytokine network. The cytokines may regulate basophilic granulocytes, as suggested by the presence of cytokine receptors IL-2Ralpha, GM-CSFRalpha, IL-1RII, IL-3R, IL-4R, IL-5R, and IL-6R on basophils from nonallergic donors.

OBJECTIVE

The purpose of this study was to demonstrate that human basophils from subjects allergic to wasp venom undergoing VIT are regulated by cytokines, as shown by the alteration of the expression of cytokine receptors (and other markers).

METHODS

The expression of the surface interleukin receptors and activation antigens on basophils from 19 nonallergic subjects and 48 patients with wasp venom allergy was investigated before, immediately after, and 1 week after VIT (20 patients only).

RESULTS

Basophilic granulocytes in allergic subjects, compared with those in healthy persons, showed elevated expression of CD32 (FcgammaRII), CD122 (IL-2Rbeta), CD124 (IL-4Ralpha), CD130 (IL-6 and 11Rbeta), CD154 (CD40L), and HLA-DR. Activation of basophils clearly increased during VIT indicated by increased expression of CD32, CD33, CD35 (CR1), CD63, CD116 (GM-CSFRalpha), CD122, CD124, CD130, and CD154. HLA-DR expression also tended to increase. The expression of IL-5R (CD125) decreased. A significant decrease of the basophilic surface antigens CD11c, CD32, CD35, CD63, CD116, CD122, CD124, CD130, and CD132 (interleukin receptor gamma) was detected 1 week after the end of rush VIT.

CONCLUSION

The rise in CD63 during VIT indicates a partial basophil degranulation with release of stored protein mediators, including IL-4. IL-4 may cause a transient upregulation of different surface antigens in an autocrine manner. Thereafter, cytokines released by T cells, which as a result of VIT have changed from a T(H)2 type to a more T(H)1 type, downregulate the activation of the basophilic granulocytes.

Loss of heterozygosity and microsatellite instability as predictive markers for neoadjuvant treatment in gastric carcinoma

We analyzed a group of gastric carcinomas treated with a cisplatin-based neoadjuvant chemotherapy regimen for microsatellite instability (MSI) and loss of heterozygosity (LOH) to determine whether there is any relation between microsatellite alterations and therapy response. Pretherapeutic endoscopic biopsies of 37 patients were studied at 11 microsatellite loci. Thirteen (35%) had a complete or partial clinical response (responders), and 24 (65%) had only a minor or no response (nonresponders). High-grade MSI was found in two tumors, both nonresponders, whereas low-grade MSI was found in five biopsies, including three non-responders and two responders. Regarding LOH, the most obvious differences between the groups were observed on chromosome 17p13, the location of the p53 gene, with 7 of 12 (58%) and 3 of 20 (15%) of the informative tumors exhibiting LOH in responders and nonresponders, respectively (P = 0.018). A statistically significant difference was also observed in the fractional allelic loss (FAL) ratio of the groups. Among the 13 responding patients, 7 (54%) tumors exhibited high FAL (>0.5-0.75), 2 (15%) showed medium FAL (>0.25-0.5), and 4 (31%) demonstrated low FAL values (0-0.25), whereas among the 22 nonresponding patients, 2 (9%) tumors showed high FAL, 5 (23%) showed medium FAL, and 15 (68%) showed low FAL (P = 0.020). These data suggest that LOH at chromosome 17p13 is associated with a good clinical response to cisplatin-based chemotherapy, suggesting that altered p53 function might render cells more sensitive to therapy. Furthermore, the association of FAL with therapy response indicates that gastric carcinomas with a high level of chromosomal alteration may be more sensitive to this type of chemotherapy.

Choriocarcinoma-induced suppression of lymphocyte activity

The aim of the investigation was to study the influence of human choriocarcinoma cell culture supernatants (HCS) on the expression of lymphocyte surface molecules. Lymphocytes were stimulated with phytohemagglutinin in culture medium supplemented with 50% HCS. After 12 h and 60 h, fluorescence-activated cell sorter analysis was performed with specific monoclonal antibodies. After 12 h of incubation, the cell surface expression of the classical activation markers CD25, CD69, CD71, CD134 and CD3/HLA-DR, as well as of the apoptosis marker CD95 were significantly suppressed by HCS. Qualitatively similar results were obtained after 60 h. It was concluded that choriocarcinoma-induced suppression might be related to a nearly complete block in the cell cycle at early activation steps. The clinical and biological relevance of this phenomenon for the maternal-fetal tolerance are briefly discussed.

Significant association of strictures and internal fistula formation in Crohn's disease

Intestinal inflammation in Crohn's disease (CD) may be complicated by the occurrence of strictures and fistulae. The pathogenesis of fistula formation is unknown. We therefore wanted to determine whether mechanical factors might contribute to the development of fistulae. Furthermore, we tried to define the path of internal fistulae through the muscular layer. For this purpose, surgical resection specimens from 42 consecutive patients with CD were prospectively studied. In gross examination the whole bowel was cut into circumferential cross sections 0.3 cm thick. Abnormal areas were histologically examined. Strictures were found in 38 patients (90.5%), and fistulae were observed in 27 (64.3%) patients. In 11 (40.7%) specimens fistulae were found within a stricture, in 15 (55.6%) at the proximal end, and in 1 (3.7%) no stricture was found. In 7 (25.9%) cases with fistulae, herniated mucosa was found within the muscularis propria or the subserosa. In 7 (25.9%) cases a blood vessel was identified near a fistula traversing the muscularis propria. From these findings we conclude that that mechanical factors may contribute to fistula formation. This is further supported by the fact that fistulae appear to traverse the muscular layer along piercing vessels.

