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Chang D, Silvester JA. Finding the sweet spot: Diagnosing celiac disease in children with type 1 diabetes. J Pediatr Gastroenterol Nutr 2024. [PMID: 39045756 DOI: 10.1002/jpn3.12330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 05/15/2024] [Indexed: 07/25/2024]
Affiliation(s)
- Denis Chang
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jocelyn Anne Silvester
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
- Division of Gastroenterology, Celiac Center, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Deamidated Gliadin Antibodies: Do They Add to Tissue Transglutaminase-IgA Assay in Screening for Celiac Disease? J Pediatr Gastroenterol Nutr 2021; 72:e112-e118. [PMID: 33346579 DOI: 10.1097/mpg.0000000000003022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Use of deamidated gliadin peptide (DGP) test kits as adjunctive to tissue-transglutaminase-IgA (TTG-IgA) for the diagnosis of celiac disease (CD) has been a controversial issue. The objectives of our study were to evaluate the diagnostic performance of DGP antibodies compared with TTG-IgA and to evaluate the correlation between DGP-antibody titers and degree of enteropathy. METHODS We included children who underwent endoscopy and biopsies because of positivity of any of the serology tests in the "celiac profile" (TTG-IgA, DGP-IgA, and DGP-IgG) from 2012 to 2019. We divided children into clinically suspected cases of CD (group 1) and asymptomatic cases screened as they were from a high-risk group (group 2). RESULTS Group 1 constituted 52 children and group 2 included 81 children (76 type-1 diabetes [T1D]). The sensitivity and positive-predictive value (PPV) of DGP-IgG in group 1 (90%, 98%) and group 2 (91%, 85.5%) were comparable with TTG-IgA (98%, 92% in group 1; 100%, 80% in group 2). By adding DGP-IgG to TTG-IgA, the performance of TTG-IgA has improved marginally in group 1 (sensitivity 100%, PPV 92.3%). All cases with DGP-IgG titer 2 times ULN in group 1, and >4 times ULN in group 2 had villous atrophy. All T1D patients with TTG IgA >10 times ULN had villous atrophy. CONCLUSIONS DGP-IgG assay did not add to the performance of TTG-IgA. DGP-IgG titer correlated with enteropathy. The diagnosis of CD can be made in asymptomatic T1D child with TTG-IgA titer >10 times ULN and positive endomyseal antibodies.
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Cerqueiro Bybrant M, Udén E, Frederiksen F, Gustafsson AL, Arvidsson C, Fureman A, Forsander G, Elding Larsson H, Ivarsson SA, Lindgren M, Ludvigsson J, Marcus C, Pundziute Lyckå A, Persson M, Samuelsson U, Särnblad S, Åkesson K, Örtqvist E, Carlsson A. Celiac disease can be predicted by high levels of tissue transglutaminase antibodies in children and adolescents with type 1 diabetes. Pediatr Diabetes 2021; 22:417-424. [PMID: 33259121 PMCID: PMC8048786 DOI: 10.1111/pedi.13165] [Citation(s) in RCA: 3] [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: 07/21/2020] [Revised: 09/24/2020] [Accepted: 11/11/2020] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES Children with type 1 diabetes (T1D) are not included in guidelines regarding diagnosis criteria for celiac disease (CD) without a diagnostic biopsy, due to lack of data. We explored whether tissue transglutaminase antibodies (anti-tTG) that were ≥ 10 times the upper limit of normal (10× ULN) predicted CD in T1D. METHODS Data from the Swedish prospective Better Diabetes Diagnosis study was used, and 2035 children and adolescents with T1D diagnosed between 2005-2010 were included. Of these, 32 had been diagnosed with CD before T1D. The children without CD were repeatedly screened for CD using anti-tTG antibodies of immunoglobulin type A. In addition, their human leukocyte antigen (HLA) were genotyped. All children with positive anti-tTG were advised to undergo biopsy. Biopsies were performed on 119 children and graded using the Marsh-Oberhüber classification. RESULTS All of the 60 children with anti-tTG ≥10x ULN had CD verified by biopsies. The degree of mucosal damage correlated with anti-tTG levels. Among 2003 screened children, 6.9% had positive anti-tTG and 5.6% were confirmed CD. The overall CD prevalence, when including the 32 children with CD before T1D, was 7.0% (145/2035). All but one of the children diagnosed with CD had HLA-DQ2 and/or DQ8. CONCLUSIONS As all screened children and adolescents with T1D with tissue transglutaminase antibodies above 10 times the positive value 10x ULN had CD, we propose that the guidelines for diagnosing CD in screened children, when biopsies can be omitted, should also apply to children and adolescents with T1D as a noninvasive method.
