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Vernon-Roberts A, Verma S, Day AS, Ho SSC. Meta-analysis: High pooled positive predictive value of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition no-biopsy approach for coeliac disease testing in children. Aliment Pharmacol Ther 2024; 60:672-685. [PMID: 39044321 DOI: 10.1111/apt.18177] [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] [Received: 03/18/2024] [Revised: 04/29/2024] [Accepted: 07/12/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND The European Society of Paediatric Gastroenterology, Hepatology and Nutrition established guidelines in 2012 for a no-biopsy approach to diagnose coeliac disease in children. This guideline required symptoms suggestive of coeliac disease, positive human leukocyte antigen (HLA) DQ2/DQ8 haplotypes, tissue transglutaminase type-2 immunoglobulin A antibody titre at levels greater than 10 times the upper limit of normal, and positive endomysial immune-globulin A antibody test. An updated 2020 guideline excluded the need for symptoms and positive HLA. AIMS To assess the pooled positive predictive value (PPV) of the no-biopsy approach with small bowel biopsy (SBB) data as the reference standard for comparison. METHODS Database searches (October 2023) provided data that we combined using a random-effects meta-analysis to provide a pooled PPV, representing the probability that a positive test result means that an individual truly has the condition. RESULTS We included 23 studies. Study sample sizes totalled 23,769 but only 3007 children had comparative SBB. The proportion of coeliac disease confirmed by the no-biopsy approach and SBB ranged from 79.2% to 100%, with an overall pooled PPV of 97.4% (95% confidence interval 96.0, 98.6). Sensitivity analysis showed higher PPV for the criteria that included HLA (98.5% vs. 96.8%; p = 0.017). CONCLUSION Both no-biopsy criteria exhibit high PPV when compared to the reference standard. These results provide a consistent message of accuracy and feasibility to inform change and improve outcomes.
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Affiliation(s)
| | - Sanjeev Verma
- Department of Pediatrics, King George Medical University, Lucknow, Uttar Pradesh, India
| | - Andrew S Day
- Department of Paediatrics, University of Otago Christchurch, Christchurch, New Zealand
| | - Shaun S C Ho
- Department of Gastroenterology and Clinical Nutrition, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
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Husby S, Choung RS, Crawley C, Lillevang ST, Murray JA. Laboratory Testing for Celiac Disease: Clinical and Methodological Considerations. Clin Chem 2024:hvae098. [PMID: 39099386 DOI: 10.1093/clinchem/hvae098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 05/30/2024] [Indexed: 08/06/2024]
Abstract
BACKGROUND Celiac disease (CeD) has an estimated prevalence of 1%-3%. The classical clinical presentation is malabsorption, but now patients may present with more subtle symptoms such as constipation, osteoporosis, or iron deficiency anemia. Children may also present with poor growth.CeD has a strong genetic component, and high-risk groups include first-degree relatives with CeD, patients with co-existing autoimmune diseases, and patients with chromosomal aberrations. CONTENT Diagnostic tests for CeD include duodenal histology, serology, and genetic testing. Duodenal histology has traditionally been the gold standard of diagnosis. However, serological tests, especially IgA tissue transglutaminase antibodies (TTG-IgA), are widely used and diagnostic algorithms are based primarily on TTG-IgA as a starting point. Human leukocyte antigen typing may also be incorporated to determine genetic risk for CeD. Guidelines for children endorse biopsy avoidance provided high levels of TTG-IgA, with diagnostic accuracy being comparable to duodenal biopsy. Confirmation may be achieved by identifying IgA endomysial antibodies in a separate blood sample. Subjects with low positive TTG-IgA levels and subjects with IgA deficiency need a biopsy to establish a diagnosis of CeD. The clinical follow-up of CeD usually includes a repeat TTG-IgA examination. In adults, healing may be delayed or incomplete, and a rare consequence of refractory celiac disease is transformation to enteric T-cell lymphoma. SUMMARY Laboratory testing, in particular TTG-IgA, plays a central role in the diagnosis and has an accuracy comparable to histology. Diagnostic algorithms utilizing laboratory testing are critical for the development of novel strategies to improve diagnosis.
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Affiliation(s)
- Steffen Husby
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Rok Seon Choung
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States
| | - Cæcilie Crawley
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Søren T Lillevang
- Department of Clinical Immunology, Odense University Hospital, Odense, Denmark
| | - Joseph A Murray
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States
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Suasnabar JH, Meijer CR, Smit L, van Overveld F, Thom H, Keeney E, Mearin ML, van den Akker-van Marle ME. Long-term Cost-effectiveness of Case Finding and Mass Screening for Celiac Disease in Children. Gastroenterology 2024:S0016-5085(24)05283-1. [PMID: 39084268 DOI: 10.1053/j.gastro.2024.07.024] [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: 01/29/2024] [Revised: 07/12/2024] [Accepted: 07/22/2024] [Indexed: 08/02/2024]
Abstract
BACKGROUND & AIMS Celiac disease (CD) is a common yet underdiagnosed autoimmune disease with substantial long-term consequences. High-accuracy point-of-care tests for CD antibodies conducted at youth primary health care centers may enable earlier identification of CD, but evidence about the cost-effectiveness of such strategies is lacking. We estimated the long-term cost-effectiveness of active case finding and mass screening compared with clinical detection in the Netherlands. METHODS A decision tree and Markov model were used to simulate a cohort of 3-year-old children with CD according to each strategy, taking into account their impact on long-term costs (from a societal perspective) and quality-adjusted life-years (QALYs). Model parameters incorporated data from the GLUTENSCREEN project, the Dutch Celiac Society, the Dutch Pediatric Surveillance Unit, and published sources. The primary outcome was the incremental cost-effectiveness ratio (ICER) between strategies. RESULTS Mass-screening produced 7.46 more QALYs and was €28,635 more costly compared with current care (ICER: €3841 per QALY), and case finding produced 4.33 more QALYs and was €15,585 more costly compared with current care (ICER: €3603 per QALY). At a willingness to pay of €20,000 per QALY, both strategies were highly cost-effective compared with current care. Scenario analyses indicated that mass screening is likely the optimal strategy, unless no benefit in detecting asymptomatic cases is assumed. CONCLUSIONS An earlier identification of CD through screening or case finding in children using a point-of-care tests leads to improved health outcomes and is cost-effective in the long-term compared with current care. If the feasibility and acceptability of the proposed strategies are successful, implementation in Dutch regular care is needed.
