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Andres MP, Peloggia A, Abrao HM, Magalhaes TF, Neto JS, Abrão MS. Evaluation of HLA-DQ2 and HLA-DQ8 haplotypes in patients with endometriosis, A case-control study. Clinics (Sao Paulo) 2024; 79:100317. [PMID: 38432123 PMCID: PMC10914556 DOI: 10.1016/j.clinsp.2023.100317] [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: 04/27/2023] [Revised: 10/31/2023] [Accepted: 11/27/2023] [Indexed: 03/05/2024] Open
Abstract
OBJECTIVE To evaluate the relationship between genetic haplotypes associated with celiac disease (Human Leucocyte Antigen [HLA] DQ2 and DQ8) with the diagnosis, clinical presentation, and location of endometriosis in Brazilian women. METHOD A retrospective cross-sectional study, was conducted in a Tertiary hospital. PATIENTS Women aged 18-50 years who underwent HLA-DQ2 and HLA-DQ8 haplotype analysis. INTERVENTION The patients were divided into endometriosis and control groups and evaluated for symptoms; endometriosis location, American Society for Reproductive Medicine (ASRM) stage, and the presence of anti-tissue transglutaminase IgA (anti-TgA), HLA-DQ2, and HLA-DQ8 markers. RESULTS A total of 434 consecutive patients with (n = 315) and without (n = 119) endometriosis were included. Pain and infertility were more frequent in the endometriosis group than in the control group. The presence of HLA-DQ2, HLA-DQ8, and anti-TgA was similar between both groups. The presence of HLA-DQ2 and HLA-DQ8 markers did not differ based on age, pain symptoms, ASRM stage, or endometriosis location. CONCLUSION Although there are similarities in inflammatory markers and pathophysiology between celiac disease and endometriosis, this study found no significant associations in the presence of HLA-DQ2 or HLA-DQ8 haplotypes and endometriosis.
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Affiliation(s)
- Marina P. Andres
- Divisão de Clínica Ginecológica, Departamento de Obstetrícia e Ginecologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
- Divisão de Clínica Ginecológica, BP ‒ A Beneficência Portuguesa de São Paulo, São Paulo, SP, Brazil
| | - Alessandra Peloggia
- Centro de Pesquisa em Saúde Reprodutiva de Campinas (CEMICAMP), Campinas, SP, Brazil
| | - Henrique M. Abrao
- Divisão de Clínica Ginecológica, BP ‒ A Beneficência Portuguesa de São Paulo, São Paulo, SP, Brazil
| | - Thais F. Magalhaes
- Divisão de Clínica Ginecológica, Departamento de Obstetrícia e Ginecologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - João Siufi Neto
- Divisão de Clínica Ginecológica, BP ‒ A Beneficência Portuguesa de São Paulo, São Paulo, SP, Brazil
| | - Mauricio Simões Abrão
- Divisão de Clínica Ginecológica, Departamento de Obstetrícia e Ginecologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
- Divisão de Clínica Ginecológica, BP ‒ A Beneficência Portuguesa de São Paulo, São Paulo, SP, Brazil
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Stahl M, Koletzko S, Andrén Aronsson C, Lindfors K, Liu E, Agardh D. Coeliac disease: what can we learn from prospective studies about disease risk? THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:63-74. [PMID: 37972632 PMCID: PMC10965251 DOI: 10.1016/s2352-4642(23)00232-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/01/2023] [Accepted: 09/06/2023] [Indexed: 11/19/2023]
Abstract
Paediatric prospective studies of coeliac disease with longitudinal collection of biological samples and clinical data offer a unique perspective on disease risk. This Review highlights the information now available from international paediatric prospective studies on genetic and environmental risk factors for coeliac disease. In addition, recent omics studies have made it possible to study complex interactions between genetic and environmental factors and thereby further our insight into the causes of the disease. In the future, paediatric prospective studies will be able to provide more detailed risk prediction models combining genes, the environment, and biological corroboration from multiomics. Such studies could also contribute to biomarker development and an improved understanding of disease pathogenesis.
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Affiliation(s)
- Marisa Stahl
- Pediatric Gastroenterology, Hepatology, and Nutrition, Digestive Health Institute, Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Sibylle Koletzko
- Department of Pediatrics, Dr von Hauner Kinderspital, LMU University Hospital, LMU Munich, Munich, Germany; Department of Pediatrics, Gastroenterology and Nutrition, School of Medicine Collegium Medicum University of Warmia and Mazury, Olsztyn, Poland
| | - Carin Andrén Aronsson
- Unit of Celiac Disease and Diabetes, Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Katri Lindfors
- Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Edwin Liu
- Pediatric Gastroenterology, Hepatology, and Nutrition, Digestive Health Institute, Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Daniel Agardh
- Unit of Celiac Disease and Diabetes, Department of Clinical Sciences, Lund University, Malmö, Sweden
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3
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Martín-Masot R, Herrador-López M, Navas-López VM, Carmona FD, Nestares T, Bossini-Castillo L. Celiac Disease Is a Risk Factor for Mature T and NK Cell Lymphoma: A Mendelian Randomization Study. Int J Mol Sci 2023; 24:ijms24087216. [PMID: 37108375 PMCID: PMC10139431 DOI: 10.3390/ijms24087216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/04/2023] [Accepted: 04/08/2023] [Indexed: 04/29/2023] Open
Abstract
Celiac disease (CeD) is an immune-mediated disorder triggered by gluten ingestion that damages the small intestine. Although CeD has been associated with a higher risk for cancer, the role of CeD as a risk factor for specific malignancies, such as enteropathy-associated T-cell lymphoma (EATL), remains controversial. Using two-sample Mendelian randomization (2SMR) methods and the summarized results of large genome-wide association studies from public repositories, we addressed the causal relationship between CeD and eight different malignancies. Eleven non-HLA SNPs were selected as instrumental variables (IVs), and causality estimates were obtained using four 2SMR methods: random-effects inverse variance-weighted, weighted median estimation, MR-Egger regression, and MR pleiotropy residual sum and outlier (MR-PRESSO). We identified a significant causal relationship between CeD and mature T/NK cell lymphomas. Under a multivariate Mendelian randomization model, we observed that the causal effect of CeD was not dependent on other known lymphoma risk factors. We found that the most instrumental IV was located in the TAGAP locus, suggesting that aberrant T cell activation might be relevant in the T/NK cell malignization process. Our findings provide new insights into the connection between immune imbalance and the development of severe comorbidities, such as EATL, in patients with CeD.