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Affiliation(s)
- Mara Cerqueiro Bybrant
- Pediatric Endocrinology Unit, Department of Women's and Children's HealthKarolinska InstitutetStockholmSweden
| | | | | | | | | | | | - Gun Forsander
- Department of PediatricsInstitute of Clinical Sciences, Sahlgrenska Academy, University of GothenburgGothenburgSweden,Department of PediatricsQueen Silvia Children's Hospital, Sahlgrenska University HospitalGothenburgSweden
| | - Helena Elding Larsson
- Department of Clinical SciencesLund University/Clinical Research Centre, Skåne University HospitalMalmöSweden
| | - Sten A Ivarsson
- Department of Clinical SciencesLund University, Skåne University HospitalPediatrics, LundSweden
| | - Marie Lindgren
- Department of Clinical SciencesLund University, Skåne University HospitalPediatrics, LundSweden,Children's Clinic, Vrinnevi hospitalNorrköpingSweden
| | - Johnny Ludvigsson
- Crown Princess Victoria's Children's and Youth Hospital, University HospitalLinköpingSweden,Division of Pediatrics, Department of Clinical and Experimental MedicineLinköping UniversityLinköpingSweden
| | - Claude Marcus
- Division of Pediatrics, Department of Clinical Science Intervention and TechnologyKarolinska InstituteStockholmSweden
| | - Auste Pundziute Lyckå
- Department of PediatricsQueen Silvia Children's Hospital, Sahlgrenska University HospitalGothenburgSweden
| | - Martina Persson
- Department of MedicineClinical Epidemiology, Karolinska University HospitalStockholmSweden
| | - Ulf Samuelsson
- Crown Princess Victoria's Children's and Youth Hospital, University HospitalLinköpingSweden,Division of Pediatrics, Department of Clinical and Experimental MedicineLinköping UniversityLinköpingSweden
| | | | - Karin Åkesson
- Department of PediatricsRyhov County HospitalJönköpingSweden,Jönköping Academy for Improvement of Health and WelfareJönköping UniversityJönköpingSweden
| | - Eva Örtqvist
- Pediatric Endocrinology Unit, Department of Women's and Children's HealthKarolinska InstitutetStockholmSweden
| | - Annelie Carlsson
- Department of Clinical SciencesLund University, Skåne University HospitalPediatrics, LundSweden
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Nonbiopsy Approach for Celiac Disease Is Accurate When Using Exact Duodenal Histomorphometry: Prospective Study in 2 Countries. J Clin Gastroenterol 2021; 55:227-232. [PMID: 32301831 DOI: 10.1097/mcg.0000000000001349] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 03/01/2020] [Indexed: 01/13/2023]
Abstract
GOALS To test the accuracy of serology-based criteria for diagnosing celiac disease utilizing quantitative histomorphometry. BACKGROUND The revised European pediatric guidelines allow noninvasive celiac disease diagnosis for a subgroup of children. However, in some of the studies on this issue, the positive predictive value (PPV) of serology has remained suboptimal, possibly because of challenges of histopathology as the reference standard. STUDY Prospectively enrolled children with transglutaminase 2 antibodies (TGA) above the upper limit of normal (ULN) underwent blood sampling and duodenal biopsy in Finland and Romania. Those with TGA ≥10× ULN, positive endomysium antibodies (EmA), and disease-associated genetics were considered to fulfill triple criteria for celiac disease. Initial histopathologic analysis was conducted using grouped classification, whereupon centralized morphometry was performed. RESULTS Altogether 88 (54%) children were triple positive. In local evaluation, 99% of triple-positive children and 73% of children with TGA <10× ULN had celiac disease. These figures increased to 100% and 85% after more precise morphometric analysis. Triple-positive children had more anemia and higher median EmA and liver enzyme values than those with TGA<10× ULN; the groups were comparable in other clinical features and laboratory parameters. CONCLUSIONS When applied as recommended, the nonbiopsy strategy had already yielded excellent PPV regardless of the site of diagnosis or clinical presentation in the local analysis. PPV further increased to 100% with standardized duodenal morphometry.