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Affiliation(s)
- Jan Heijdra Suasnabar
- Department of Biomedical Data Science, Leiden University Medical Centre, Leiden, the Netherlands.
| | - Caroline R Meijer
- Department of Pediatric Gastroenterology, Willem-Alexander Children's Hospital, Leiden University Medical Center, the Netherlands
| | - Lucy Smit
- Youth Health Care Centre, Kennemerland, the Netherlands
| | | | - Howard Thom
- Department of Population Health Sciences, Bristol Medical School, Bristol, United Kingdom
| | - Edna Keeney
- Department of Population Health Sciences, Bristol Medical School, Bristol, United Kingdom
| | - M Luisa Mearin
- Department of Pediatric Gastroenterology, Willem-Alexander Children's Hospital, Leiden University Medical Center, the Netherlands
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4
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du Pre MF, Iversen R, Sollid LM. Coeliac disease: the paradox of diagnosing a food hypersensitivity disorder with autoantibodies. Gut 2024; 73:844-853. [PMID: 38378252 DOI: 10.1136/gutjnl-2023-331595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 01/30/2024] [Indexed: 02/22/2024]
Abstract
Serum antibodies to the autoantigen transglutaminase 2 (TG2) are increasingly harnessed to diagnose coeliac disease. Diagnostic guidelines for children give recommendation for a no-biopsy-based diagnosis through detection of high amounts of IgA anti-TG2 antibodies in serum with confirmation of positivity in a separate blood sample by characteristic autoantibody-staining of tissue. While measurement of IgA anti-TG2 also is important in the diagnostic workup of adults, the adult guidelines still mandate examination of gut biopsies. This requirement might well change in the future, as might the necessity for confirming autoantibody positivity by tissue staining. The key role of autoantibody serology for diagnosis of coeliac disease is paradoxical. Coeliac disease was considered, and still can be considered, a food intolerance disorder where autoantibodies at face value are out of place. The immunological mechanisms underlying the formation of autoantibodies in response to gluten exposure have been dissected. This review presents the current insights demonstrating that the autoantibodies in coeliac disease are intimately integrated in the maladapted immune response to gluten.
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Affiliation(s)
- M Fleur du Pre
- Norwegian Coeliac Disease Research Centre, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Immunology, Oslo University Hosptial - Rikshospitalet, Oslo, Norway
| | - Rasmus Iversen
- Norwegian Coeliac Disease Research Centre, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Immunology, Oslo University Hosptial - Rikshospitalet, Oslo, Norway
| | - Ludvig M Sollid
- Norwegian Coeliac Disease Research Centre, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Immunology, Oslo University Hosptial - Rikshospitalet, Oslo, Norway
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Teniou A, Rhouati A, Marty JL. Recent Advances in Biosensors for Diagnosis of Autoimmune Diseases. SENSORS (BASEL, SWITZERLAND) 2024; 24:1510. [PMID: 38475046 DOI: 10.3390/s24051510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 02/01/2024] [Accepted: 02/14/2024] [Indexed: 03/14/2024]
Abstract
Over the last decade, autoimmune diseases (ADs) have undergone a significant increase because of genetic and/or environmental factors; therefore, their simple and fast diagnosis is of high importance. The conventional diagnostic techniques for ADs require tedious sample preparation, sophisticated instruments, a dedicated laboratory, and qualified personnel. For these reasons, biosensors could represent a useful alternative to these methods. Biosensors are considered to be promising tools that can be used in clinical analysis for an early diagnosis due to their high sensitivity, simplicity, low cost, possible miniaturization (POCT), and potential ability for real-time analysis. In this review, recently developed biosensors for the detection of autoimmune disease biomarkers are discussed. In the first part, we focus on the main AD biomarkers and the current methods of their detection. Then, we discuss the principles and different types of biosensors. Finally, we overview the characteristics of biosensors based on different bioreceptors reported in the literature.
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Affiliation(s)
- Ahlem Teniou
- Bioengineering Laboratory, Higher National School of Biotechnology, Constantine 25100, Algeria
| | - Amina Rhouati
- Bioengineering Laboratory, Higher National School of Biotechnology, Constantine 25100, Algeria
| | - Jean-Louis Marty
- Laboratoire BAE, Université de Perpignan through Domitia, 66860 Perpignan, France
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Parrinello G, Da Re M, Grizzo F, Camelliti S, Cozzi M, Marinoni F, Villalta D. Diagnostic accuracy of a novel point-of-care test for simultaneous detection of anti-transglutaminase IgA and anti-deamidated gliadin IgG antibodies. J Clin Lab Anal 2024; 38:e25003. [PMID: 38291818 PMCID: PMC10873685 DOI: 10.1002/jcla.25003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 12/28/2023] [Accepted: 01/01/2024] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND Point-of-care tests (POCTs) may have a role in detecting undiagnosed cases of Celiac disease (CD). We assessed the diagnostic accuracy of a novel POCT, compared with the conventional serological methods, for simultaneous anti-transglutaminase (tTG) IgA and anti-deamidated gliadin (DGP) IgG antibody detection. Furthermore, we evaluated the effect of different biological matrices (whole blood and serum) on test performance. METHODS Serum and whole blood from celiac or suspected celiac patients who underwent duodenal biopsy were assayed for the presence of anti-tTG IgA and anti-DGP IgG both with the reference standard methods (Thermo Fisher Scientific, Uppsala, Sweden) and with the POCT (PRIMA Lab SA, Balerna, Switzerland). RESULTS 266 sera (101 negative and 165 positive) and 60 whole blood samples (34 positive and 26 negative) were included in the study. POCT for anti-DGP IgG showed a sensitivity of 84.3% and a specificity of 90.1%, with positive (PPV) and negative predictive values (NPV) of 91.07% and 82.73%. POCT for anti-tTG IgA showed a sensitivity of 98.31% and a specificity of 98.02%, with a PPV and NPV of 98.31% and 98.02%. Test accuracies were 86.94% and 98.17%, respectively. The agreement of the results between the two different matrices showed a strong correlation rate: 95% for anti-DGP IgG and 100% for anti-tTG IgA. CONCLUSION The anti-tTG IgA/anti-DGP IgG-based POCT showed good diagnostic accuracy with comparable sensitivities and specificities to reference standard methods in detecting CD in symptomatic patients and could be considered as a mass screening test before referring to conventional serology.
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Affiliation(s)
| | - Mirella Da Re
- Immunology and Allergy UnitSanta Maria degli Angeli HospitalPordenoneItaly
| | - Francesca Grizzo
- Immunology and Allergy UnitSanta Maria degli Angeli HospitalPordenoneItaly
| | | | | | | | - Danilo Villalta
- Immunology and Allergy UnitSanta Maria degli Angeli HospitalPordenoneItaly
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Shiha MG, Chetcuti Zammit S, Elli L, Sanders DS, Sidhu R. Updates in the diagnosis and management of coeliac disease. Best Pract Res Clin Gastroenterol 2023; 64-65:101843. [PMID: 37652646 DOI: 10.1016/j.bpg.2023.101843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 07/02/2023] [Indexed: 09/02/2023]
Abstract
Coeliac disease is a common autoimmune disorder induced by ingesting gluten, the protein component of wheat, barley, and rye. It is estimated that one-in-hundred people worldwide have coeliac disease, of whom the majority remain undiagnosed. Coeliac disease is characterized by a wide range of gastrointestinal and extraintestinal symptoms but can also present asymptomatically. Diagnosing coeliac disease depends on the concordance of clinical, serological and histopathological data. However, the diagnosis can be challenging and frequently overlooked. Undiagnosed coeliac disease is associated with an increased risk of complications and detrimental effects on quality of life. Early diagnosis and treatment of coeliac disease are necessary to reduce the risk of long-term complications.