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Affiliation(s)
- Rafael Martín-Masot
- Sección de Gastroenterología y Nutrición Infantil, Hospital Regional Universitario de Málaga, 29011 Málaga, Spain
- Instituto de Nutrición y Tecnología de los Alimentos "José Mataix Verdú" (INYTA), Centro de Investigación Biomédica (CIBM), Universidad de Granada, 18016 Granada, Spain
| | - Marta Herrador-López
- Sección de Gastroenterología y Nutrición Infantil, Hospital Regional Universitario de Málaga, 29011 Málaga, Spain
| | - Víctor Manuel Navas-López
- Sección de Gastroenterología y Nutrición Infantil, Hospital Regional Universitario de Málaga, 29011 Málaga, Spain
| | - Francisco David Carmona
- Departamento de Genética e Instituto de Biotecnología, Centro de Investigación Biomédica (CIBM), Universidad de Granada, 18016 Granada, Spain
- Reproducción Humana y Enfermedades Hereditarias y Complejas (IBS-TEC14), Terapias Avanzadas y Tecnologías Biomédicas, Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), 18012 Granada, Spain
| | - Teresa Nestares
- Instituto de Nutrición y Tecnología de los Alimentos "José Mataix Verdú" (INYTA), Centro de Investigación Biomédica (CIBM), Universidad de Granada, 18016 Granada, Spain
- Departamento de Fisiología, Facultad de Farmacia, Universidad de Granada, 18071 Granada, Spain
| | - Lara Bossini-Castillo
- Departamento de Genética e Instituto de Biotecnología, Centro de Investigación Biomédica (CIBM), Universidad de Granada, 18016 Granada, Spain
- Reproducción Humana y Enfermedades Hereditarias y Complejas (IBS-TEC14), Terapias Avanzadas y Tecnologías Biomédicas, Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), 18012 Granada, Spain
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4
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Auricchio R, Galatola M, Cielo D, Rotondo R, Carbone F, Mandile R, Carpinelli M, Vitale S, Matarese G, Gianfrani C, Troncone R, Auricchio S, Greco L. Antibody Profile, Gene Expression and Serum Cytokines in At-Risk Infants before the Onset of Celiac Disease. Int J Mol Sci 2023; 24:ijms24076836. [PMID: 37047806 PMCID: PMC10095049 DOI: 10.3390/ijms24076836] [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: 07/13/2022] [Revised: 03/23/2023] [Accepted: 03/30/2023] [Indexed: 04/14/2023] Open
Abstract
Immunological events that precede the development of villous atrophy in celiac disease (CeD) are still not completely understood. We aimed to explore CeD-associated antibody production (anti-native gliadin (AGA), anti-deamidated gliadin (DGP) and anti-tissue transglutaminase (anti-tTG)) in infants at genetic risk for CeD from the Italian cohorts of the PREVENT-CD and Neocel projects, as well as the relationship between antibody production and systemic inflammation. HLA DQ2 and/or DQ8 infants from families with a CeD case were followed from birth. Out of 220 at-risk children, 182 had not developed CeD by 6 years of age (CTRLs), and 38 developed celiac disease (CeD). The profiles of serum cytokines (INFγ, IL1β, IL2, IL4, IL6, IL10, IL12p70, IL17A and TNFα) and the expression of selected genes (FoxP3, IL10, TGFβ, INFγ, IL4 and IL2) were evaluated in 46 children (20 CeD and 26 CTRLs). Among the 182 healthy CTRLs, 28 (15.3%) produced high levels of AGA-IgA (AGA+CTRLs), and none developed anti-tTG-IgA or DGP-IgA, compared to 2/38 (5.3%) CeD infants (Chi Sq. 5.97, p = 0.0014). AGAs appeared earlier in CTRLs than in those who developed CeD (19 vs. 28 months). Additionally, the production of AGAs in CeD overlapped with the production of DGP and anti-tTG. In addition, gene expression as well as serum cytokine levels discriminated children who developed CeD from CTRLs. In conclusion, these findings suggest that the early and isolated production of AGA-IgA antibodies is a CeD-tolerogenic marker and that changes in gene expression and cytokine patterns precede the appearance of anti-tTG antibodies.
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Affiliation(s)
- Renata Auricchio
- Department of Translational Medical Science, University Federico II, 80131 Naples, Italy
- European Laboratory for Food Induced Diseases, University Federico II, 80131 Naples, Italy
| | - Martina Galatola
- Department of Translational Medical Science, University Federico II, 80131 Naples, Italy
| | - Donatella Cielo
- Department of Translational Medical Science, University Federico II, 80131 Naples, Italy
| | - Roberta Rotondo
- Department of Translational Medical Science, University Federico II, 80131 Naples, Italy
| | - Fortunata Carbone
- Laboratory of Immunology, Institute for Experimental Endocrinology and Oncology, National Research Council of Italy (IEOS-CNR), c/o Department of Molecular Medicine and Medical Biotechnology, University Federico II, 80131 Naples, Italy
- Neuroimmunology Unit, IRCCS Fondazione Santa Lucia, 00179 Rome, Italy
| | - Roberta Mandile
- Department of Translational Medical Science, University Federico II, 80131 Naples, Italy
- European Laboratory for Food Induced Diseases, University Federico II, 80131 Naples, Italy
| | - Martina Carpinelli
- Department of Translational Medical Science, University Federico II, 80131 Naples, Italy
- European Laboratory for Food Induced Diseases, University Federico II, 80131 Naples, Italy
| | - Serena Vitale
- Institute of Biochemistry and Cell Biology, National Research Council of Italy (IBBC-CNR), 80131 Naples, Italy
| | - Giuseppe Matarese
- Laboratory of Immunology, Institute for Experimental Endocrinology and Oncology, National Research Council of Italy (IEOS-CNR), c/o Department of Molecular Medicine and Medical Biotechnology, University Federico II, 80131 Naples, Italy
| | - Carmen Gianfrani
- European Laboratory for Food Induced Diseases, University Federico II, 80131 Naples, Italy
- Institute of Biochemistry and Cell Biology, National Research Council of Italy (IBBC-CNR), 80131 Naples, Italy
| | - Riccardo Troncone
- Department of Translational Medical Science, University Federico II, 80131 Naples, Italy
- European Laboratory for Food Induced Diseases, University Federico II, 80131 Naples, Italy
| | - Salvatore Auricchio
- European Laboratory for Food Induced Diseases, University Federico II, 80131 Naples, Italy
| | - Luigi Greco
- European Laboratory for Food Induced Diseases, University Federico II, 80131 Naples, Italy
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5
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Malignancies in Patients with Celiac Disease: Diagnostic Challenges and Molecular Advances. Genes (Basel) 2023; 14:genes14020376. [PMID: 36833303 PMCID: PMC9956047 DOI: 10.3390/genes14020376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/26/2023] [Accepted: 01/29/2023] [Indexed: 02/04/2023] Open
Abstract
Celiac disease (CD) is a multiorgan autoimmune disorder of the chronic intestinal disease group characterized by duodenal inflammation in genetically predisposed individuals, precipitated by gluten ingestion. The pathogenesis of celiac disease is now widely studied, overcoming the limits of the purely autoimmune concept and explaining its hereditability. The genomic profiling of this condition has led to the discovery of numerous genes involved in interleukin signaling and immune-related pathways. The spectrum of disease manifestations is not limited to the gastrointestinal tract, and a significant number of studies have considered the possible association between CD and neoplasms. Patients with CD are found to be at increased risk of developing malignancies, with a particular predisposition of certain types of intestinal cancer, lymphomas, and oropharyngeal cancers. This can be partially explained by common cancer hallmarks present in these patients. The study of gut microbiota, microRNAs, and DNA methylation is evolving to find the any possible missing links between CD and cancer incidence in these patients. However, the literature is extremely mixed and, therefore, our understanding of the biological interplay between CD and cancer remains limited, with significant implications in terms of clinical management and screening protocols. In this review article, we seek to provide a comprehensive overview of the genomics, epigenomics, and transcriptomics data on CD and its relation to the most frequent types of neoplasms that may occur in these patients.
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6
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Barone MV, Auricchio R, Nanayakkara M, Greco L, Troncone R, Auricchio S. Pivotal Role of Inflammation in Celiac Disease. Int J Mol Sci 2022; 23:ijms23137177. [PMID: 35806180 PMCID: PMC9266393 DOI: 10.3390/ijms23137177] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/20/2022] [Accepted: 06/22/2022] [Indexed: 01/27/2023] Open
Abstract
Celiac disease (CD) is an immune-mediated enteropathy triggered in genetically susceptible individuals by gluten-containing cereals. A central role in the pathogenesis of CD is played by the HLA-restricted gliadin-specific intestinal T cell response generated in a pro-inflammatory environment. The mechanisms that generate this pro-inflammatory environment in CD is now starting to be addressed. In vitro study on CD cells and organoids, shows that constant low-grade inflammation is present also in the absence of gluten. In vivo studies on a population at risk, show before the onset of the disease and before the introduction of gluten in the diet, cellular and metabolic alterations in the absence of a T cell-mediated response. Gluten exacerbates these constitutive alterations in vitro and in vivo. Inflammation, may have a main role in CD, adding this disease tout court to the big family of chronic inflammatory diseases. Nutrients can have pro-inflammatory or anti-inflammatory effects, also mediated by intestinal microbiota. The intestine function as a crossroad for the control of inflammation both locally and at distance. The aim of this review is to discuss the recent literature on the main role of inflammation in the natural history of CD, supported by cellular fragility with increased sensitivity to gluten and other pro-inflammatory agents.