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Popp A, Mäki M. Changing Pattern of Childhood Celiac Disease Epidemiology: Contributing Factors. Front Pediatr 2019; 7:357. [PMID: 31555624 PMCID: PMC6727179 DOI: 10.3389/fped.2019.00357] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 08/15/2019] [Indexed: 12/14/2022] Open
Abstract
Up until the 1960s and 1970s, diarrhea, malabsorption syndrome, and failure to thrive were the presenting symptoms and signs of celiac disease (CD) in young infants; however this disease was also at the same time reported to be disappearing. Indeed, clinical childhood CD was seen to transform into a milder form, resulting in an upward shift in age at diagnosis during the 1970s (and years later for many countries). This changing pattern of CD presentation then altered the epidemiology of the disease, with major differences between and within countries observed. An awareness of the changing clinical nature of CD and use of case-finding tools to detect even clinically silent CD became an important factor in this changing epidemiology. Countries report both low and high prevalence but it seems to be on the increase resulting in a population-based level of 1-2%. This paper discusses the potential causes and environmental factors behind these observed clinical changes, identifying new clues from different studies published at the time this transformation took place. For instance, it was found that breastfeeding postponed the diagnosis of the disease but did not altogether prevent it. Moreover, gluten introduction at a young age, specifically at the mean age of 2 months, seemed to also have a clear impact in inducing malabsorption syndrome and failure to thrive in young infants in addition to other factors such as gluten intake volume and type of cereal present in the weaning food. Further, the impact of cow's milk and its high osmolarity might have played an important role; humanized milk formulas were not yet invented. Future epidemiological studies on the contributing environmental factors to the shift in CD presentation are thus recommended for countries in which these changing clinical features are still being observed.
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Affiliation(s)
- Alina Popp
- Faculty of Medicine and Health Technology, Tampere Center of Child Health Research, Tampere University and Tampere University Hospital, Tampere, Finland
- National Institute for Mother and Child Health “Alessandrescu-Rusescu”, University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania
| | - Markku Mäki
- Faculty of Medicine and Health Technology, Tampere Center of Child Health Research, Tampere University and Tampere University Hospital, Tampere, Finland
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Diagnosing Celiac Disease: Towards Wide-Scale Screening and Serology-Based Criteria? Gastroenterol Res Pract 2019; 2019:2916024. [PMID: 31467522 PMCID: PMC6701393 DOI: 10.1155/2019/2916024] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 07/16/2019] [Indexed: 12/12/2022] Open
Abstract
Celiac disease is one of the most common food-related chronic disorders in children. Unfortunately, this multifaceted disease is challenging to recognize and remains markedly underdiagnosed. Screening of either known at-risk groups or even the whole population could increase the suboptimal diagnostic yield substantially. Many recent guidelines recommend screening of at least selected risk groups, but more wide-scale screening remains controversial. The increasing prevalence of celiac disease and the development of autoantibody assays have also led to a gradual shift in the diagnostics towards less invasive serology-based criteria in a subgroup of symptomatic children. The main open questions concern whether these criteria are applicable to all countries and clinical settings, as well as to adult patients. On the other hand, widening screening and the mistaken practice of initiating a gluten-free diet before the appropriate exclusion of celiac disease increase the number of borderline seropositive cases, which may also challenge the classical histopathological diagnostics. Sophisticated diagnostic methods and a deeper understanding of the natural history of early developing celiac disease may prove useful in these circumstances.