[Consensus of the Chronic Inflammatory Bowl Disease Study Group of the Austrian Society of Gastroenterology and Hepatology on the topic of "diagnosis and therapy of chronic inflammatory bowel diseases in adolescence"]

Although up to 20% of patients with Crohn's disease have their first flare during childhood or adolescence, there are no or only a few randomized, controlled studies. However, big differences and uncertainty may be observed between the diagnosis and therapy of pediatricians and gastroenterologists specialized for adults. In addition, special problems result from the enormous somatic and psychological evolution during adolescence. The diagnosis is done as in adult patients by enteroclysm and ileocolonoscopy (including multiple biopsies) whereas a deep sedoanalgesia or anesthesia should be performed routinely. Corticosteroids are the gold standard for therapy of Crohn's disease in the adolescence (especially in cases with high inflammatory activity), but also enteral nutrition over 4-12 weeks--or a combination of both. A recent randomized controlled study demonstrates the positive effect of 6-mercaptopurine in newly diagnosed patients with Crohn's disease in the adolescence. 5-aminosalicylates or the probably more effective azathioprine/6-mercaptopurine could be used for prevention of recurrence in Crohn's disease. The therapy of ulcerative colitis is performed as in adults including the very effective local rectal applications. An accompanying psychosomatic therapy is recommended especially in young patients with disturbed separation from the parents and inadequate coping. The indication for surgery is similar to adults. However, a specific indication for earlier surgery is given, if severe malabsorption and delay of growth takes place in spite of adequate therapy, because this delay of growth could be only caught up before puberty. A conservative therapeutic regimen is recommended in young patients with perianal Crohn's disease.

Selective T-cell deficiency in Turner's syndrome

The case of a 29-year-old Caucasian woman with 45 X0 karyotype, known as Turner's syndrome, and a recently diagnosed selective T-cell deficiency is reported. The main clinical features of the patient were recurrent sinopulmonary infections and a negative skin test with seven common recall antigens. Laboratory findings included lymphocytopenia, highly elevated CD45RA/CD45R0 ratio, as well as reduced expression of the co-stimulatory molecules CD154, CD86, CD80 and CD28 on CD4+ cells in combination with disturbed lymphocyte transformation in vitro. Markedly decreased levels of interleukin (IL)-2R, both on lymphocyte surface as well as the soluble analog, suggest a new form of x-linked immunodeficiency associated with Turner's syndrome.

Exocrine pancreatic function in critically ill patients: septic shock versus non-septic patients

OBJECTIVE

To determine the exocrine pancreatic function in critically ill patients.

DESIGN

Prospective cohort study.

SETTING

Medical intensive care unit.

PATIENTS

A total of 18 critically ill patients (11 patients with septic shock according to the criteria of the American College of Chest Physicians/Society of Critical Care Medicine, 7 nonseptic patients). The results obtained in these subjects were compared with the data obtained in seven healthy volunteers.

INTERVENTIONS

Examination of exocrine pancreatic function was done by means of a cholecystokinin-secretin test. Intravenous stimulation of the exocrine pancreas with cholecystokinin and secretin (1 unit/kg body weight/hr each) and aspiration of duodenal fluid by a gastroscopically inserted oroduodenal tube was done during a period of 1 hr.

MEASUREMENTS AND MAIN RESULTS

The content of amylase, chymotrypsin, and trypsin in aspirated duodenal fluid was significantly reduced in patients with septic shock compared with nonseptic patients as well as healthy subjects (p < .01). The volume of aspirated fluid was significantly reduced in patients with septic shock compared with healthy controls (p = .03), but not in nonseptic patients. The content of bicarbonate was not statistically different in the three groups. No significant correlation was to find between variables of exocrine pancreatic function and Acute Physiology and Chronic Health Evaluation III score, sepsis-related organ failure assessment score, systolic arterial pressure and mean arterial pressure in septic shock patients. Positive end-expiratory pressure was significantly correlated with the content of trypsin (r2 = 0.52; p = .02). Postmortem examinations of five septic patients who died during the intensive care stay did not reveal gross morphologic alterations of pancreatic tissue.

CONCLUSIONS

The study shows two pancreatic enzyme systems, namely, amylase as a carbohydrate splitting enzyme and the proteolytic enzymes trypsin and chymotrypsin, strongly affected in critically ill patients with septic shock.

Calcaneal ultrasound attenuation and vitamin-D-receptor genotypes in celiac disease

BACKGROUND

Osteopenia is common in patients with celiac disease and is believed to result from malnutrition. Osteoporosis in otherwise healthy individuals is related to genetically determined polymorphisms within the vitamin-D-receptor (VDR) gene. We hypothesized that in celiac patients particular genes of the VDR enhance the susceptibility for malnutrition-associated low-bone density.

METHODS

We determined allelic frequencies within the VDR gene by restriction fragment length polymorphism analysis in 92 patients with celiac disease (age, 15-83 years). Thirty-eight patients were on a gluten-free diet; 54 patients did not adhere to a diet. The determined VDR polymorphisms in 111 unrelated newborns served as controls. Osteopenia was determined by means of ultrasound measurements of the calcaneus (n = 78). Bone turnover was estimated by osteocalcin determination (n = 60).

RESULTS

There was no difference in the frequency of the VDR gene polymorphisms in patients with celiac disease compared with controls. Adjusted ultrasound measures of the calcaneus were low in 47% of patients, but there was no difference of the VDR gene frequencies in these patients compared with those with normal ultrasound results or controls. Bone turnover was higher in patients without a gluten-free diet (P = 0.02). Again, there was no association with any particular VDR gene.

CONCLUSIONS

Patients with celiac disease frequently have osteopenia, which is not related to any of the determined genes within the VDR.