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Affiliation(s)
- Mohamed G Shiha
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, United Kingdom; Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom.
| | | | - Luca Elli
- Center for Prevention and Diagnosis of Celiac Disease, Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - David S Sanders
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, United Kingdom; Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Reena Sidhu
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, United Kingdom; Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
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Point-of-Care Screening for Coeliac Disease in Schoolchildren Reveals Higher Disease Prevalence in Croatia. Healthcare (Basel) 2022; 11:healthcare11010064. [PMID: 36611524 PMCID: PMC9819334 DOI: 10.3390/healthcare11010064] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/16/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022] Open
Abstract
Coeliac disease (CD) is an immune-mediated inflammatory disease triggered by dietary gluten and related proteins in genetically predisposed individuals. Point-of-care (POC) methods are non-invasive and easily performed tests, which could help to reduce the diagnostic delay of CD. The aim of our study was to determine the prevalence of CD using rapid POC test in first-grade schoolchildren in Zagreb, Croatia. A rapid qualitative immunoassay POC test designed for detection of immunoglobulin (Ig) A and IgG deamidated gliadin antibodies (DGP), as well as total IgA (to identify IgA deficient patients) in whole blood, was used to test healthy children on gluten containing diet. Out of 1404 tested children (51% female), 85 (6.05%) had a positive rapid POC test result and were referred to paediatric gastroenterologist. Finally, 7 children were diagnosed with CD (0.5%). There was no significant difference in children with CD and children with positive POC but negative serology in sex, BMI, or symptoms. However, children diagnosed with CD complained of abdominal pain significantly more often. The prevalence of CD in first-grade schoolchildren was 1:200 (0.5%), higher than in previous studies performed in Croatia. The results imply the possible benefit of IgA and IgG DGP-based POC tests in population screening.
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Elwenspoek MM, Thom H, Sheppard AL, Keeney E, O'Donnell R, Jackson J, Roadevin C, Dawson S, Lane D, Stubbs J, Everitt H, Watson JC, Hay AD, Gillett P, Robins G, Jones HE, Mallett S, Whiting PF. Defining the optimum strategy for identifying adults and children with coeliac disease: systematic review and economic modelling. Health Technol Assess 2022; 26:1-310. [PMID: 36321689 PMCID: PMC9638887 DOI: 10.3310/zuce8371] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Coeliac disease is an autoimmune disorder triggered by ingesting gluten. It affects approximately 1% of the UK population, but only one in three people is thought to have a diagnosis. Untreated coeliac disease may lead to malnutrition, anaemia, osteoporosis and lymphoma. OBJECTIVES The objectives were to define at-risk groups and determine the cost-effectiveness of active case-finding strategies in primary care. DESIGN (1) Systematic review of the accuracy of potential diagnostic indicators for coeliac disease. (2) Routine data analysis to develop prediction models for identification of people who may benefit from testing for coeliac disease. (3) Systematic review of the accuracy of diagnostic tests for coeliac disease. (4) Systematic review of the accuracy of genetic tests for coeliac disease (literature search conducted in April 2021). (5) Online survey to identify diagnostic thresholds for testing, starting treatment and referral for biopsy. (6) Economic modelling to identify the cost-effectiveness of different active case-finding strategies, informed by the findings from previous objectives. DATA SOURCES For the first systematic review, the following databases were searched from 1997 to April 2021: MEDLINE® (National Library of Medicine, Bethesda, MD, USA), Embase® (Elsevier, Amsterdam, the Netherlands), Cochrane Library, Web of Science™ (Clarivate™, Philadelphia, PA, USA), the World Health Organization International Clinical Trials Registry Platform ( WHO ICTRP ) and the National Institutes of Health Clinical Trials database. For the second systematic review, the following databases were searched from January 1990 to August 2020: MEDLINE, Embase, Cochrane Library, Web of Science, Kleijnen Systematic Reviews ( KSR ) Evidence, WHO ICTRP and the National Institutes of Health Clinical Trials database. For prediction model development, Clinical Practice Research Datalink GOLD, Clinical Practice Research Datalink Aurum and a subcohort of the Avon Longitudinal Study of Parents and Children were used; for estimates for the economic models, Clinical Practice Research Datalink Aurum was used. REVIEW METHODS For review 1, cohort and case-control studies reporting on a diagnostic indicator in a population with and a population without coeliac disease were eligible. For review 2, diagnostic cohort studies including patients presenting with coeliac disease symptoms who were tested with serological tests for coeliac disease and underwent a duodenal biopsy as reference standard were eligible. In both reviews, risk of bias was assessed using the quality assessment of diagnostic accuracy studies 2 tool. Bivariate random-effects meta-analyses were fitted, in which binomial likelihoods for the numbers of true positives and true negatives were assumed. RESULTS People with dermatitis herpetiformis, a family history of coeliac disease, migraine, anaemia, type 1 diabetes, osteoporosis or chronic liver disease are 1.5-2 times more likely than the general population to have coeliac disease; individual gastrointestinal symptoms were not useful for identifying coeliac disease. For children, women and men, prediction models included 24, 24 and 21 indicators of coeliac disease, respectively. The models showed good discrimination between patients with and patients without coeliac disease, but performed less well when externally validated. Serological tests were found to have good diagnostic accuracy for coeliac disease. Immunoglobulin A tissue transglutaminase had the highest sensitivity and endomysial antibody the highest specificity. There was little improvement when tests were used in combination. Survey respondents (n = 472) wanted to be 66% certain of the diagnosis from a blood test before starting a gluten-free diet if symptomatic, and 90% certain if asymptomatic. Cost-effectiveness analyses found that, among adults, and using serological testing alone, immunoglobulin A tissue transglutaminase was most cost-effective at a 1% pre-test probability (equivalent to population screening). Strategies using immunoglobulin A endomysial antibody plus human leucocyte antigen or human leucocyte antigen plus immunoglobulin A tissue transglutaminase with any pre-test probability had similar cost-effectiveness results, which were also similar to the cost-effectiveness results of immunoglobulin A tissue transglutaminase at a 1% pre-test probability. The most practical alternative for implementation within the NHS is likely to be a combination of human leucocyte antigen and immunoglobulin A tissue transglutaminase testing among those with a pre-test probability above 1.5%. Among children, the most cost-effective strategy was a 10% pre-test probability with human leucocyte antigen plus immunoglobulin A tissue transglutaminase, but there was uncertainty around the most cost-effective pre-test probability. There was substantial uncertainty in economic model results, which means that there would be great value in conducting further research. LIMITATIONS The interpretation of meta-analyses was limited by the substantial heterogeneity between the included studies, and most included studies were judged to be at high risk of bias. The main limitations of the