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Joshi KK, Haynes A, Davis EA, D'Orsogna L, McLean-Tooke A. Role of HLA-DQ typing and anti-tissue transglutaminase antibody titers in diagnosing celiac disease without duodenal biopsy in type 1 diabetes: A study of the population-based pediatric type 1 diabetes cohort of Western Australia. Pediatr Diabetes 2019; 20:567-573. [PMID: 30985044 DOI: 10.1111/pedi.12857] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 04/03/2019] [Accepted: 04/05/2019] [Indexed: 12/14/2022] Open
Abstract
AIM The primary aim of the present study was to determine if it is cost effective to use human leukocyte antigen (HLA) typing as a first-line screening test for celiac disease (CD) in children with type 1 diabetes (T1D), as recommended by the European Society of Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN). The second aim was to investigate whether anti-tissue transglutaminase IgA (anti-tTGA) antibodies can be used to diagnose CD without the need for a confirmatory duodenal biopsy in T1D. METHODS Data for all T1D patients aged <18 years, who attended the diabetes clinics in Western Australia up to June 2017, were extracted from the Western Australian Children's Diabetes Database (WACDD) and analyzed for their demographic data and CD permissive HLA alleles (DQ2, DQ8, and DQ7). For T1D patients already diagnosed with CD, the mode of diagnosis of CD, anti-tTGA titers, and CD permissive HLA alleles were analyzed. RESULTS Of the 936 eligible T1D patients identified, HLA-DQ typing was available for 551 (59%). Of these 551 patients, 504 (91.2%) were positive for celiac permissive HLA alleles. Eight percent (n = 75) of the T1D patients had a co-diagnosis of CD. High anti-tTGA titers were observed in those who were diagnosed with a positive duodenal biopsy. CONCLUSION HLA-DQ typing is not cost effective as a first-line screening test for CD in T1D patients because of over-representation of CD permissive HLA alleles in this group. Anti-tTGA titers may be useful in diagnosing CD in T1D without duodenal biopsy, as high levels were found to be strongly predictive of CD.
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Affiliation(s)
- Kiranjit K Joshi
- Department of Endocrinology and Diabetes, Princess Margaret Hospital, Perth, WA, Australia
| | - Aveni Haynes
- Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Elizabeth A Davis
- Department of Endocrinology and Diabetes, Princess Margaret Hospital, Perth, WA, Australia.,Telethon Kids Institute, University of Western Australia, Perth, WA, Australia.,School of Paediatrics and Child Health, University of Western Australia, Perth, WA, Australia
| | - Lloyd D'Orsogna
- Department of Clinical Immunology and PathWest, Fiona Stanley Hospital, Murdoch, WA, Australia.,School of Biomedical Science, University of Western Australia, Perth, WA, Australia
| | - Andrew McLean-Tooke
- Department of Clinical Immunology, Sir Charles Gairdner Hospital, Perth, WA, Australia.,Department of Laboratory Immunology, PathWest QEII Medical Centre, Perth, WA, Australia
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Mearns ES, Taylor A, Boulanger T, Craig KJ, Gerber M, Leffler DA, Drahos J, Sanders DS, Lebwohl B. Systematic Literature Review of the Economic Burden of Celiac Disease. PHARMACOECONOMICS 2019; 37:45-61. [PMID: 30221333 DOI: 10.1007/s40273-018-0707-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND The prevalence of celiac disease (CD) has rapidly increased over recent decades, but costs related to CD remain poorly quantified. OBJECTIVE This systematic review assessed the economic burden of CD in North America and Europe. METHODS MEDLINE, EMBASE, EconLit, and the Cochrane Library databases were systematically searched to identify English-language literature from 2007 to 2018 that assessed costs, cost effectiveness, and health resource utilization for CD. RESULTS Forty-nine studies met the inclusion criteria, of which 28 (57.1%) addressed costs of testing and diagnosis; 33 (67.3%) were from Europe. The cost per positive CD diagnosis of testing patients already undergoing esophagogastroduodenoscopy for other indications ranged from 1300 Canadian dollars ($Can) in Canada (2016 value) to €44,712 in the Netherlands (2013 value). Adding the CD test was cost effective when it combined diagnostic modalities (e.g., serology and biopsy). Direct annual excess costs to a US payer per diagnosed CD patient totaled $US6000 (2013 value) more than for a person without CD, chiefly due to outpatient care. Hospitalizations, emergency visits, and medication use were more common with CD. After initiating a gluten-free diet (GFD), patients visited primary care providers less often, used more medications, and missed fewer days from school and work. CONCLUSIONS Most of the few available economic studies of CD assess testing and diagnosis costs, especially in Europe. Methods of testing generally are considered cost effective when they combine diagnostic modalities in symptomatic patients. Most costs to a payer of managing CD derive from outpatient care. Following GFD initiation, patients lose fewer days from work and school than pretreatment.
