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Stefanolo JP, Temprano MDLP, Smecuol E, Puebla R, Portillo JD, Niveloni S, Verdú EF, Bai JC. Comparison of weekly gluten immunogenic peptide measurement and conventional tools to assess adherence to the gluten-free diet in celiac disease: An observational prospective study. Am J Clin Nutr 2023; 118:1106-1112. [PMID: 37806557 DOI: 10.1016/j.ajcnut.2023.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 09/18/2023] [Accepted: 10/02/2023] [Indexed: 10/10/2023] Open
Abstract
BACKGROUND Adherence to the gluten-free diet (GFD) is critical to achieving symptom control and mucosal healing in celiac disease (CeD), but its assessment is difficult. OBJECTIVES We sought to compare stool gluten immunogenic peptides (GIPs) measurements over a 4-wk period with conventional tools commonly used to monitor compliance with a GFD. METHODS Consecutive adult patients with CeD attending the Small Bowel Section of the Buenos Aires Gastroenterology Hospital were invited to this observational study and were instructed to collect stool samples on Fridays for 4 consecutive weeks. Weekly mean stool GIP concentration was measured was estimated. GIP results were compared with a self-assessment scale of adherence, specific CeD serology, the celiac symptom index, and the assessment by an expert dietitian. RESULTS Fifty-three CeD patients were enrolled and those with stool GIP ≥0.65 μg/g/wk (n = 13; 24.5%) had higher serum concentrations of IgA deamidated gliadin peptides (DGPs) antibodies [69 (29-109) compared with 14 (13-29); P = 0.0005] and IgA tissue transglutaminase [42 (14-200) compared with 10 (7-16); P = 0.02], higher proportion of cases with IgA DGP antibodies >20 AU/mL (84.6% compared with 33.3%; P = 0.002), and a higher self-estimated adherence score [5 (4-9) compared with 9 (7-10); P = 0.003]. GIP did not correlate with celiac symptom index scores (55.6% compared with 30.8%; P = 0.9). Expert dietitian assessment identified 69% [odds ratio (OR): 5.25; 95% CI: 1.1-27.2; P = 0.01] of nonadherent cases when high stool GIP. Logistic regression analysis determined that IgA DGP (adjusted OR: 1.1; 95% CI: 1.01-1.11; P = 0.02) and males (adjusted OR: 28.3; 95% CI: 1.1-722.6; P = 0.04) were independently associated with excessive gluten exposure. CONCLUSIONS Weekly stool GIP identifies gluten exposure that is not always detected by commonly used GFD adherence assessment methods. The higher the concentration of stool GIP, the better the predictive value of serology and dietitian interviews. Stool GIP is a useful and practical test for GFD monitoring, particularly for risky gluten exposure in real-life scenarios.
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Affiliation(s)
- Juan P Stefanolo
- Small Bowel Section, Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires, Argentina
| | | | - Edgardo Smecuol
- Small Bowel Section, Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires, Argentina
| | - Roberto Puebla
- Small Bowel Section, Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires, Argentina
| | | | - Sonia Niveloni
- Small Bowel Section, Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires, Argentina
| | - Elena F Verdú
- Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Julio C Bai
- Small Bowel Section, Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires, Argentina; Research Institutes, Universidad del Salvador, Buenos Aires, Argentina.
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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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Mulder CJJ, Elli L, Lebwohl B, Makharia GK, Rostami K, Rubio-Tapia A, Schumann M, Tye-Din J, Zeitz J, Al-Toma A. Follow-Up of Celiac Disease in Adults: "When, What, Who, and Where". Nutrients 2023; 15:2048. [PMID: 37432208 DOI: 10.3390/nu15092048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 04/14/2023] [Accepted: 04/21/2023] [Indexed: 07/12/2023] Open
Abstract
For patients with celiac disease (CeD), a lifelong gluten-free diet is not a voluntary lifestyle choice-it is a necessity. The key end points in clinical follow-up are symptom resolution, the normalization of weight, prevention of overweight, seroconversion, and negation or minimization of increased long-term morbidity. For the latter, a surrogate endpoint is mucosal healing, which means the normalization of histology to Marsh 0-1. Ideally, celiac follow-up care includes a multidisciplinary approach, effective referral processes, improved access that leverages technological advances, and following guidelines with the identification of measurable quality indicators, ideally informed by evidence-based research. Face-to-face CeD care and telemedicine are considered the standards for this process, although published data are insufficient. Guidelines and statements on diagnosis are readily available. However, data are lacking on optimal clinic visit intervals and outcomes and quality indicators such as improvement of symptoms, function and quality of life, survival and disease control, and how to most effectively use healthcare resources. The results of future research should provide the basis for general recommendations for evidence-based standards of quality of care in CeD.