prediction models were that we were restricted to diagnostic indicators that were recorded by general practitioners and that, because coeliac disease is underdiagnosed, it is also under-reported in health-care data. The cost-effectiveness model is a simplification of coeliac disease and modelled an average cohort rather than individuals. Evidence was weak on the probability of routine coeliac disease diagnosis, the accuracy of serological and genetic tests and the utility of a gluten-free diet. CONCLUSIONS Population screening with immunoglobulin A tissue transglutaminase (1% pre-test probability) and of immunoglobulin A endomysial antibody followed by human leucocyte antigen testing or human leucocyte antigen testing followed by immunoglobulin A tissue transglutaminase with any pre-test probability appear to have similar cost-effectiveness results. As decisions to implement population screening cannot be made based on our economic analysis alone, and given the practical challenges of identifying patients with higher pre-test probabilities, we recommend that human leucocyte antigen combined with immunoglobulin A tissue transglutaminase testing should be considered for adults with at least a 1.5% pre-test probability of coeliac disease, equivalent to having at least one predictor. A more targeted strategy of 10% pre-test probability is recommended for children (e.g. children with anaemia). FUTURE WORK Future work should consider whether or not population-based screening for coeliac disease could meet the UK National Screening Committee criteria and whether or not it necessitates a long-term randomised controlled trial of screening strategies. Large prospective cohort studies in which all participants receive accurate tests for coeliac disease are needed. STUDY REGISTRATION This study is registered as PROSPERO CRD42019115506 and CRD42020170766. FUNDING This project was funded by the National Institute for Health and Care Research ( NIHR ) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 44. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Martha Mc Elwenspoek
- National Institute for Health and Care Research Applied Research Collaboration West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Howard Thom
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Athena L Sheppard
- National Institute for Health and Care Research Applied Research Collaboration West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Edna Keeney
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Rachel O'Donnell
- National Institute for Health and Care Research Applied Research Collaboration West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Joni Jackson
- National Institute for Health and Care Research Applied Research Collaboration West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Cristina Roadevin
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sarah Dawson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | | | - Hazel Everitt
- Primary Care Research Centre, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Jessica C Watson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Alastair D Hay
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Peter Gillett
- Paediatric Gastroenterology, Hepatology and Nutrition Department, Royal Hospital for Sick Children, Edinburgh, UK
| | - Gerry Robins
- Department of Gastroenterology, York Teaching Hospital NHS Foundation Trust, York, UK
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sue Mallett
- Centre for Medical Imaging, University College London, London, UK
| | - Penny F Whiting
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Singh P, Singh AD, Ahuja V, Makharia GK. Who to screen and how to screen for celiac disease. World J Gastroenterol 2022; 28:4493-4507. [PMID: 36157923 PMCID: PMC9476868 DOI: 10.3748/wjg.v28.i32.4493] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 03/03/2022] [Accepted: 06/16/2022] [Indexed: 02/06/2023] Open
Abstract
Celiac disease (CeD) is a chronic gluten-induced enteropathy with plethoric manifestations. The typical manifestations of CeD such as chronic diarrhea and malabsorption are widely recognized, however, many patients have atypical manifestations like iron deficiency anemia, idiopathic short stature, hypertransaminesemia or infertility, etc. These patients often present to the primary care physicians and/or non-gastrointestinal specialties. However, due to a lack of awareness among the healthcare professionals about the various atypical manifestations, many patients are not screened for CeD. In this review, we have summarized the available literature about the prevalence of CeD in various gastrointestinal (chronic diarrhea) and non-gastrointestinal conditions (iron deficiency anemia, short stature, cryptogenic hypertransaminesemia, cryptogenic cirrhosis or idiopathic ataxia etc.) where the diagnosis of CeD should be con-sidered. In addition, we also discuss special scenarios where screening for CeD should be considered even in absence of symptoms such as patients with type 1 diabetes, Down’s syndrome, and first-degree relatives of patients with CeD. Further, we discuss the diagnostic performance and limitations of various screening tests for CeD such as IgA anti-tissue transglutaminase antibodies, anti-endomysial antibodies and anti-deamidated gliadin antibodies. Based on the current recommendations, we propose a diagnostic algorithm for patients with suspected CeD.
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Affiliation(s)
- Prashant Singh
- Department of Gastroenterology, University of Michigan, Ann Arbor, MI 48109, United States
| | | | - Vineet Ahuja
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Govind K Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, India
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Magazzù G, Aquilina S, Barbara C, Bondin R, Brusca I, Bugeja J, Camilleri M, Cascio D, Costa S, Cuzzupè C, Duca A, Fregapane M, Gentile V, Giuliano A, Grifò A, Grima AM, Ieni A, Li Calzi G, Maisano F, Melita G, Pallio S, Panasiti I, Pellegrino S, Romano C, Sorce S, Tabacchi ME, Taormina V, Tegolo D, Tortora A, Valenti C, Vella C, Raso G. Recognizing the Emergent and Submerged Iceberg of the Celiac Disease: ITAMA Project-Global Strategy Protocol. Pediatr Rep 2022; 14:293-311. [PMID: 35736659 PMCID: PMC9227897 DOI: 10.3390/pediatric14020037] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/19/2022] [Accepted: 06/06/2022] [Indexed: 12/12/2022] Open
Abstract
Coeliac disease (CD) is frequently underdiagnosed with a consequent heavy burden in terms of morbidity and health care costs. Diagnosis of CD is based on the evaluation of symptoms and anti-transglutaminase antibodies IgA (TGA-IgA) levels, with values above a tenfold increase being the basis of the biopsy-free diagnostic approach suggested by present guidelines. This study showcased the largest screening project for CD carried out to date in school children (n=20,000) aimed at assessing the diagnostic accuracy of minimally invasive finger prick point-of-care tests (POCT) which, combined with conventional celiac serology and the aid of an artificial intelligence-based system, may eliminate the need for intestinal biopsy. Moreover, this study delves deeper into the "coeliac iceberg" in an attempt to identify people with disorders who may benefit from a gluten-free diet, even in the absence of gastrointestinal symptoms, abnormal serology and histology. This was achieved by looking for TGA-IgA mucosal deposits in duodenal biopsy. This large European multidisciplinary health project paves the way to an improved quality of life for patients by reducing the costs for diagnosis due to delayed findings of CD and to offer business opportunities in terms of diagnostic tools and support.
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Affiliation(s)
- Giuseppe Magazzù
- Dipartimento di Patologia Umana dell’Adulto e dell’Età Evolutiva “Gaetano Barresi”, Università di Messina, 98122 Messina, Italy; (C.C.); (A.G.); (A.I.); (F.M.); (G.M.); (I.P.); (C.R.)