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Affiliation(s)
| | | | | | - Kelly J Craig
- Truven Health Analytics, An IBM Company, Cambridge, MA, USA
| | - Michele Gerber
- Takeda Pharmaceuticals International Co, Cambridge, MA, USA
| | | | | | - David S Sanders
- Royal Hallamshire Hospital and University of Sheffield, Sheffield, UK
| | - Benjamin Lebwohl
- Department of Medicine, Celiac Disease Center, Columbia University Medical Center, New York, NY, USA
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Abstract
GOALS To compare the diagnostic yield and cost-consequences of 2 strategies, screening regardless of symptoms versus case finding (CF), using a point-of-care test (POCT), for the detection of celiac disease (CD) in primary care, to bridge the diagnostic gap of CD in adults. MATERIALS AND METHODS All subjects under 75 years of age who consecutively went to their general practitioners' offices were offered POCT for anti-transglutaminase immunoglobulin A antibodies. The POCT was performed on all subjects who agreed, and then a systematic search for symptoms or conditions associated with higher risk for CD was performed, immediately after the test but before knowing the test results. The 2 resulting groups were: (a) POCT positive and (b) symptomatic subject at CF. Subjects were defined as symptomatic at CF in the presence of 1 or more symptoms. All POCT-positive or symptomatic subjects at CF were referred to the CD Centers for confirmation of CD. Data on resource consumption were gathered from patients' charts. Cost of examinations, and diagnostic and laboratory tests were estimated with regional outpatient tariffs (Sicily), and a price of &OV0556;2.5 was used for each POCT. RESULTS Of a total of 2197 subjects who agreed to participate in the study, 36 (1.6%) and 671 (30.5%) were POCT positive and symptomatic at CF, respectively. The yield from the screening and CF was 5 new celiac patients. The total cost and mean cost for each new CD case were &OV0556;7497.35 and &OV0556;1499.47 for the POCT screening strategy, and &OV0556;9855.14 and &OV0556;1971.03 for the CF strategy, respectively. Assuming consecutive use of both strategies, performing POCT only in symptomatic subjects at CF, the calculated yield would be 4 new diagnoses with a total cost of &OV0556;2345.84 and a mean cost of &OV0556;586.46 for each newly diagnosed patient. Only 1 patient was celiac despite a negative POCT. CONCLUSIONS Testing symptomatic subjects at CF only by POCT seems the most cost-effective strategy to bridge the diagnostic gap of adult CD in primary care.
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Abstract
The incidence of celiac disease (CD) has increased over the last half-century, resulting in rising interest in identifying risk factors for CD. The necessity of duodenal biopsies in the diagnosis of CD has recently been challenged. Areas covered: This review covers the recent literature regarding the role of infant feeding practices, including breastfeeding and timing of gluten introduction, and the microbiota in the development of CD. Additionally, the application of the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition guidelines for a non-biopsy approach to the diagnosis of CD is reviewed. Expert commentary: Recent investigations have not revealed any significant effect of breastfeeding or timing of gluten introduction on the risk of CD in at-risk populations. There are alterations in the microbiota of CD patients. However, the role of the microbiome and whether its manipulation has a clinical effect are unknown. Preliminary data suggests a non-biopsy approach to diagnosis of pediatric CD can be applied to several populations, although additional studies are needed. Prospective investigations are underway to examine the interplay of infant feeding practices and the microbiome and to identify particular CD-specific biomarkers that may aid in the diagnosis and ultimately prevention of CD.