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Affiliation(s)
- Maria Vittoria Barone
- Department of Translational Medical Science, University Federico II, Via S. Pansini 5, 80131 Naples, Italy; (R.A.); (M.N.); (L.G.); (R.T.)
- European Laboratory for the Investigation of Food Induced Disease (ELFID), University Federico II, Via S. Pansini 5, 80131 Naples, Italy;
- Correspondence:
| | - Renata Auricchio
- Department of Translational Medical Science, University Federico II, Via S. Pansini 5, 80131 Naples, Italy; (R.A.); (M.N.); (L.G.); (R.T.)
- European Laboratory for the Investigation of Food Induced Disease (ELFID), University Federico II, Via S. Pansini 5, 80131 Naples, Italy;
| | - Merlin Nanayakkara
- Department of Translational Medical Science, University Federico II, Via S. Pansini 5, 80131 Naples, Italy; (R.A.); (M.N.); (L.G.); (R.T.)
- European Laboratory for the Investigation of Food Induced Disease (ELFID), University Federico II, Via S. Pansini 5, 80131 Naples, Italy;
| | - Luigi Greco
- Department of Translational Medical Science, University Federico II, Via S. Pansini 5, 80131 Naples, Italy; (R.A.); (M.N.); (L.G.); (R.T.)
- European Laboratory for the Investigation of Food Induced Disease (ELFID), University Federico II, Via S. Pansini 5, 80131 Naples, Italy;
| | - Riccardo Troncone
- Department of Translational Medical Science, University Federico II, Via S. Pansini 5, 80131 Naples, Italy; (R.A.); (M.N.); (L.G.); (R.T.)
- European Laboratory for the Investigation of Food Induced Disease (ELFID), University Federico II, Via S. Pansini 5, 80131 Naples, Italy;
| | - Salvatore Auricchio
- European Laboratory for the Investigation of Food Induced Disease (ELFID), University Federico II, Via S. Pansini 5, 80131 Naples, Italy;
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7
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Ramírez-Sánchez AD, Chu X, Modderman R, Kooy-Winkelaar Y, Koletzko S, Korponay-Szabó IR, Troncone R, Wijmenga C, Mearin L, Withoff S, Jonkers IH, Li Y. Single-Cell RNA Sequencing of Peripheral Blood Mononuclear Cells From Pediatric Coeliac Disease Patients Suggests Potential Pre-Seroconversion Markers. Front Immunol 2022; 13:843086. [PMID: 35371081 PMCID: PMC8964997 DOI: 10.3389/fimmu.2022.843086] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 02/22/2022] [Indexed: 11/30/2022] Open
Abstract
Celiac Disease (CeD) is a complex immune disorder involving villous atrophy in the small intestine that is triggered by gluten intake. Current CeD diagnosis is based on late-stage pathophysiological parameters such as detection of specific antibodies in blood and histochemical detection of villus atrophy and lymphocyte infiltration in intestinal biopsies. To date, no early onset biomarkers are available that would help prevent widespread villous atrophy and severe symptoms and co-morbidities. To search for novel CeD biomarkers, we used single-cell RNA sequencing (scRNAseq) to investigate PBMC samples from 11 children before and after seroconversion for CeD and 10 control individuals matched for age, sex and HLA-genotype. We generated scRNAseq profiles of 9559 cells and identified the expected major cellular lineages. Cell proportions remained stable across the different timepoints and health conditions, but we observed differences in gene expression profiles in specific cell types when comparing patient samples before and after disease development and comparing patients with controls. Based on the time when transcripts were differentially expressed, we could classify the deregulated genes as biomarkers for active CeD or as potential pre-diagnostic markers. Pathway analysis showed that active CeD biomarkers display a transcriptional profile associated with antigen activation in CD4+ T cells, whereas NK cells express a subset of biomarker genes even before CeD diagnosis. Intersection of biomarker genes with CeD-associated genetic risk loci pinpointed genetic factors that might play a role in CeD onset. Investigation of potential cellular interaction pathways of PBMC cell subpopulations highlighted the importance of TNF pathways in CeD. Altogether, our results pinpoint genes and pathways that are altered prior to and during CeD onset, thereby identifying novel potential biomarkers for CeD diagnosis in blood.
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Affiliation(s)
- Aarón D Ramírez-Sánchez
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Xiaojing Chu
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.,Department of Computational Biology for Individualised Medicine, Centre for Individualised Infection Medicine (CiiM) & TWINCORE, Joint Ventures Between the Helmholtz-Centre for Infection Research (HZI) and the Hannover Medical School (MHH), Hannover, Germany
| | - Rutger Modderman
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Yvonne Kooy-Winkelaar
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, Netherlands
| | - Sibylle Koletzko
- Department of Pediatrics, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-Universität München (LMU) Klinikum Munich, Munich, Germany.,Department of Pediatric Gastroenterology and Nutrition, School of Medicine Collegium Medicum University of Warmia and Mazury, Olsztyn, Poland
| | - Ilma R Korponay-Szabó
- Coeliac Disease Center, Heim Pál National Paediatric Institute, Budapest, Hungary.,Department of Paediatrics, Faculty of Medicine and Clinical Center, University of Debrecen, Debrecen, Hungary
| | - Riccardo Troncone
- Department of Medical Translational Sciences and European Laboratory for the Investigation of Food Induced Diseases, University Federico II, Naples, Italy
| | - Cisca Wijmenga
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Luisa Mearin
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, Netherlands
| | - Sebo Withoff
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Iris H Jonkers
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Yang Li
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.,Department of Computational Biology for Individualised Medicine, Centre for Individualised Infection Medicine (CiiM) & TWINCORE, Joint Ventures Between the Helmholtz-Centre for Infection Research (HZI) and the Hannover Medical School (MHH), Hannover, Germany.,Department of Internal Medicine and Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
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8
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Auricchio R, Calabrese I, Galatola M, Cielo D, Carbone F, Mancuso M, Matarese G, Troncone R, Auricchio S, Greco L. Gluten consumption and inflammation affect the development of celiac disease in at-risk children. Sci Rep 2022; 12:5396. [PMID: 35354862 PMCID: PMC8968719 DOI: 10.1038/s41598-022-09232-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 03/11/2022] [Indexed: 12/20/2022] Open
Abstract
Gene expression, lipidomic and growth impairment findings suggest that the natural history of celiac disease (CD) starts before the gluten-induced immune response. Gluten intake in the first years of life is a controversial risk factor. We aimed to estimate the risk of developing CD associated with the amount of gluten intake and the serum inflammatory profile in genetically predisposed infants. From an Italian cohort of children at risk for CD, we enrolled 27 children who developed CD (cases) and 56 controls matched by sex and age. A dietary interview at 9, 12, 18, 24 and 36 months was performed. Serum cytokines (INFγ, IL1β, IL2, IL4, IL6, IL10 IL12p70, IL17, and TNFα) were analysed at 4 and 36 months. Infants who developed CD by 6 years showed an increase in serum cytokines (INFγ, IL1β, IL2, IL6, IL10, IL12p70 and TNFα) at 4 months of age before gluten introduction. CD cases ate significantly more gluten in the second year of life than controls, and gluten intake in the second year of life was strongly correlated with serum cytokines (INFγ, IL2, IL4, IL12p70, IL17) at 36 months only in CD cases. The dietary pattern of infants who developed CD was characterized by high consumption of biscuits and fruit juices and low intake of milk products, legumes, vegetables and fruits. Genetically predisposed infants who developed CD showed a unique serum cytokine profile at 4 months before gluten consumption. The amount of gluten was strongly correlated with an inflammatory profile in serum cytokines at 36 months only in infants who developed CD.