- Correspondence:
| | - Samuel Aquilina
- Department of Paediatrics, Mater Dei Hospital, 2090 Msida, Malta; (S.A.); (R.B.); (A.-M.G.); (C.V.)
| | - Christopher Barbara
- Department of Pathology, Mater Dei Hospital, 2090 Msida, Malta; (C.B.); (M.C.)
| | - Ramon Bondin
- Department of Paediatrics, Mater Dei Hospital, 2090 Msida, Malta; (S.A.); (R.B.); (A.-M.G.); (C.V.)
| | - Ignazio Brusca
- Ospedale Fatebenefratelli, Buccheri La Ferla, 90123 Palermo, Italy; (I.B.); (M.F.)
| | | | - Mark Camilleri
- Department of Pathology, Mater Dei Hospital, 2090 Msida, Malta; (C.B.); (M.C.)
| | - Donato Cascio
- Dipartimento di Fisica e Chimica-“E. Segrè”, Università di Palermo, 90133 Palermo, Italy; (D.C.); (V.G.); (G.L.C.); (S.S.); (V.T.); (G.R.)
| | - Stefano Costa
- DAI Materno-Infantile, AOU Policlinico G. Martino, 98124 Messina, Italy; (S.C.); (S.P.)
| | - Chiara Cuzzupè
- Dipartimento di Patologia Umana dell’Adulto e dell’Età Evolutiva “Gaetano Barresi”, Università di Messina, 98122 Messina, Italy; (C.C.); (A.G.); (A.I.); (F.M.); (G.M.); (I.P.); (C.R.)
| | - Annalise Duca
- AcrossLimits Ltd., 4013 Birkirkara, Malta; (J.B.); (A.D.); (A.G.)
| | - Maria Fregapane
- Ospedale Fatebenefratelli, Buccheri La Ferla, 90123 Palermo, Italy; (I.B.); (M.F.)
| | - Vito Gentile
- Dipartimento di Fisica e Chimica-“E. Segrè”, Università di Palermo, 90133 Palermo, Italy; (D.C.); (V.G.); (G.L.C.); (S.S.); (V.T.); (G.R.)
| | - Angele Giuliano
- AcrossLimits Ltd., 4013 Birkirkara, Malta; (J.B.); (A.D.); (A.G.)
| | - Alessia Grifò
- Dipartimento di Patologia Umana dell’Adulto e dell’Età Evolutiva “Gaetano Barresi”, Università di Messina, 98122 Messina, Italy; (C.C.); (A.G.); (A.I.); (F.M.); (G.M.); (I.P.); (C.R.)
| | - Anne-Marie Grima
- Department of Paediatrics, Mater Dei Hospital, 2090 Msida, Malta; (S.A.); (R.B.); (A.-M.G.); (C.V.)
| | - Antonio Ieni
- Dipartimento di Patologia Umana dell’Adulto e dell’Età Evolutiva “Gaetano Barresi”, Università di Messina, 98122 Messina, Italy; (C.C.); (A.G.); (A.I.); (F.M.); (G.M.); (I.P.); (C.R.)
| | - Giada Li Calzi
- Dipartimento di Fisica e Chimica-“E. Segrè”, Università di Palermo, 90133 Palermo, Italy; (D.C.); (V.G.); (G.L.C.); (S.S.); (V.T.); (G.R.)
| | - Fabiana Maisano
- Dipartimento di Patologia Umana dell’Adulto e dell’Età Evolutiva “Gaetano Barresi”, Università di Messina, 98122 Messina, Italy; (C.C.); (A.G.); (A.I.); (F.M.); (G.M.); (I.P.); (C.R.)
| | - Giuseppinella Melita
- Dipartimento di Patologia Umana dell’Adulto e dell’Età Evolutiva “Gaetano Barresi”, Università di Messina, 98122 Messina, Italy; (C.C.); (A.G.); (A.I.); (F.M.); (G.M.); (I.P.); (C.R.)
| | - Socrate Pallio
- Dipartimento di Medicina Clinica e Sperimentale, Università di Messina, 98122 Messina, Italy;
| | - Ilenia Panasiti
- Dipartimento di Patologia Umana dell’Adulto e dell’Età Evolutiva “Gaetano Barresi”, Università di Messina, 98122 Messina, Italy; (C.C.); (A.G.); (A.I.); (F.M.); (G.M.); (I.P.); (C.R.)
| | - Salvatore Pellegrino
- DAI Materno-Infantile, AOU Policlinico G. Martino, 98124 Messina, Italy; (S.C.); (S.P.)
| | - Claudio Romano
- Dipartimento di Patologia Umana dell’Adulto e dell’Età Evolutiva “Gaetano Barresi”, Università di Messina, 98122 Messina, Italy; (C.C.); (A.G.); (A.I.); (F.M.); (G.M.); (I.P.); (C.R.)
| | - Salvatore Sorce
- Dipartimento di Fisica e Chimica-“E. Segrè”, Università di Palermo, 90133 Palermo, Italy; (D.C.); (V.G.); (G.L.C.); (S.S.); (V.T.); (G.R.)
- Facoltà di Ingegneria e Architettura, Università degli Studi di Enna “Kore”, 94100 Enna, Italy
| | - Marco Elio Tabacchi
- Dipartimento di Matematica e Informatica, Università di Palermo, 90133 Palermo, Italy; (M.E.T.); (D.T.); (C.V.)
| | - Vincenzo Taormina
- Dipartimento di Fisica e Chimica-“E. Segrè”, Università di Palermo, 90133 Palermo, Italy; (D.C.); (V.G.); (G.L.C.); (S.S.); (V.T.); (G.R.)
| | - Domenico Tegolo
- Dipartimento di Matematica e Informatica, Università di Palermo, 90133 Palermo, Italy; (M.E.T.); (D.T.); (C.V.)
| | - Andrea Tortora
- DAI Scienze Mediche, AOU Policlinico G. Martino, 98124 Messina, Italy;
| | - Cesare Valenti
- Dipartimento di Matematica e Informatica, Università di Palermo, 90133 Palermo, Italy; (M.E.T.); (D.T.); (C.V.)
| | - Cecil Vella
- Department of Paediatrics, Mater Dei Hospital, 2090 Msida, Malta; (S.A.); (R.B.); (A.-M.G.); (C.V.)
| | - Giuseppe Raso
- Dipartimento di Fisica e Chimica-“E. Segrè”, Università di Palermo, 90133 Palermo, Italy; (D.C.); (V.G.); (G.L.C.); (S.S.); (V.T.); (G.R.)
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12
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Emerging Biomarkers for Screening and Management of Celiac Disease. BIOMED RESEARCH INTERNATIONAL 2022; 2022:2756242. [PMID: 35669726 PMCID: PMC9167106 DOI: 10.1155/2022/2756242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 05/18/2022] [Indexed: 11/17/2022]
Abstract
Celiac disease (CeD) is a chronic, immune-mediated enteropathy that is precipitated by dietary gluten in genetically predisposed individuals expressing HLA-DQ2 and/or HLA-DQ8. In the current clinical practice, there are many serologic studies to aid in the diagnosis of CeD which include autoantibodies like IgA antitissue transglutaminase, antiendomysium, and antideamidated forms of gliadin peptide antibodies. Small intestinal biopsy has long been considered an essential step for the diagnosis of CeD. However, in the recent era, researchers have explored the possibility of CeD screening and diagnosis without endoscopy or biopsy. The newer emerging biomarkers of CeD appear promising in diagnostic evaluation and subsequent monitoring of disease. In this review of literature, we have explored the emerging biomarker-based diagnostic evaluation and monitoring of CeD.