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Affiliation(s)
- Grace J Lee
- a Division of Pediatric Gastroenterology, Department of Pediatrics and Communicable Diseases , C.S. Mott Children's Hospital, University of Michigan , Ann Arbor , MI , USA
| | - John Y Kao
- b Division of Gastroenterology, Department of Internal Medicine , University of Michigan , Ann Arbor , MI , USA
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Alves C, Santos LS, Toralles MBP. Association of type 1 diabetes mellitus and autoimmune disorders in Brazilian children and adolescents. Indian J Endocrinol Metab 2016; 20:381-386. [PMID: 27186558 PMCID: PMC4855969 DOI: 10.4103/2230-8210.179994] [Citation(s) in RCA: 8] [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] [Indexed: 01/17/2023] Open
Abstract
CONTEXT Type 1 diabetes mellitus (T1DM) is caused by an immune-mediated destruction of pancreatic beta cells. Other autoimmune diseases can be observed in association with T1DM. The screening for celiac disease (CD) and Hashimoto's thyroiditis is necessary due to the increased prevalence of these pathologies in T1DM patients. AIMS This study aimed to investigate the prevalence of autoimmune markers for pancreatitis, thyroiditis, and CD in racially admixtured children and adolescents with T1DM. SETTINGS AND DESIGN Cross-sectional clinic-based study. METHODS Seventy-one patients with T1DM (average: 11.6 ± 5.1 years). In all patients, the following antibodies were surveyed: Anti-glutamic acid decarboxylase (anti-GAD), immunoglobulin A (IgA) anti-transglutaminase (anti-tTG), Antithyroglobulin (AAT), anti-thyroid peroxidase (anti-TPO), and IgA. STATISTICAL ANALYSIS USED The quantitative variables were expressed as a mean and standard deviation and the qualitative variables in contingency tables. Student's t-test and χ(2) tests were used to assess the differences between the groups. The level of significance was established as P < 0.05. RESULTS The prevalence of anti-GAD antibodies was 5.9%; anti-tTG IgA, 7.4%; anti-TPO, 11.8%; and AAT, 11.8%. CONCLUSIONS Children and adolescents with T1DM have increased the prevalence of antithyroid and CD-related antibodies. The positivity for anti-GAD and antithyroid antibodies was less frequent than in other studies. The prevalence of anti-tTG antibodies was similar to the literature.
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Affiliation(s)
- Crésio Alves
- Department of Pediatrics, Pediatric Endocrinology Unit, Faculty of Medicine, University Hospital Prof. Edgard Santos, Federal University of Bahia, Salvador, Bahia, Brazil
| | - Larissa Siqueira Santos
- Department of Pediatrics, Pediatric Endocrinology Unit, Faculty of Medicine, University Hospital Prof. Edgard Santos, Federal University of Bahia, Salvador, Bahia, Brazil
| | - Maria Betânia P. Toralles
- Department of Pediatrics, Pediatric Endocrinology Unit, Faculty of Medicine, University Hospital Prof. Edgard Santos, Federal University of Bahia, Salvador, Bahia, Brazil
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Bakker SF, Tushuizen ME, von Blomberg BME, Bontkes HJ, Mulder CJ, Simsek S. Screening for coeliac disease in adult patients with type 1 diabetes mellitus: myths, facts and controversy. Diabetol Metab Syndr 2016; 8:51. [PMID: 27478507 PMCID: PMC4966870 DOI: 10.1186/s13098-016-0166-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 07/10/2016] [Indexed: 12/23/2022] Open
Abstract
This review aims at summarizing the present knowledge on the clinical consequences of concomitant coeliac disease (CD) in adult patients with type 1 diabetes mellitus (T1DM). The cause of the increased prevalence of CD in T1DM patients is a combination of genetic and environmental factors. Current screening guidelines for CD in adult T1DM patients are not uniform. Based on the current evidence of effects of CD on bone mineral density, diabetic complications, quality of life, morbidity and mortality in patients with T1DM, we advise periodic screening for CD in adult T1DM patients to prevent delay in CD diagnosis and subsequent CD and/or T1DM related complications.
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Affiliation(s)
- Sjoerd F. Bakker
- Department of Gastroenterology and Hepatology, VU University Medical Centre, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Maarten E. Tushuizen
- Department of Gastroenterology and Hepatology, VU University Medical Centre, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | | | - Hetty J. Bontkes
- Department of Pathology, Unit Medical Immunology, VU University Medical Centre, Amsterdam, The Netherlands
| | - Chris J. Mulder
- Department of Gastroenterology and Hepatology, VU University Medical Centre, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Suat Simsek
- Department of Internal Medicine, North West Clinics, Alkmaar, The Netherlands
- Department of Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands
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Korponay-Szabó IR, Troncone R, Discepolo V. Adaptive diagnosis of coeliac disease. Best Pract Res Clin Gastroenterol 2015; 29:381-98. [PMID: 26060104 DOI: 10.1016/j.bpg.2015.05.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 04/24/2015] [Accepted: 05/07/2015] [Indexed: 01/31/2023]
Abstract
Coeliac disease has for a long time simply been regarded as a gluten-dependent enteropathy and a duodenal biopsy was required in all patients for the diagnosis. It is now accepted that autoimmunity against transglutaminase 2 is an earlier, more universal and more specific feature of coeliac disease than histologic lesions. Moreover, high serum levels of combined anti-transglutaminase 2 and anti-endomysium antibody positivity have excellent predictive value for the presence of enteropathy with villous atrophy. This makes the histology evaluation of the gut no longer necessary in well defined symptomatic paediatric patients with compatible HLA-DQ2 and/or DQ8 background. The biopsy-sparing diagnostic route is not yet recommended by gastroenterologists for adults, and certain clinical circumstances (immunodeficiency conditions, extraintestinal manifestations, type-1 diabetes mellitus, age less than 2 years) may require modified diagnostic approaches. Coeliac patients with preserved duodenal villous structure do exist and these need a more extended evaluation by immunologic and molecular biology tools.