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Affiliation(s)
- Renata Auricchio
- Department of Translational Medical Science, University Federico II, Via S. Pansini 5, 80131, Naples, Italy. .,European Laboratory for Food Induced Diseases, University Federico II, Via S. Pansini 5, 80131, Naples, Italy.
| | - Ilaria Calabrese
- Department of Clinical Medicine and Surgery, University Federico II, Naples, Italy
| | - Martina Galatola
- Department of Translational Medical Science, University Federico II, Via S. Pansini 5, 80131, Naples, Italy
| | - Donatella Cielo
- Department of Translational Medical Science, University Federico II, Via S. Pansini 5, 80131, Naples, Italy
| | - Fortunata Carbone
- Laboratory of Immunology, Institute for Experimental Endocrinology and Oncology, National Research Council (IEOS-CNR), Naples, Italy.,Neuroimmunology Unit, IRCCS Fondazione Santa Lucia, Rome, Italy
| | - Marianna Mancuso
- Department of Translational Medical Science, University Federico II, Via S. Pansini 5, 80131, Naples, Italy
| | - Giuseppe Matarese
- Laboratory of Immunology, Institute for Experimental Endocrinology and Oncology, National Research Council (IEOS-CNR), Naples, Italy.,Department of Molecular Medicine and Medical Biotechnology, University Federico II, Naples, Italy
| | - Riccardo Troncone
- Department of Translational Medical Science, University Federico II, Via S. Pansini 5, 80131, Naples, Italy.,European Laboratory for Food Induced Diseases, University Federico II, Via S. Pansini 5, 80131, Naples, Italy
| | - Salvatore Auricchio
- European Laboratory for Food Induced Diseases, University Federico II, Via S. Pansini 5, 80131, Naples, Italy
| | - Luigi Greco
- European Laboratory for Food Induced Diseases, University Federico II, Via S. Pansini 5, 80131, Naples, Italy
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9
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Tan IL, Coutinho de Almeida R, Modderman R, Stachurska A, Dekens J, Barisani D, Meijer CR, Roca M, Martinez-Ojinaga E, Shamir R, Auricchio R, Korponay-Szabó IR, Castillejo G, Szajewska H, Koletzko S, Zhernakova A, Kumar V, Li Y, Visschedijk MC, Weersma RK, Troncone R, Mearin ML, Wijmenga C, Jonkers I, Withoff S. Circulating miRNAs as Potential Biomarkers for Celiac Disease Development. Front Immunol 2021; 12:734763. [PMID: 34950132 PMCID: PMC8688806 DOI: 10.3389/fimmu.2021.734763] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 11/05/2021] [Indexed: 12/11/2022] Open
Abstract
Background & Aims Celiac disease (CeD), an immune-mediated disease with enteropathy triggered by gluten, affects ~1% of the general European population. Currently, there are no biomarkers to predict CeD development. MicroRNAs (miRNAs) are short RNAs involved in post-transcriptional gene regulation, and certain disease- and stage-specific miRNA profiles have been found previously. We aimed to investigate whether circulating miRNAs can predict the development of CeD. Methods Using next-generation miRNA-sequencing, we determined miRNAs in >200 serum samples from 53 participants of the PreventCD study, of whom 33 developed CeD during follow-up. Following study inclusion at 3 months of age, samples were drawn at predefined ages, diagnosis (first anti-transglutaminase antibody (TGA) positivity or diagnostic biopsy) and after the start of a gluten-free diet (GFD). This allowed identification of circulating miRNAs that are deregulated before TGA positivity. For validation of the biomarkers for CeD and GFD response, two additional cohorts were included in subsequent meta-analyses. Additionally, miRNAs were measured in duodenal biopsies in a case-control cohort. Results 53 circulating miRNAs were increased (27) or decreased (26) in CeD versus controls. We assessed specific trends in these individual miRNAs in the PreventCD cohort by grouping the pre-diagnostic samples of the CeD patients (all had negative TGA) by how close to seroconversion (first sample positive TGA) the samples were taken. 8/53 miRNAs differed significantly between controls and samples taken <1 year before TGA positivity: miR-21-3p, miR-374a-5p, 144-3p, miR-500a-3p, miR-486-3p let-7d-3p, let-7e-5p and miR-3605-3p. 6/26 downregulated miRNAs reconstituted upon GFD, including miR-150-5p/-3p, whereas no upregulated miRNAs were downregulated upon GFD. 15/53 biomarker candidates also differed between CeD biopsies and controls, with a concordant direction, indicating that these circulating miRNAs might originate from the intestine. Conclusions We identified 53 circulating miRNAs that are potential early biomarkers for CeD, of which several can be detected more than a year before TGA positivity and some start to normalize upon GFD.
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Affiliation(s)
- Ineke L Tan
- Department of Genetics, University of Groningen and University Medical Center Groningen, Groningen, Netherlands.,Department of Gastroenterology and Hepatology, University of Groningen and University Medical Center Groningen, Groningen, Netherlands
| | - Rodrigo Coutinho de Almeida
- Department of Biomedical Data Sciences, Section Molecular Epidemiology, Leiden University Medical Center, Leiden, Netherlands
| | - Rutger Modderman
- Department of Genetics, University of Groningen and University Medical Center Groningen, Groningen, Netherlands
| | - Anna Stachurska
- Department of Genetics, University of Groningen and University Medical Center Groningen, Groningen, Netherlands
| | - Jackie Dekens
- Department of Genetics, University of Groningen and University Medical Center Groningen, Groningen, Netherlands.,Center of Development and Innovation, University of Groningen and University Medical Center Groningen, Groningen, Netherlands
| | - Donatella Barisani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Caroline R Meijer
- Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - María Roca
- Celiac Disease and Digestive Immunopathology Unit, Instituto de Investigación Sanitaria La Fe, La Fe University Hospital, Valencia, Spain
| | - Eva Martinez-Ojinaga
- Celiac Disease and Digestive Immunopathology Unit, Instituto de Investigación Sanitaria La Fe, La Fe University Hospital, Madrid, Spain
| | - Raanan Shamir
- Institute of Pediatric Gastroenterology, Nutrition, and Liver Diseases, Schneider Children's Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Renata Auricchio
- Department of Medical Translational Sciences and European Laboratory for the Investigation of Food Induced Diseases, University Federico II, Naples, Italy
| | - Ilma R Korponay-Szabó
- Coeliac Disease Center, Heim Pál National Paediatric Institute, Budapest, Hungary and Dept. of Paediatrics, Faculty of Medicine and Clinical Center, University of Debrecen, Debrecen, Hungary
| | - Gemma Castillejo
- Unitat de gastroenterologia pediàtrica, Hospital Universitari Sant Joan de Reus, Universitat Rovira i virgili, Institut d'Investigació Sanitària Pere Virgili (IISPV), Reus, Spain
| | - Hania Szajewska
- Department of Paediatrics, The Medical University of Warsaw, Warsaw, Poland
| | - Sibylle Koletzko
- Department of Pediatrics, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-Universität München (LMU) Klinikum Munich, Munich, Germany.,Department of Pediatric Gastroenterology and Nutrition, School of Medicine Collegium Medicum University of Warmia and Mazury, Olsztyn, Poland
| | - Alexandra Zhernakova
- Department of Genetics, University of Groningen and University Medical Center Groningen, Groningen, Netherlands
| | - Vinod Kumar
- Department of Genetics, University of Groningen and University Medical Center Groningen, Groningen, Netherlands.,Department of Internal Medicine and Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, Netherlands
| | - Yang Li
- Department of Genetics, University of Groningen and University Medical Center Groningen, Groningen, Netherlands.,Department of Computational Biology for Individualised Infection Medicine, Centre for Individualised Infection Medicine (CiiM) & TWINCORE, Joint Ventures Between the Helmholtz-Centre for Infection Research (HZI) and the Hannover Medical School (MHH), Hannover, Germany.,Department of Internal Medicine and Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Marijn C Visschedijk
- Department of Gastroenterology and Hepatology, University of Groningen and University Medical Center Groningen, Groningen, Netherlands
| | - Rinse K Weersma
- Department of Gastroenterology and Hepatology, University of Groningen and University Medical Center Groningen, Groningen, Netherlands
| | - Riccardo Troncone
- Department of Medical Translational Sciences and European Laboratory for the Investigation of Food Induced Diseases, University Federico II, Naples, Italy
| | - M Luisa Mearin
- Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Cisca Wijmenga
- Department of Genetics, University of Groningen and University Medical Center Groningen, Groningen, Netherlands
| | - Iris Jonkers