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13
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The global burden of coeliac disease: opportunities and challenges. Nat Rev Gastroenterol Hepatol 2022; 19:313-327. [PMID: 34980921 DOI: 10.1038/s41575-021-00552-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/08/2021] [Indexed: 02/06/2023]
Abstract
Coeliac disease is a systemic disorder characterized by immune-mediated enteropathy, which is caused by gluten ingestion in genetically susceptible individuals. The clinical presentation of coeliac disease is highly variable and ranges from malabsorption through solely extra-intestinal manifestations to asymptomatic. As a result, the majority of patients with coeliac disease remain undiagnosed, misdiagnosed or experience a substantial delay in diagnosis. Coeliac disease is diagnosed by a combination of serological findings of disease-related antibodies and histological evidence of villous abnormalities in duodenal biopsy samples. However, variability in histological grading and in the diagnostic performance of some commercially available serological tests remains unacceptably high and confirmatory assays are not readily available in many parts of the world. Currently, the only effective treatment for coeliac disease is a lifelong, strict, gluten-free diet. However, many barriers impede patients' adherence to this diet, including lack of widespread availability, high cost, cross-contamination and its overall restrictive nature. Routine follow-up is necessary to ensure adherence to a gluten-free diet but considerable variation is evident in follow-up protocols and the optimal disease management strategy is not clear. However, these challenges in the diagnosis and management of coeliac disease suggest opportunities for future research.
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14
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Sheppard AL, Elwenspoek MMC, Scott LJ, Corfield V, Everitt H, Gillett PM, Hay AD, Jones HE, Mallett S, Watson J, Whiting PF. Systematic review with meta-analysis: the accuracy of serological tests to support the diagnosis of coeliac disease. Aliment Pharmacol Ther 2022; 55:514-527. [PMID: 35043426 PMCID: PMC9305515 DOI: 10.1111/apt.16729] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/08/2021] [Accepted: 11/28/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND There is growing support for a biopsy avoidant approach to diagnose coeliac disease in both children and adults, using a serological diagnosis instead. AIMS To assess the diagnostic accuracy of serological tests for coeliac disease in adults and children. METHODS Seven electronic databases were searched between January 1990 and August 2020. Eligible diagnostic studies evaluated the accuracy of serological tests for coeliac disease against duodenal biopsy. Risk of bias assessment was performed using QUADAS-2. Bivariate random-effects meta-analyses were used to estimate serology sensitivity and specificity at the most commonly reported thresholds. RESULTS 113 studies (n = 28,338) were included, all in secondary care populations. A subset of studies were included in meta-analyses due to variations in diagnostic thresholds. Summary sensitivity and specificity of immunoglobulin A (IgA) anti-tissue transglutaminase were 90.7% (95% confidence interval: 87.3%, 93.2%) and 87.4% (84.4%, 90.0%) in adults (5 studies) and 97.7% (91.0%, 99.4%) and 70.2% (39.3%, 89.6%) in children (6 studies); and of IgA endomysial antibodies were 88.0% (75.2%, 94.7%) and 99.6% (92.3%, 100%) in adults (5 studies) and 94.5% (88.9%, 97.3%) and 93.8% (85.2%, 97.5%) in children (5 studies). CONCLUSIONS Anti-tissue transglutaminase sensitivity appears to be sufficient to rule out coeliac disease in children. The high specificity of endomysial antibody in adults supports its use to rule in coeliac disease. This evidence underpins the current development of clinical guidelines for a serological diagnosis of coeliac disease. Studies in primary care are needed to evaluate serological testing strategies in this setting.
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Affiliation(s)
- Athena L. Sheppard
- The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol NHS Foundation TrustBristolUK
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
| | - Martha M. C. Elwenspoek
- The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol NHS Foundation TrustBristolUK
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
| | - Lauren J. Scott
- The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol NHS Foundation TrustBristolUK
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
| | - Victoria Corfield
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
| | - Hazel Everitt
- Primary Care Research CentreFaculty of MedicineUniversity of SouthamptonSouthamptonUK
| | - Peter M. Gillett
- Paediatric Gastroenterology DepartmentRoyal Hospital for Children and Young PeopleEdinburghUK
| | - Alastair D. Hay
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
| | - Hayley E. Jones
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
| | - Susan Mallett
- Centre for Medical ImagingUniversity College LondonLondonUK
| | - Jessica Watson
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
| | - Penny F. Whiting
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
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15
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Sahin Y. Celiac disease in children: A review of the literature. World J Clin Pediatr 2021; 10:53-71. [PMID: 34316439 PMCID: PMC8290992 DOI: 10.5409/wjcp.v10.i4.53] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/23/2021] [Accepted: 05/22/2021] [Indexed: 02/06/2023] Open
Abstract
Celiac disease is an immune-mediated systemic disease triggered by intake of gluten in genetically susceptible individuals. The prevalence of celiac disease in the general population is estimated to be 1% in the world. Its prevalence differs depending on geographical and ethnic variations. The prevalence of celiac disease has increased significantly in the last 30 years due to the increased knowledge and awareness of physicians and the widespread use of highly sensitive and specific diagnostic tests for celiac disease. Despite increased awareness and knowledge about celiac disease, up to 95% of celiac patients still remain undiagnosed. The presentations of celiac disease have significantly changed in the last few decades. Classical symptoms of celiac disease occur in a minority of celiac patients, while older children have either minimal or atypical symptoms. Serologic tests for celiac disease should be done in patients with unexplained chronic or intermittent diarrhea, failure to thrive, weight loss, delayed puberty, short stature, amenorrhea, iron deficiency anemia, nausea, vomiting, chronic abdominal pain, abdominal distension, chronic constipation, recurrent aphthous stomatitis, and abnormal liver enzyme elevation, and in children who belong to specific groups at risk. Early diagnosis of celiac disease is very important to prevent long-term complications. Currently, the only effective treatment is a lifelong gluten-free diet. In this review, we will discuss the epidemiology, clinical findings, diagnostic tests, and treatment of celiac disease in the light of the latest literature.
