[Study of celiac disease in adults with type 1 diabetes mellitus]

Prevalence of celiac disease in Moroccan children with type 1 diabetes mellitus: A 16-year cross-sectional study

BACKGROUND

There is limited data available regarding the prevalence of celiac disease (CD) among children with type 1 diabetes mellitus (T1DM) in Arab countries and the Middle East. This cross-sectional study has been designed to explore the prevalence of CD specifically within the population of Moroccan children and adolescents diagnosed with type 1 diabetes mellitus (T1DM).

PATIENTS AND METHODS

This is a cross-sectional study of patients who underwent regular follow-up for T1DM at the Pediatric Endocrinology Unit, Abderrahim Harouchi Children's University Hospital in Casablanca, over a 16-year period from 2004 to 2020. Patients were screened for CD by measuring anti-tissue transglutaminase IgA, and those with positive antibodies underwent endoscopy assessment.

RESULTS AND DISCUSSION

All 550 patients regularly followed up with TIDM were screened for CD. Fifty-five (33 girls/22 boys) of the screened patients had histologically documented CD, yielding a prevalence of 10%. Nineteen (41.9%) patients had developed CD within the initial four years of diagnosis with T1DM. Therefore, among the six confirmed CD patients, the average age at the onset of T1DM was 3.7 years. For twenty-four (57.5%) of the patients, exhibited no apparent clinical indications of CD, and their condition was only identified through systematic screening.

CONCLUSION

This study showed a high prevalence rate of CD associated with type 1 diabetes T1DM, particularly among young children. The results of this paper indicate one of the highest prevalence rates reported in the existing literature for the coexistence of CD and T1DM. These findings may suggest the necessity of a systematic screening of CD in T1DM patients.

The role of flow cytometry in celiac disease screening using human leukocyte antigen in adult patients with type 1 diabetes mellitus

BACKGROUND

Patients with type 1 diabetes mellitus (DM1) have an increased risk of celiac disease (CD). Since CD can be seronegative, more sensible tests for detection are needed. In seronegative patients, CD diagnosis may be difficult because of a lack of specificity. Flow cytometry analysis of lymphocyte populations can be useful in this situation. We aimed to study the prevalence of CD in adult DM1 using human leukocyte antigen (HLA) compatibility-based screening. A secondary goal was to study the role of flow cytometry as a complementary tool in these patients.

METHODS

We selected 200 patients with DM1, of whom 190 (95%) had HLA DQ2, DQ8 or both. Of these, 136 agreed to participate and provided epidemiological data. All patients underwent blood tests and gastroscopy.

RESULTS

Sixteen patients had a histology consistent with CD. After ruling out other diagnoses, 6 patients were diagnosed with CD, 2 of whom had negative antibodies. All were DQ2.5 homozygous, with a CD prevalence of 9.8% in this group. In the flow cytometry analysis of duodenal biopsy samples, when we compared all non-CD with CD patients, we found that the γ/δ intraepithelial lymphocyte (IEL) percentage was significantly higher and the CD3 negative IEL percentage significantly lower in the CD group. We found similar results when we compared only those with histological lesions.

CONCLUSIONS

Screening of CD in patients with DM1 by HLA detects only 1% of seronegative patients with CD. DQ2.5 homozygous patients are at most risk of developing CD. The study of lymphocyte populations in the duodenal biopsy by flow cytometry discriminates patients with CD from those without CD with high sensitivity and specificity.

[Serological tests for celiac disease in Moroccan patients with type 1 diabetes]

La maladie cœliaque (MC) est l'une des maladies auto-immunes les plus fréquemment associées au diabète de type 1 (DT1). La prévalence de MC dans DT1 varie de 3 à 6%. La présentation clinique de MC dans DT1 est classé comme asymptomatiques dans environ la moitié des cas. L'objectif de notre étude est de déterminer la fréquence des auto-anticorps anti-transglutaminase tissulaire (AtTG) et anti-gliadines (AAG) chez les patients diabétiques de type 1 dans le but de recommander une éventuelle biopsie jéjunale et d'instaurer un régime sans gluten précocement avant l'installation des signes cliniques et des complications de la maladie cœliaque. Les sujets inclus dans cette étude sont des patients atteints de DT1 non traités pour la MC et qui ne présentent pas de signes en faveur de cette pathologie. La détection des AtTG de classe IgG et IgA et AAG classe IgG et IgA a été réalisée par technologie Luminex. Nous avons inclus 31 patients. Il s'agit de 16 hommes et 15 femmes. Les AAG de classe IgA étaient positifs chez 4(13%) patients et chez 7(22,5%) patients pour les IgG. Les AtTG de classe IgA étaient positifs chez 3(10%) patients et chez une patiente (3%) pour les IgG. Dans notre étude l'association du diabète type 1 et des marqueurs biologiques de la MC n'est pas rare d'où l'intérêt de son dépistage systématique chez des diabétiques de type 1. Le diagnostic de cette forme atypique et silencieuse de la MC est important compte tenu du risque de complications sérieuses à type de malabsorption et de cancers digestifs.