- Department of Genetics, University of Groningen and University Medical Center Groningen, Groningen, Netherlands
| | - Sebo Withoff
- Department of Genetics, University of Groningen and University Medical Center Groningen, Groningen, Netherlands
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10
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He W, Zhao J, Liu X, Li S, Mu K, Zhang J, Zhang JA. Associations between CD160 polymorphisms and autoimmune thyroid disease: a case-control study. BMC Endocr Disord 2021; 21:148. [PMID: 34238277 PMCID: PMC8268507 DOI: 10.1186/s12902-021-00810-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 06/28/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Recent researches suggest that the CD160/HVEM/LIGHT/BTLA signaling pathway may contribute to the pathogeneses of autoimmune diseases, but the relationship between CD160 polymorphisms and autoimmune thyroid disease (AITD) has not been reported yet. This study aimed to evaluate the associations between CD160 polymorphisms and AITD. METHODS A total of 1017 patients with AITD (634 Graves' disease and 383 Hashimoto's thyroiditis) and 856 unrelated healthy controls were recruited into our study. Odds ratios (ORs) with 95% confidence interval (95%CI) were calculated through logistic regression analyses. The CD160 SNPs were detected using Hi-SNP high-throughput genotyping. RESULTS There was a statistically significant difference between Graves' disease patients and the control group with respect to both the genotype distribution (P = 0.014) and allele frequency of rs744877 (P = 0.034). A significant association of CD160 rs744877 with AITD was observed before adjusted age and gender under a dominant model (OR = 0.79, 95%CI 0.66-0.95; P = 0.013) and an additive model (OR = 0.77, 95%CI 0.64-0.94, P = 0.008), and was also observed after adjusted age and gender under a dominant model (OR = 0.78, 95%CI 0.65-0.95; P = 0.011) and an additive model (OR = 0.76, 95%CI 0.63-0.93, P = 0.007). A significant association of rs744877 with Graves' disease was observed under an allele model (OR = 0.84, 95%CI 0.71-0.98, P = 0.027), a dominant model (OR = 0.74, 95%CI 0.60-0.91; P = 0.005), and an additive model (OR = 0.72, 95%CI 0.58-0.90, P = 0.004). Multivariate logistic regression analyses suggested that the association remained significant after adjustment for age and gender. However, rs744877 was not related to Hashimoto's thyroiditis. Furthermore, CD160 rs3766526 was not significantly related to either Graves' disease or Hashimoto's thyroiditis. CONCLUSION This is the first identification of the association of CD160 rs744877 with Graves' disease. Our findings add new data to the genetic contribution to Graves' disease susceptibility and support the crucial role of the CD160/HVEM/LIGHT/BTLA pathway in the pathogenesis of Graves' disease.
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Affiliation(s)
- Weiwei He
- Department of Endocrinology and Rheumatology, Shanghai University of Medicine & Health Sciences Affiliated Zhoupu Hospital, Shanghai, 201508, China
| | - Jing Zhao
- Department of Endocrinology and Rheumatology, Shanghai University of Medicine & Health Sciences Affiliated Zhoupu Hospital, Shanghai, 201508, China
- Department of Endocrinology, Nanjing Medical University Affiliated Wuxi People's Hospital, Wuxi, 214000, China
| | - Xuerong Liu
- Department of Endocrinology, Affiliated Hospital of Yanan University, Yan'an, Shanxi, China
| | - Sheli Li
- Department of Endocrinology, Affiliated Hospital of Yanan University, Yan'an, Shanxi, China
| | - Kaida Mu
- Department of Endocrinology and Rheumatology, Shanghai University of Medicine & Health Sciences Affiliated Zhoupu Hospital, Shanghai, 201508, China
| | - Jing Zhang
- Department of Endocrinology and Rheumatology, Shanghai University of Medicine & Health Sciences Affiliated Zhoupu Hospital, Shanghai, 201508, China
| | - Jin-An Zhang
- Department of Endocrinology and Rheumatology, Shanghai University of Medicine & Health Sciences Affiliated Zhoupu Hospital, Shanghai, 201508, China.
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11
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Auricchio R, Troncone R. Can Celiac Disease Be Prevented? Front Immunol 2021; 12:672148. [PMID: 34054850 PMCID: PMC8160282 DOI: 10.3389/fimmu.2021.672148] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 04/20/2021] [Indexed: 12/20/2022] Open
Abstract
Celiac disease (CD) is an autoimmune disorder triggered by gluten in genetically susceptible individuals characterized by a variable combination of gluten-dependent symptoms, presence of specific autoantibodies and enteropathy. The health burden of CD is considerable, as it reduces quality of life and, at a societal level, has extensive negative economic consequences. Prevention strategies are based on the identification of at-risk subjects and identification and elimination of risk factors. A number of prospective observational and interventional studies conducted on the general population, and more often in subjects at-risk, have given important information on the natural history of the disease. Both genetic and environmental factors have been identified with the former, in particular histocompatibility genes, playing a major role. Environmental factors, some operating already before birth, have been identified, with feeding pattern in the first year of life (breast feeding, amount and time of introduction of gluten) and infections being the most relevant. Prospective studies have also allowed the identification of biomarkers predictive of the disease which in perspective could better define the population on which to intervene. Interventions have been so far limited to modifications of feeding patterns. However, as also learnt from diseases that share with CD genetic risk factors and mechanisms of damage, such as type 1 diabetes (T1D), future strategies may be envisaged based on protection from infections, manipulation of microbiota, intervention on T cells.
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Affiliation(s)
- Renata Auricchio
- Department of Medical Translational Sciences & European Laboratory for the Investigation of Food-Induced Diseases, University Federico II, Naples, Italy
| | - Riccardo Troncone
- Department of Medical Translational Sciences & European Laboratory for the Investigation of Food-Induced Diseases, University Federico II, Naples, Italy
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12
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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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13
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Auricchio R, Stellato P, Bruzzese D, Cielo D, Chiurazzi A, Galatola M, Castilljeo G, Crespo Escobar P, Gyimesi J, Hartman C, Kolacek S, Koletzko S, Korponay-Szabo I, Mearin ML, Meijer C, Pieścik-Lech M, Polanco I, Ribes-Koninckx C, Shamir R, Szajewska H, Troncone R, Greco L. Growth rate of coeliac children is compromised before the onset of the disease. Arch Dis Child 2020; 105:964-968. [PMID: 32354718 DOI: 10.1136/archdischild-2019-317976] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 04/03/2020] [Accepted: 04/08/2020] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Growth impairment has often been described in children who develop coeliac disease (CD). Based on data from the multicentre, longitudinal PreventCD study, we analysed the growth patterns of infants at genetic risk of CD, comparing those who developed CD by 6 years of age (CD 'cases', 113 infants) versus those who did not develop CD by 6 years (no CD 'controls', 831 infants). METHODS Weight and length/height were measured using a longitudinal protocol. Raw measurements were standardised, computing z-scores for length/height and weight; a linear mixed model was fitted to the data in order to compare the rate of growth in the two cohorts. RESULTS Neither cases nor controls had significant growth failure. However, when the mean z-scores for weight and height were analysed, there was a difference between the two groups starting at fourth month of life. When the growth pattern in the first year was analysed longitudinally using mixed models, it emerged that children who develop CD had a significantly lower growth rate in weight z-score (-0.028/month; 95% CI -0.038 to -0.017; p<0.001) and in length/height z-score (-0.018/month; 95% CI -0.031 to -0.005; p=0.008) than those who do not develop CD. When the whole follow-up period was analysed (0-6 years), differences between groups in both weight and length/height z-scores were confirmed. CONCLUSION The growth of children at risk of CD rarely fell below 'clinical standards'. However, growth rate was significantly lower in cases than in controls. Our data suggest that peculiar pathways of growth are present in children who develop CD, long before any clinical or serological signs of the disease appear.