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Affiliation(s)
- Yasin Sahin
- Pediatric Gastroenterology-Hepatology and Nutrition, Medical Park Gaziantep Hospital, Gaziantep 27560, Turkey
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16
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Seronegative celiac disease: to find it, you have to look for it. A pediatric case report. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2021; 86:317-319. [PMID: 34210463 DOI: 10.1016/j.rgmxen.2021.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 08/27/2020] [Indexed: 11/23/2022]
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17
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Ramírez-Sánchez AD, Tan IL, Gonera-de Jong B, Visschedijk MC, Jonkers I, Withoff S. Molecular Biomarkers for Celiac Disease: Past, Present and Future. Int J Mol Sci 2020; 21:E8528. [PMID: 33198309 PMCID: PMC7697360 DOI: 10.3390/ijms21228528] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 11/10/2020] [Indexed: 12/19/2022] Open
Abstract
Celiac disease (CeD) is a complex immune-mediated disorder that is triggered by dietary gluten in genetically predisposed individuals. CeD is characterized by inflammation and villous atrophy of the small intestine, which can lead to gastrointestinal complaints, malnutrition, and malignancies. Currently, diagnosis of CeD relies on serology (antibodies against transglutaminase and endomysium) and small-intestinal biopsies. Since small-intestinal biopsies require invasive upper-endoscopy, and serology cannot predict CeD in an early stage or be used for monitoring disease after initiation of a gluten-free diet, the search for non-invasive biomarkers is ongoing. Here, we summarize current and up-and-coming non-invasive biomarkers that may be able to predict, diagnose, and monitor the progression of CeD. We further discuss how current and emerging techniques, such as (single-cell) transcriptomics and genomics, can be used to uncover the pathophysiology of CeD and identify non-invasive biomarkers.
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Affiliation(s)
- Aarón D. Ramírez-Sánchez
- Department of Genetics, University of Groningen, University Medical Center Groningen, 9700 RB Groningen, The Netherlands; (A.D.R.-S.); (I.L.T.); (I.J.)
| | - Ineke L. Tan
- Department of Genetics, University of Groningen, University Medical Center Groningen, 9700 RB Groningen, The Netherlands; (A.D.R.-S.); (I.L.T.); (I.J.)
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, 9700 RB Groningen, The Netherlands;
| | - B.C. Gonera-de Jong
- Department of Pediatrics, Wilhelmina Hospital Assen, 9401 RK Assen, The Netherlands;
| | - Marijn C. Visschedijk
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, 9700 RB Groningen, The Netherlands;
| | - Iris Jonkers
- Department of Genetics, University of Groningen, University Medical Center Groningen, 9700 RB Groningen, The Netherlands; (A.D.R.-S.); (I.L.T.); (I.J.)
| | - Sebo Withoff
- Department of Genetics, University of Groningen, University Medical Center Groningen, 9700 RB Groningen, The Netherlands; (A.D.R.-S.); (I.L.T.); (I.J.)
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18
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Agarwal A, Chauhan A, Ahuja V, Makharia GK. Opportunities and challenges in the management of celiac disease in Asia. JGH Open 2020; 4:795-799. [PMID: 33102747 PMCID: PMC7578313 DOI: 10.1002/jgh3.12381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 06/11/2020] [Indexed: 12/12/2022]
Abstract
Although once considered uncommon, there is increasing recognition of celiac disease (CeD) in Asia. It is now clear that CeD is a disorder as frequent in certain Asian countries as that in western countries, although it often remains undiagnosed. With increasing awareness and diagnosis, the absolute numbers of celiac patients are expected to increase markedly in Asia. Asia, with 60% of the population of the world, is probably the major "reservoir" of undiagnosed CeD in the world. As Asia has a huge landscape along with highly heterogenous genetic, social, cultural, and nutritional practices, similar heterogeneity is seen in the epidemiology, diagnostic, and therapeutic facilities for CeD in Asia. In this article, we have reviewed the changes in the epidemiology, diagnostics, and management of CeD in Asia and summarized the challenges and opportunities for its emergence in Asia.
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Affiliation(s)
- Ashish Agarwal
- Department of Gastroenterology and Human NutritionAll India Institute of Medical SciencesNew DelhiIndia
| | - Ashish Chauhan
- Department of Gastroenterology and Human NutritionAll India Institute of Medical SciencesNew DelhiIndia
| | - Vineet Ahuja
- Department of Gastroenterology and Human NutritionAll India Institute of Medical SciencesNew DelhiIndia
| | - Govind K Makharia
- Department of Gastroenterology and Human NutritionAll India Institute of Medical SciencesNew DelhiIndia
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Riechmann ER, Villasante GCD, Pascual MLC, Aliaga ED, Allué IP, Sánchez-Valverde F, Koninckx CR. Rational application of the new European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) 2020 criteria for the diagnosis of coeliac disease. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.anpede.2019.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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20
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Aplicación racional de los nuevos criterios de la European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) 2020 para el diagnóstico de la enfermedad celíaca. An Pediatr (Barc) 2020; 92:110.e1-110.e9. [DOI: 10.1016/j.anpedi.2019.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 11/25/2019] [Accepted: 12/05/2019] [Indexed: 12/19/2022] Open
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21
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Rusanen J, Toivonen A, Hepojoki J, Hepojoki S, Arikoski P, Heikkinen M, Vaarala O, Ilonen J, Hedman K. LFRET, a novel rapid assay for anti-tissue transglutaminase antibody detection. PLoS One 2019; 14:e0225851. [PMID: 31770411 PMCID: PMC6879146 DOI: 10.1371/journal.pone.0225851] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 11/13/2019] [Indexed: 12/27/2022] Open
Abstract
The diagnosis of celiac disease (CD) is currently based on serology and intestinal biopsy, with detection of anti-tissue transglutaminase (tTG) IgA antibodies recommended as the first-line test. Emphasizing the increasing importance of serological testing, new guidelines and evidence suggest basing the diagnosis solely on serology without confirmatory biopsy. Enzyme immunoassays (EIAs) are the established approach for anti-tTG antibody detection, with the existing point-of-care (POC) tests lacking sensitivity and/or specificity. Improved POC methods could help reduce the underdiagnosis and diagnostic delay of CD. We have previously developed rapid homogenous immunoassays based on time-resolved Förster resonance energy transfer (TR-FRET), and demonstrated their suitability in serodiagnostics with hanta- and Zika virus infections as models. In this study, we set out to establish a protein L -based TR-FRET assay (LFRET) for the detection of anti-tTG antibodies. We studied 74 patients with biopsy-confirmed CD and 70 healthy controls, with 1) the new tTG-LFRET assay, and for reference 2) a well-established EIA and 3) an existing commercial POC test. IgG depletion was employed to differentiate between anti-tTG IgA and IgG positivity. The sensitivity and specificity of the first-generation tTG-LFRET POC assay in detection of CD were 87.8% and 94.3%, respectively, in line with those of the reference POC test. The sensitivity and specificity of EIA were 95.9% and 91.9%, respectively. This study demonstrates the applicability of LFRET to serological diagnosis of autoimmune diseases in general and of CD in particular.