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Affiliation(s)
- Chris J J Mulder
- Department of Gastroenterology, Amsterdam UMC, Location Vrije Universiteit, 1081 HV Amsterdam, The Netherlands
| | - Luca Elli
- Center for Prevention and Diagnosis of Celiac Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Benjamin Lebwohl
- Department of Medicine, Celiac Disease Center, Columbia University Medical Center, 180 Fort Washington Avenue, Suite 936, New York, NY 10032, USA
| | - Govind K Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
| | - Kamran Rostami
- Department of Gastroenterology, Palmerston North Hospital, Palmerston North 4442, New Zealand
| | - Alberto Rubio-Tapia
- Division of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Michael Schumann
- Department of Gastroenterology, Infectious Diseases, and Rheumatology, Campus Benjamin Franklin, Charité-University Medicine Berlin, 13125 Berlin, Germany
| | - Jason Tye-Din
- Department of Immunology, The Walter and Eliza Hall Institute, Parkville, VIC 3052, Australia
- Department of Gastroenterology, The Royal Melbourne Hospital, Parkville, VIC 3050, Australia
| | - Jonas Zeitz
- Division of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
- Swiss Celiac Center, Center of Gastroenterology, Clinic Hirslanden, 8032 Zurich, Switzerland
| | - Abdulbaqi Al-Toma
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, 3435 CM Nieuwegein, The Netherlands
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ESPGHAN Position Paper on Management and Follow-up of Children and Adolescents With Celiac Disease. J Pediatr Gastroenterol Nutr 2022; 75:369-386. [PMID: 35758521 DOI: 10.1097/mpg.0000000000003540] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To gather the current evidence and to offer recommendations for follow-up and management. METHODS The Special Interest Group on Celiac Diseases of the European Society of Paediatric Gastroenterology Hepatology and Nutrition formulated ten questions considered to be essential for follow-up care. A literature search (January 2010-March 2020) was performed in PubMed or Medline. Relevant publications were identified and potentially eligible studies were assessed. Statements and recommendations were developed and discussed by all coauthors. Recommendations were voted upon: joint agreement was set as at least 85%. RESULTS Publications (n = 2775) were identified and 164 were included. Using evidence or expert opinion, 37 recommendations were formulated on: The need to perform follow-up, its frequency and what should be assessed, how to assess adherence to the gluten-free diet, when to expect catch-up growth, how to treat anemia, how to approach persistent high serum levels of antibodies against tissue-transglutaminase, the indication to perform biopsies, assessment of quality of life, management of children with unclear diagnosis for which a gluten-challenge is indicated, children with associated type 1 diabetes or IgA deficiency, cases of potential celiac disease, which professionals should perform follow-up, how to improve the communication to patients and their parents/caregivers and transition from pediatric to adult health care. CONCLUSIONS We offer recommendations to improve follow-up of children and adolescents with celiac disease and highlight gaps that should be investigated to further improve management.
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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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Wessels M, Auricchio R, Dolinsek J, Donat E, Gillett P, Mårild K, Meijer C, Popp A, Mearin ML. Review on pediatric coeliac disease from a clinical perspective. Eur J Pediatr 2022; 181:1785-1795. [PMID: 35034201 DOI: 10.1007/s00431-022-04379-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 12/19/2022]
Abstract
Coeliac disease is an immune-mediated condition characterized by chronic inflammation of the small bowel with villous atrophy driven by gluten ingestion in genetically predisposed individuals. It occurs frequently in both children and adults, affecting 1-4% of the population. The disease is associated with both gastrointestinal and extra-intestinal symptoms related to malabsorption and/or immune activation, and autoantibodies to tissue transglutaminase. Removal of gluten from the diet results in resolution of symptoms and enteropathy in the majority of patients. A good diagnostic work-up is important to avoid unnecessary restrictive diets in children. In this review on pediatric coeliac disease, we address epidemiology including predisposing environmental factors and possible preventive strategies, as well as the clinical presentation, diagnosis and follow-up. What is Known: •Primary prevention of coeliac disease is not possible; however, secondary prevention by targeting high-risk groups is recommended. •The diagnosis is safe without duodenal biopsies if specific conditions are met, also in asymptomatic children. What is New: •HLA-DQ typing is not routinely required for the diagnosis, whereas it can rule out coeliac disease if HLA-DQ2 and HLA-DQ8 are absent. •Follow-up could be improved by a more rational use of (laboratory) tests, increased intention to dietary compliance and quality of life.