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Affiliation(s)
- Renata Auricchio
- Department of Translational Medical Science, University of Naples Federico II, Napoli, Italy
| | - Pio Stellato
- Department of Translational Medical Science, University of Naples Federico II, Napoli, Italy
| | - Dario Bruzzese
- Department of Public Health, Federico II University, Naples, Italy
| | - Donatella Cielo
- Department of Translational Medical Science, University of Naples Federico II, Napoli, Italy
| | - Alfredo Chiurazzi
- Department of Translational Medical Science, University of Naples Federico II, Napoli, Italy
| | - Martina Galatola
- Department of Translational Medical Science, University of Naples Federico II, Napoli, Italy
| | | | - Paula Crespo Escobar
- Department of Health Science, European University Miguel de Cervantes, Valladolid, Spain
| | | | - Corina Hartman
- Institute for Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Center, Tel Aviv, Israel
| | - Sanja Kolacek
- Referral Center for Pediatric Gastroenterology and Nutrition, Zagreb University, Medical School, Zagreb, Croatia
| | - Sybille Koletzko
- Department of Pediatric Gastroenterology and Hepatology, Ludwig Maximilian's University Munich Medical Center, Munich, Germany
| | | | | | - Caroline Meijer
- Department of Pediatrics, Medical University of Warsaw, Warsaw, Poland
| | | | - Isabel Polanco
- Department of Pediatric Gastroenterology and Nutrition, La Paz University Hospital, Madrid, Spain
| | | | - Raanan Shamir
- Institute of Gastroenterology, Nutrition, and Liver Diseases, Schneider Children's Medical Center of Israel, Petach Tikvah, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hania Szajewska
- Department of Paediatrics, The Medical University of Warsaw, Warsaw, Poland
| | - Riccardo Troncone
- Department of Translational Medical Science, University of Naples Federico II, Napoli, Italy
| | - Luigi Greco
- Department of Translational Medical Science, University of Naples Federico II, Napoli, Italy
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14
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Perez-Diaz-del-Campo N, Abete I, Cantero I, Marin-Alejandre BA, Monreal JI, Elorz M, Herrero JI, Benito-Boillos A, Riezu-Boj JI, Milagro FI, Tur JA, Martinez JA, Zulet MA. Association of the SH2B1 rs7359397 Gene Polymorphism with Steatosis Severity in Subjects with Obesity and Non-Alcoholic Fatty Liver Disease. Nutrients 2020; 12:nu12051260. [PMID: 32365683 PMCID: PMC7282006 DOI: 10.3390/nu12051260] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 04/24/2020] [Accepted: 04/27/2020] [Indexed: 12/12/2022] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is a major cause of liver disease worldwide. Some genetic variants might be involved in the progression of this disease. The study hypothesized that individuals with the rs7359397 T allele have a higher risk of developing severe stages of NAFLD compared with non-carriers where dietary intake according to genotypes could have a key role on the pathogenesis of the disease. SH2B1 genetic variant was genotyped in 110 overweight/obese subjects with NAFLD. Imaging techniques, lipidomic analysis and blood liver biomarkers were performed. Body composition, general biochemical and dietary variables were also determined. The SH2B1 risk genotype was associated with higher HOMA-IR p = 0.001; and Fatty Liver Index (FLI) p = 0.032. Higher protein consumption (p = 0.028), less mono-unsaturated fatty acid and fiber intake (p = 0.045 and p = 0.049, respectively), was also referred to in risk allele genotype. Lipidomic analysis showed that T allele carriers presented a higher frequency of non-alcoholic steatohepatitis (NASH) (69.1% vs. 44.4%; p = 0.006). In the genotype risk group, adjusted logistic regression models indicated a higher risk of developing an advanced stage of NAFLD measured by FLI (OR 2.91) and ultrasonography (OR 4.15). Multinomial logistic regression models showed that risk allele carriers had higher liver fat accumulation risk (RRR 3.93) and an increased risk of NASH (RRR 7.88). Consequently, subjects carrying the T allele were associated with a higher risk of developing a severe stage of NAFLD. These results support the importance of considering genetic predisposition in combination with a healthy dietary pattern in the personalized evaluation and management of NAFLD.
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Affiliation(s)
- Nuria Perez-Diaz-del-Campo
- Department of Nutrition, Food Science and Physiology, Faculty of Pharmacy and Nutrition, University of Navarra, 31008 Pamplona, Spain; (N.P-D.-d.-C.); (I.C.); (B.A.M.-A.); (J.I.R.-B.); (F.I.M.); (J.A.M.)
- Centre for Nutrition Research, Faculty of Pharmacy and Nutrition, University of Navarra, 31008 Pamplona, Spain
| | - Itziar Abete
- Department of Nutrition, Food Science and Physiology, Faculty of Pharmacy and Nutrition, University of Navarra, 31008 Pamplona, Spain; (N.P-D.-d.-C.); (I.C.); (B.A.M.-A.); (J.I.R.-B.); (F.I.M.); (J.A.M.)
- Centre for Nutrition Research, Faculty of Pharmacy and Nutrition, University of Navarra, 31008 Pamplona, Spain
- Biomedical Research Centre Network in Physiopathology of Obesity and Nutrition (CIBERobn), Instituto de Salud Carlos III, 28029 Madrid, Spain;
- Navarra Institute for Health Research (IdiSNA), 31008 Pamplona, Spain; (J.I.M.); (M.E.); (J.I.H.); (A.B.-B.)
- Correspondence: (I.A.); (M.A.Z.); Tel.: +34-948-25-60-00 (I.A.)
| | - Irene Cantero
- Department of Nutrition, Food Science and Physiology, Faculty of Pharmacy and Nutrition, University of Navarra, 31008 Pamplona, Spain; (N.P-D.-d.-C.); (I.C.); (B.A.M.-A.); (J.I.R.-B.); (F.I.M.); (J.A.M.)
- Centre for Nutrition Research, Faculty of Pharmacy and Nutrition, University of Navarra, 31008 Pamplona, Spain
| | - Bertha Araceli Marin-Alejandre
- Department of Nutrition, Food Science and Physiology, Faculty of Pharmacy and Nutrition, University of Navarra, 31008 Pamplona, Spain; (N.P-D.-d.-C.); (I.C.); (B.A.M.-A.); (J.I.R.-B.); (F.I.M.); (J.A.M.)
- Centre for Nutrition Research, Faculty of Pharmacy and Nutrition, University of Navarra, 31008 Pamplona, Spain
| | - J. Ignacio Monreal
- Navarra Institute for Health Research (IdiSNA), 31008 Pamplona, Spain; (J.I.M.); (M.E.); (J.I.H.); (A.B.-B.)
- Clinical Chemistry Department, Clínica Universidad de Navarra, 31008 Pamplona, Spain
| | - Mariana Elorz
- Navarra Institute for Health Research (IdiSNA), 31008 Pamplona, Spain; (J.I.M.); (M.E.); (J.I.H.); (A.B.-B.)
- Department of Radiology, Clínica Universidad de Navarra, 31008 Pamplona, Spain
| | - José Ignacio Herrero
- Navarra Institute for Health Research (IdiSNA), 31008 Pamplona, Spain; (J.I.M.); (M.E.); (J.I.H.); (A.B.-B.)