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Affiliation(s)
- Juuso Rusanen
- University of Helsinki, Medicum, Department of Virology, Helsinki, Finland
- * E-mail:
| | - Anne Toivonen
- Laboratory Services (HUSLAB), Department of Virology and Immunology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Clinical Microbiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Jussi Hepojoki
- University of Helsinki, Medicum, Department of Virology, Helsinki, Finland
- Institute of Veterinary Pathology, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | - Satu Hepojoki
- University of Helsinki, Medicum, Department of Virology, Helsinki, Finland
| | - Pekka Arikoski
- Department of Pediatrics, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Markku Heikkinen
- Department of Gastroenterology, Kuopio University Hospital, Kuopio, Finland
| | - Outi Vaarala
- Clinicum, University of Helsinki, Helsinki, Finland
| | - Jorma Ilonen
- Immunogenetics Laboratory, Institute of Biomedicine, University of Turku and Clinical Microbiology, Turku University Hospital, Turku, Finland
| | - Klaus Hedman
- University of Helsinki, Medicum, Department of Virology, Helsinki, Finland
- Laboratory Services (HUSLAB), Department of Virology and Immunology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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22
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Grode L, Møller Jensen T, Parkner T, Agerholm IE, Humaidan P, Hammer Bech B, Ramlau-Hansen C. Diagnostic Accuracy of a Point-of-Care Test for Celiac Disease Antibody Screening among Infertile Patients. Inflamm Intest Dis 2019; 4:123-130. [PMID: 31559264 PMCID: PMC6751420 DOI: 10.1159/000501520] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 06/17/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Screening for celiac disease among infertile patients has been suggested. Several rapid point-of-care (POC) tests aimed at detecting celiac disease antibodies have been developed. It has been suggested that these POC tests can be implemented as a replacement for standard laboratory tests. OBJECTIVE To evaluate the diagnostic accuracy of a POC test (Simtomax®) that detects celiac disease antibodies compared with standard laboratory tests when screening for celiac disease among patients referred for fertility treatment in 2 Danish fertility clinics. METHODS Serum samples were analyzed for IgA anti-tissue transglutaminase (TGA) as the reference standard test with a cutoff of ≥7 kU/L and by the index POC test based on IgA and IgG antibodies against deamidated gliadin peptides (DGP). In IgA deficiency, the reference standard test was IgG DGP with a cutoff of ≥7 kU/L. Participants answered a questionnaire on gluten intake, symptoms, and risk factors. Diagnostic confirmation was made by duodenal biopsies. IgA TGA/IgG DGP were used as the reference standard to calculate positive and negative predictive values. RESULTS A total of 622 men and women (51.6%) were enrolled during 2015. The reference standard IgA TGA/IgG DGP was positive in 7 participants (1.1% [95% CI 0.5-2.3]) and the POC test was positive in 84 participants (13.5% [95% CI 10.9-16.4]), 3 of whom also had positive reference standard tests. This yields a sensitivity of the index POC test of 42.9% (95% CI 9.9-81.6) and a specificity of 86.8% (95% CI 83.9-89.4). Positive and negative predictive values were 3.57% (95% CI 0.7-10.1) and 99.3% (95% CI 98.1-99.8). CONCLUSION The sensitivity of the POC test was low; however, the specificity was moderately good. The POC test had a high negative predictive value in this low prevalent population but missed 1 patient with biopsy-confirmed celiac disease. However, because of many false-positive tests, it cannot be recommended as replacement for standard laboratory tests but rather as a triage test to decide if the standard serology tests should be performed.
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Affiliation(s)
- Louise Grode
- Department of Medicine, Horsens Regional Hospital, Horsens, Denmark
| | | | - Tina Parkner
- Department of Clinical Biochemistry, Arhus University Hospital, Aarhus, Denmark
| | - Inge Errebo Agerholm
- Department of Clinical Biochemistry, Arhus University Hospital, Origio, Måløv, Denmark
| | - Peter Humaidan
- Fertility Clinic, Skive Regional Hospital, Skive, Denmark
- Faculty of Health, Aarhus University, Aarhus, Denmark
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Singh A, Pramanik A, Acharya P, Makharia GK. Non-Invasive Biomarkers for Celiac Disease. J Clin Med 2019; 8:jcm8060885. [PMID: 31234270 PMCID: PMC6616864 DOI: 10.3390/jcm8060885] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 05/30/2019] [Accepted: 06/02/2019] [Indexed: 12/13/2022] Open
Abstract
Once thought to be uncommon, celiac disease has now become a common disease globally. While avoidance of the gluten-containing diet is the only effective treatment so far, many new targets are being explored for the development of new drugs for its treatment. The endpoints of therapy include not only reversal of symptoms, normalization of immunological abnormalities and healing of mucosa, but also maintenance of remission of the disease by strict adherence of the gluten-free diet (GFD). There is no single gold standard test for the diagnosis of celiac disease and the diagnosis is based on the presence of a combination of characteristics including the presence of a celiac-specific antibody (anti-tissue transglutaminase antibody, anti-endomysial antibody or anti-deamidated gliadin peptide antibody) and demonstration of villous abnormalities. While the demonstration of enteropathy is an important criterion for a definite diagnosis of celiac disease, it requires endoscopic examination which is perceived as an invasive procedure. The capability of prediction of enteropathy by the presence of the high titer of anti-tissue transglutaminase antibody led to an option of making a diagnosis even without obtaining mucosal biopsies. While present day diagnostic tests are great, they, however, have certain limitations. Therefore, there is a need for biomarkers for screening of patients, prediction of enteropathy, and monitoring of patients for adherence of the gluten-free diet. Efforts are now being made to explore various biomarkers which reflect different changes that occur in the intestinal mucosa using modern day tools including transcriptomics, proteomics, and metabolomics. In the present review, we have discussed comprehensively the pros and cons of available biomarkers and also summarized the current status of emerging biomarkers for the screening, diagnosis, and monitoring of celiac disease.
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Affiliation(s)
- Alka Singh
- Department of Gastroenterology and Human Nutrition; All India Institute of Medical Sciences, New Delhi-110029, India.
| | - Atreyi Pramanik
- Department of Biochemistry, All India Institute of Medical Sciences, New Delhi-110029, India.
| | - Pragyan Acharya
- Department of Biochemistry, All India Institute of Medical Sciences, New Delhi-110029, India.
| | - Govind K Makharia
- Department of Gastroenterology and Human Nutrition; All India Institute of Medical Sciences, New Delhi-110029, India.
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Abstract
Coeliac disease is an immune-mediated enteropathy against dietary gluten present in wheat, rye and barley and is one of the most common lifelong food-related disorders worldwide. Coeliac disease is also considered to be a systemic disorder characterized by a variable combination of gluten-related signs and symptoms and disease-specific antibodies in addition to enteropathy. The ingestion of gluten leads to the generation of harmful gluten peptides, which, in predisposed individuals, can induce adaptive and innate immune responses. The clinical presentation is extremely variable; patients may have severe gastrointestinal symptoms and malabsorption, extraintestinal symptoms or have no symptoms at all. Owing to the multifaceted clinical presentation, diagnosis remains a challenge and coeliac disease is heavily underdiagnosed. The diagnosis of coeliac disease is achieved by combining coeliac disease serology and small intestinal mucosal histology during a gluten-containing diet. Currently, the only effective treatment for coeliac disease is a lifelong strict gluten-free diet; however, the diet is restrictive and gluten is difficult to avoid. Optimizing diagnosis and care in coeliac disease requires continuous research and education of both patients and health-care professionals.
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