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Affiliation(s)
- Margreet Wessels
- Department of Pediatrics, Rijnstate Hospital, Arnhem, the Netherlands.
| | - Renata Auricchio
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Jernej Dolinsek
- Department of Pediatrics, Hepatology and Nutrition Unit and Medical Faculty, Dept. of Pediatrics, University Medical Centre Maribor, GastroenterologyMaribor, Slovenia
| | - Ester Donat
- Pediatric Gastroenterology and Hepatology Unit, Celiac Disease and Digestive Immunopathology Unit, Hospital Universitari I Politècnic La Fe, Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - Peter Gillett
- Department of Pediatric Gastroenterology, Royal Hospital for Children and Young People, Scotland, Edinburgh, UK
| | - Karl Mårild
- Department of Pediatrics, Institute of Clinical Sciences, Department of Pediatric Gastroenterology, Sahlgrenska Academy, Queen Silvia Children's Hospital, Gothenburg, Sweden
| | - Caroline Meijer
- Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Alina Popp
- University of Medicine and Pharmacy ''Carol Davila'', National Institute for Mother and Child Health, Bucharest, Romania
| | - M Luisa Mearin
- Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
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Vernero M, Schiepatti A, Maimaris S, Lusetti F, Scalvini D, Megang F, Nicolardi ML, Gabrielli GM, Sprio E, Baiardi P, Biagi F. The GLU-10: a validated ten-point score to identify poorly instructed coeliac patients in need of dietary interventions. Minerva Gastroenterol (Torino) 2021; 68:91-97. [PMID: 34547859 DOI: 10.23736/s2724-5985.21.03037-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND A standard tool to assess patients' knowledge about gluten and the gluten-free diet (GFD) is lacking. METHODS We aimed to develop and validate a questionnaire to assess GFD knowledge. A 10-point questionnaire (GLU10) covering different aspects of knowledge about gluten content in food/non-food products and the gluten-free living was developed. To validate this questionnaire, it was administered to adult coeliac patients already instructed on gluten and the GFD and non-coeliac controls. Patients were prospectively recruited at our gastroenterology outpatient clinic between August 2020 and February 2021. RESULTS One hundred and six patients (52 coeliac patients and 54 controls) participated in the validation phase. Coeliac patients scored significantly higher than controls on the GLU10 questionnaire (median 6 points vs 2 points,p<0.001). Higher self-reported knowledge of the GFD was related to a higher score (p<0.001). ROC curve confirmed the ability of the GLU10 questionnaire to discriminate between subjects with good and poor GFD knowledge (AUC 0.94, 95%CI 0.90-0.98). A score of 5 was identified as the best cut-off (sensitivity 80.8%, specificity 94.4%). On multivariable logistic regression analysis, being a coeliac patient (p<0.001) and having a university degree (p=0.04) were associated to a high GLU10 score (≥5). CONCLUSIONS GLU10 is the first validated questionnaire for assessing knowledge of a GFD in coeliac patients and the general population.
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Affiliation(s)
- Marta Vernero
- Gastroenterology Unit of Pavia Institute, Istituti Clinici Scientifici Maugeri, IRCCS, University of Pavia, Pavia, Italy
| | - Annalisa Schiepatti
- Gastroenterology Unit of Pavia Institute, Istituti Clinici Scientifici Maugeri, IRCCS, University of Pavia, Pavia, Italy -
| | - Stiliano Maimaris
- Gastroenterology Unit of Pavia Institute, Istituti Clinici Scientifici Maugeri, IRCCS, University of Pavia, Pavia, Italy
| | - Francesca Lusetti
- Gastroenterology Unit of Pavia Institute, Istituti Clinici Scientifici Maugeri, IRCCS, University of Pavia, Pavia, Italy
| | - Davide Scalvini
- Gastroenterology Unit of Pavia Institute, Istituti Clinici Scientifici Maugeri, IRCCS, University of Pavia, Pavia, Italy
| | - Fabiola Megang
- Gastroenterology Unit of Pavia Institute, Istituti Clinici Scientifici Maugeri, IRCCS, University of Pavia, Pavia, Italy
| | - Maria Luisa Nicolardi
- Gastroenterology Unit of Pavia Institute, Istituti Clinici Scientifici Maugeri, IRCCS, University of Pavia, Pavia, Italy
| | - Gian Marco Gabrielli
- Gastroenterology Unit of Pavia Institute, Istituti Clinici Scientifici Maugeri, IRCCS, University of Pavia, Pavia, Italy
| | - Elisa Sprio
- Department of Internal Medicine, IRCCS Policlinico San Matteo, Pavia, Italy
| | - Paola Baiardi
- Direzione Scientifica Centrale, Istituti Clinici Scientifici Maugeri, IRCCS, Pavia, Italy
| | - Federico Biagi
- Gastroenterology Unit of Pavia Institute, Istituti Clinici Scientifici Maugeri, IRCCS, University of Pavia, Pavia, Italy
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