- Liver Unit, Clinica Universidad de Navarra, 31008 Pamplona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
| | - Alberto Benito-Boillos
- Navarra Institute for Health Research (IdiSNA), 31008 Pamplona, Spain; (J.I.M.); (M.E.); (J.I.H.); (A.B.-B.)
- Department of Radiology, Clínica Universidad de Navarra, 31008 Pamplona, Spain
| | - Jose I. Riezu-Boj
- Department of Nutrition, Food Science and Physiology, Faculty of Pharmacy and Nutrition, University of Navarra, 31008 Pamplona, Spain; (N.P-D.-d.-C.); (I.C.); (B.A.M.-A.); (J.I.R.-B.); (F.I.M.); (J.A.M.)
- Centre for Nutrition Research, Faculty of Pharmacy and Nutrition, University of Navarra, 31008 Pamplona, Spain
- Navarra Institute for Health Research (IdiSNA), 31008 Pamplona, Spain; (J.I.M.); (M.E.); (J.I.H.); (A.B.-B.)
| | - Fermín I. Milagro
- Department of Nutrition, Food Science and Physiology, Faculty of Pharmacy and Nutrition, University of Navarra, 31008 Pamplona, Spain; (N.P-D.-d.-C.); (I.C.); (B.A.M.-A.); (J.I.R.-B.); (F.I.M.); (J.A.M.)
- Centre for Nutrition Research, Faculty of Pharmacy and Nutrition, University of Navarra, 31008 Pamplona, Spain
- Biomedical Research Centre Network in Physiopathology of Obesity and Nutrition (CIBERobn), Instituto de Salud Carlos III, 28029 Madrid, Spain;
- Navarra Institute for Health Research (IdiSNA), 31008 Pamplona, Spain; (J.I.M.); (M.E.); (J.I.H.); (A.B.-B.)
| | - Josep A. Tur
- Biomedical Research Centre Network in Physiopathology of Obesity and Nutrition (CIBERobn), Instituto de Salud Carlos III, 28029 Madrid, Spain;
- Research Group on Community Nutrition and Oxidative Stress, University of Balearic Islands & Balearic Islands Institute for Health Research (IDISBA), 07122 Palma, Spain
| | - J. Alfredo Martinez
- Department of Nutrition, Food Science and Physiology, Faculty of Pharmacy and Nutrition, University of Navarra, 31008 Pamplona, Spain; (N.P-D.-d.-C.); (I.C.); (B.A.M.-A.); (J.I.R.-B.); (F.I.M.); (J.A.M.)
- Centre for Nutrition Research, Faculty of Pharmacy and Nutrition, University of Navarra, 31008 Pamplona, Spain
- Biomedical Research Centre Network in Physiopathology of Obesity and Nutrition (CIBERobn), Instituto de Salud Carlos III, 28029 Madrid, Spain;
- Navarra Institute for Health Research (IdiSNA), 31008 Pamplona, Spain; (J.I.M.); (M.E.); (J.I.H.); (A.B.-B.)
| | - M. Angeles Zulet
- Department of Nutrition, Food Science and Physiology, Faculty of Pharmacy and Nutrition, University of Navarra, 31008 Pamplona, Spain; (N.P-D.-d.-C.); (I.C.); (B.A.M.-A.); (J.I.R.-B.); (F.I.M.); (J.A.M.)
- Centre for Nutrition Research, Faculty of Pharmacy and Nutrition, University of Navarra, 31008 Pamplona, Spain
- Biomedical Research Centre Network in Physiopathology of Obesity and Nutrition (CIBERobn), Instituto de Salud Carlos III, 28029 Madrid, Spain;
- Navarra Institute for Health Research (IdiSNA), 31008 Pamplona, Spain; (J.I.M.); (M.E.); (J.I.H.); (A.B.-B.)
- Correspondence: (I.A.); (M.A.Z.); Tel.: +34-948-25-60-00 (I.A.)
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15
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Auricchio R, Galatola M, Cielo D, Amoresano A, Caterino M, De Vita E, Illiano A, Troncone R, Greco L, Ruoppolo M. A Phospholipid Profile at 4 Months Predicts the Onset of Celiac Disease in at-Risk Infants. Sci Rep 2019; 9:14303. [PMID: 31586100 PMCID: PMC6778072 DOI: 10.1038/s41598-019-50735-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 09/12/2019] [Indexed: 02/06/2023] Open
Abstract
Celiac disease (CeD) is a multifactorial disease influenced by both genetic and environmental risk factors. CeD genetic components are mainly due to HLA class II genes, which account for approximately 40% of the disease heritability. The environmental factor is linked to gliadin ingestion. Despite genetic and epigenetic studies, the pathological molecular mechanism remains unclarified. The strong genetic component does not explain more than half of the hereditability; we identified several epigenetic features that contribute to the understanding of the missing hereditability. The lipid profile of infants has been proposed as a potential biomarker of CeD metabolism that can be measured before they exhibit developmental disorders and clinical symptoms. We suggest that the state of the host is a main factor for the abnormal immune response to gluten. Long before any exposure to the offending agent or any production of specific antibodies, several molecular mechanisms are differentially expressed in infants who will develop CeD compared to their peers matched for the same genetic profile. The present study explored the serum phospholipid profile of a group of infants at risk for celiac disease, followed up to 8 years to monitor the onset of CeD. We compared 30 patients who developed the disease with 20 age- and sex-matched peers with similar genetic profiles who did not develop the disease within 8 years. Serum phospholipids were analysed at 4 months, before exposure to gluten, and at 12 months of age, when none showed any marker of disease. In the 30 CeD patients, we also analysed the serum at the time of diagnosis (>24 months). The serum phospholipid profile was fairly constant across 4 and 12 months of age and, in CeD, up to 24–36 months. The phospholipid signature was dramatically different in infants who developed CeD when compared to that of control NY-CeD (Not Yet developing Celiac Disease) peers. We identified a specific serum phospholipid signature that predicts the onset of celiac disease in HLA at-risk infants years before the appearance of antibodies specific for CeD in the serum and before any clinical symptoms, even before gluten introduction into the diet at 4 months. Specifically, lysophosphatidylcholine, phosphatidylcholine, alkylacyl-phosphatidylcholine, phosphoethanolamines, phosphatidylserines, phosphatidylglycerol and phosphatidylinositol were found to be differentially represented in CeD versus NY-CeD. A set constituted by a limited number of alkylacyl-phosphatidylcholine and lyso-phosphatidylcholine, together with the duration of breast-feeding, allows the discrimination of infants who develop celiac disease before 8 years of age from those at a similar genetic risk who do not develop the disease. In addition to recent discovery, our paper unveiled a specifc phopholipid profile, able to discriminate infants who eventually develop celiac disease years before antibodies or clinical symptoms ensue.
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Affiliation(s)
- R Auricchio
- Department of Translational Medical Sciences, University of Naples "Federico II", Napoli, Italy.,European Laboratory for the Investigation of Food Induced Diseases (ELFID), University of Naples "Federico II", Napoli, Italy
| | - M Galatola
- Department of Translational Medical Sciences, University of Naples "Federico II", Napoli, Italy.,European Laboratory for the Investigation of Food Induced Diseases (ELFID), University of Naples "Federico II", Napoli, Italy
| | - D Cielo
- Department of Translational Medical Sciences, University of Naples "Federico II", Napoli, Italy.,European Laboratory for the Investigation of Food Induced Diseases (ELFID), University of Naples "Federico II", Napoli, Italy
| | - A Amoresano
- Department of Chemical Sciences, University of Naples "Federico II", Napoli, Italy
| | - M Caterino
- Department of Molecular Medicine and Medical Biotechnology, University of Naples "Federico II", Napoli, Italy.,CEINGE, Biotecnonologie Avanzate s.c.ar.l., Napoli, Italy
| | - E De Vita
- Department of Chemical Sciences, University of Naples "Federico II", Napoli, Italy
| | - A Illiano
- Department of Chemical Sciences, University of Naples "Federico II", Napoli, Italy
| | - R Troncone
- Department of Translational Medical Sciences, University of Naples "Federico II", Napoli, Italy.,European Laboratory for the Investigation of Food Induced Diseases (ELFID), University of Naples "Federico II", Napoli, Italy
| | - L Greco
- Department of Translational Medical Sciences, University of Naples "Federico II", Napoli, Italy.,European Laboratory for the Investigation of Food Induced Diseases (ELFID), University of Naples "Federico II", Napoli, Italy
| | - M Ruoppolo
- Department of Molecular Medicine and Medical Biotechnology, University of Naples "Federico II", Napoli, Italy. .,CEINGE, Biotecnonologie Avanzate s.c.ar.l., Napoli, Italy.