Coexistence of coeliac disease and type 1 diabetes

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

Type 1 diabetes mellitus and celiac disease: endothelial dysfunction

Many reports indicate a hypercoagulative state in diabetes mellitus as result of endothelial damage. Experimental evidence suggests that a metabolic derangement triggers a cascade of biochemical events that lead to vascular dysfunction. The net effect is to convert the endothelium from thromboresistant to thrombogenic surface. In literature, a strong association between type 1 diabetes mellitus (DM1) and celiac disease (CD) has been reported. We do not have information about the hemostatic system in these associated conditions. Our study aims at evaluating whether the presence of CD in a group of DM1 patients is associated with a different expression of some hemostatic factors and with a different manifestation and/or progression of microvascular complications of DM1 in comparison with patients with only diabetes. Ninety-four adult DM1 patients were enrolled in the study and subsequently screened for CD. Anti-endomysial antibodies (EMA) were positive in 13 of 94 DM1 patients (13.8%). CD diagnosis was confirmed by histology and organ culture. The mean age and duration of DM1 of patients also affected by CD were similar to those of only diabetic patients, but the metabolic control and the hemocoagulative parameters were significantly different between the two groups: DM1 patients also affected by CD presented significantly lower concentrations of glycosylated hemoglobin (HbA1c) (P < 0.05), cholesterol (P < 0.001), triglycerides (P < 0.001), factor VII antigen (FVII:ag) (P < 0.005), factor VII coagulant activity (FVII:c) (P < 0.05), and prothrombin degradation fragments (F1+2) (P < 0.001), as well as higher values of activated C protein (APC) (<0.001). No retinal abnormalities and no signs of renal damage were observed in DM1 patients also affected by CD. Our results suggest a potential protective role of CD in the prothrombotic state of DM1.

Celiac disease and autoimmune-associated conditions

Celiac disease (CD) is frequently accompanied by a variety of extradigestive manifestations, thus making it a systemic disease rather than a disease limited to the gastrointestinal tract. This is primarily explained by the fact that CD belongs to the group of autoimmune diseases. The only one with a known etiology is related to a permanent intolerance to gluten. Remarkable breakthroughs have been achieved in the last decades, due to a greater interest in the diagnosis of atypical and asymptomatic patients, which are more frequent in adults. The known presence of several associated diseases provides guidance in the search of oligosymptomatic cases as well as studies performed in relatives of patients with CD. The causes for the onset and manifestation of associated diseases are diverse; some share a similar genetic base, like type 1 diabetes mellitus (T1D); others share pathogenic mechanisms, and yet, others are of unknown nature. General practitioners and other specialists must remember that CD may debut with extraintestinal manifestations, and associated illnesses may appear both at the time of diagnosis and throughout the evolution of the disease. The implementation of a gluten-free diet (GFD) improves the overall clinical course and influences the evolution of the associated diseases. In some cases, such as iron deficiency anemia, the GFD contributes to its disappearance. In other disorders, like T1D, this allows a better control of the disease. In several other complications and/or associated diseases, an adequate adherence to a GFD may slow down their evolution, especially if implemented during an early stage.

Prevalence of IgA antitissue transglutaminase antibodies in children with type 1 diabetes mellitus

The association of celiac disease with type 1 diabetes mellitus is known, but the evolution of celiac disease is most frequently asymptomatic, without any clinical signs. Thus, diagnosis is impossible to make in the absence of serological tests. Our study aimed to determine the prevalence and the efficiency of IgA antitissue transglutaminase antibodies in the screening of celiac disease in children with type 1 diabetes mellitus.

METHOD

During the course of 2008-2009, we performed an analytical clinical study that included the determination of IgA antitissue transglutaminase antibodies in a group of 119 children with type 1 diabetes mellitus. Fifty-seven percent of the subjects were male and 43% were female, with a mean age of 11±4 years.

RESULTS

By evaluating IgA antitissue transglutaminase antibodies, we obtained a prevalence of 9.2% in children with type 1 diabetes mellitus, with a sensitivity and specificity of 80 and 82.6%, respectively.

CONCLUSIONS

There is an increased prevalence of IgA antitissue transglutaminase antibodies, which suggests the need to use this method as an effective first-line test in the screening of celiac disease in children with type 1 diabetes mellitus.