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16
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Abstract
Celiac disease (CD) is an immune-mediated gastrointestinal (GI) disorder driven by innate and adaptive immune responses to gluten. Presentation of CD has changed over time, with non-GI symptoms, such as anemia and osteoporosis, presenting more commonly. With improved screening and diagnostic methods, the reported prevalence of CD has increased globally, and there is considerable global variation in diagnostic and treatment practices. The objective of this study was to describe the current state of CD diagnosis and treatment patterns. A targeted review of literature from MEDLINE, Embase, the Cochrane Library, and screening of relevant conference abstracts was performed. The generally recommended diagnostic approach is GI endoscopy with small bowel biopsy; however, in selected patients, biopsy may be avoided and diagnosis based on positive serology and clinical symptoms. Diagnosis often is delayed; the average diagnostic delay after symptom onset is highly variable and can last up to 12 years. Barriers to accurate and timely diagnosis include atypical presentation, lack of physician awareness about current diagnostic criteria, misdiagnosis, and limited access to specialists. Currently, strict adherence to a gluten-free diet (GFD) is the only recommended treatment, which is not successful in all patients. Only one-third of patients are monitored regularly following diagnosis. Unmet needs for CD include improvements in the accuracy and timeliness of diagnosis, and the development of treatments for both refractory CD and GFD nonresponsive CD. Further research should investigate the impact of education about gluten-free eating and the availability of gluten-free foods support adherence and improve outcomes in patients with CD.
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17
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Cielo D, Galatola M, Fernandez-Jimenez N, De Leo L, Garcia-Etxebarria K, Loganes C, Tommasini A, Not T, Auricchio R, Greco L, Bilbao JR. Combined Analysis of Methylation and Gene Expression Profiles in Separate Compartments of Small Bowel Mucosa Identified Celiac Disease Patients' Signatures. Sci Rep 2019; 9:10020. [PMID: 31292504 PMCID: PMC6620355 DOI: 10.1038/s41598-019-46468-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 06/14/2019] [Indexed: 02/07/2023] Open
Abstract
By GWAS studies on celiac disease, gene expression was studied at the level of the whole intestinal mucosa, composed by two different compartments: epithelium and lamina propria. Our aim is to analyse the gene-expression and DNA methylation of candidate genes in each of these compartments. Epithelium was separated from lamina propria in biopsies of CeD patients and CTRs using magnetic beads. Gene-expression was analysed by RT-PC; methylation analysis required bisulfite conversion and NGS. Reverse modulation of gene-expression and methylation in the same cellular compartment was observed for the IL21 and SH2B3 genes in CeD patients relative to CTRs. Bioinformatics analysis highlighted the regulatory elements in the genomic region of SH2B3 that altered methylation levels. The cREL and TNFAIP3 genes showed methylation patterns that were significantly different between CeD patients and CTRs. In CeD, the genes linked to inflammatory processes are up-regulated, whereas the genes involved in the cell adhesion/integrity of the intestinal barrier are down-regulated. These findings suggest a correlation between gene-expression and methylation profile for the IL21 and SH2B3 genes. We identified a “gene-expression phenotype” of CeD and showed that the abnormal response to dietary antigens in CeD might be related not to abnormalities of gene structure but to the regulation of molecular pathways.
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Affiliation(s)
- D Cielo
- Department of Translational Medical Sciences, University of Naples "Federico II", Naples, Italy.,European Laboratory for the Investigation of Food Induced Diseases (ELFID), University of Naples "Federico II", Naples, Italy
| | - M Galatola
- Department of Translational Medical Sciences, University of Naples "Federico II", Naples, Italy. .,European Laboratory for the Investigation of Food Induced Diseases (ELFID), University of Naples "Federico II", Naples, Italy.
| | - N Fernandez-Jimenez
- Department of Genetics, Physical Anthropology and Animal Physiology, University of the Basque Country (UPV-EHU), BioCruces Health Research Institute, Leioa, Spain
| | - L De Leo
- Institute for Maternal and Child Health, IRCCS "Burlo Garofolo", Trieste, Italy
| | - K Garcia-Etxebarria
- Department of Genetics, Physical Anthropology and Animal Physiology, University of the Basque Country (UPV-EHU), BioCruces Health Research Institute, Leioa, Spain
| | - C Loganes
- Institute for Maternal and Child Health, IRCCS "Burlo Garofolo", Trieste, Italy
| | - A Tommasini
- Institute for Maternal and Child Health, IRCCS "Burlo Garofolo", Trieste, Italy
| | - T Not
- Department of Genetics, Physical Anthropology and Animal Physiology, University of the Basque Country (UPV-EHU), BioCruces Health Research Institute, Leioa, Spain.,Institute for Maternal and Child Health, IRCCS "Burlo Garofolo", Trieste, Italy
| | - R Auricchio
- Department of Translational Medical Sciences, University of Naples "Federico II", Naples, Italy.,European Laboratory for the Investigation of Food Induced Diseases (ELFID), University of Naples "Federico II", Naples, Italy
| | - L Greco
- Department of Translational Medical Sciences, University of Naples "Federico II", Naples, Italy.,European Laboratory for the Investigation of Food Induced Diseases (ELFID), University of Naples "Federico II", Naples, Italy
| | - J R Bilbao
- Department of Genetics, Physical Anthropology and Animal Physiology, University of the Basque Country (UPV-EHU), BioCruces Health Research Institute, Leioa, Spain
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18
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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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19
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Salazar C, García-Cárdenas JM, Paz-y-Miño C. Understanding Celiac Disease From Genetics to the Future Diagnostic Strategies. CLINICAL MEDICINE INSIGHTS. GASTROENTEROLOGY 2017; 10:1179552217712249. [PMID: 37791320 PMCID: PMC9980758 DOI: 10.1177/1179552217712249] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 05/04/2017] [Indexed: 10/05/2023]
Abstract
Celiac disease (CD) is an autoimmune disorder characterized by the permanent inflammation of the small bowel, triggered by the ingestion of gluten. It is associated with a number of symptoms, the most common being gastrointestinal. The prevalence of this illness worldwide is 1%. One of the main problems of CD is its difficulty to be diagnosed due to the various presentations of the disease. Besides, in many cases, CD is asymptomatic. Celiac disease is a multifactorial disease, HLA-DQ2 and HLA-DQ8 haplotypes are predisposition factors. Nowadays, molecular markers are being studied as diagnostic tools. In this review, we explore CD from its basic concept, manifestations, types, current and future methods of diagnosis, and associated disorders. Before addressing the therapeutic approaches, we also provide a brief overview of CD genetics and treatment.
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Affiliation(s)
- Carolina Salazar
- Centro de Investigación Genética y Genómica,
Facultad de Ciencias de la Salud Eugenio Espejo, Universidad Tecnológica
Equinoccial, Quito, Ecuador
| | - Jennyfer M García-Cárdenas
- Centro de Investigación Genética y Genómica,
Facultad de Ciencias de la Salud Eugenio Espejo, Universidad Tecnológica
Equinoccial, Quito, Ecuador
| | - César Paz-y-Miño
- Centro de Investigación Genética y Genómica,
Facultad de Ciencias de la Salud Eugenio Espejo, Universidad Tecnológica
Equinoccial, Quito, Ecuador
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