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Affiliation(s)
- Ilma R Korponay-Szabó
- Department of Paediatrics, University of Debrecen Medical School, Nagyerdei krt 98, Debrecen 4032, Hungary; Coeliac Disease Centre, Heim Pál Children's Hospital, Üllöi út 86, Budapest 1089, Hungary.
| | - Riccardo Troncone
- University of Naples Federico II, Department of Medical Translational Sciences, Section of Pediatrics, Via Sergio Pansini 5, 80131 Napoli, Italy
| | - Valentina Discepolo
- University of Naples Federico II, Department of Medical Translational Sciences, Section of Pediatrics, Via Sergio Pansini 5, 80131 Napoli, Italy; University of Chicago, Department of Medicine and the University of Chicago Celiac Disease Center, Chicago 900 E 57th Street, 60615 Chicago, IL, USA
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Celiac disease can be predicted by high levels of anti-tissue transglutaminase antibodies in population-based screening. J Pediatr Gastroenterol Nutr 2015; 60:787-91. [PMID: 25564816 DOI: 10.1097/mpg.0000000000000688] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES The aim of the present study was to evaluate any potential correlation between anti-tissue transglutaminase antibodies of type immunoglobulin A (tTG-IgA) and the degree of gluten-induced enteropathy in children participating in a screening study for celiac disease (CD) and to assess to what extent the revised European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) guidelines cover this group of patients. METHODS The present study is a substudy of a cross-sectional CD screening study, Exploring the Iceberg of Celiacs in Sweden, a 2-phased study performed during 2005 to 2006 and 2009 to 2010. The 13,279 participating children had a blood test obtained, and those with positive tTG-IgA were recommended a small intestinal biopsy. The tTG-IgA levels at the time of biopsy were compared with those at the assessment of the biopsy. RESULTS There were 267 children included, of whom 230 were diagnosed as having CD. Of all of the children, 67 children had low tTG-IgA levels (<5 U/mL), of whom 55% had Marsh 3 lesions. All of the children with tTG-IgA levels exceeding 10 times the upper limit of normal values of 5 U/mL, that is, 50 U/mL, were diagnosed as having CD. Lowering the cutoff to 3 U/mL, all but 1 child with 30 U/mL got CD diagnosis. CONCLUSIONS By adopting the revised ESPGHAN criteria, biopsies could have been omitted in one-fourth of all of the patients. Our results indicate that the criteria may be useful even in screened children. Further studies are needed to confirm whether the 2012 ESPGHAN guidelines should be revised to also apply to the populations being screened.
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Hansson T, Dahlbom I, Tuvemo T, Frisk G. Silent coeliac disease is over-represented in children with type 1 diabetes and their siblings. Acta Paediatr 2015; 104:185-91. [PMID: 25283799 DOI: 10.1111/apa.12823] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 08/14/2014] [Accepted: 10/01/2014] [Indexed: 12/13/2022]
Abstract
AIM This study measured autoantibodies against tissue transglutaminase (anti-tTG) to detect untreated coeliac disease in children with type 1 diabetes and their siblings. METHODS Anti-tTG was measured in prospectively collected sera from 169 children at the onset of diabetes, 88 of their siblings and 96 matched control children. Coeliac disease was confirmed with a small intestinal biopsy. RESULTS Coeliac disease was diagnosed in five children before diabetes onset. A further 12 children were diagnosed after diabetes onset, without any gastrointestinal symptoms, and 11 of these had anti-tTG at the onset of diabetes, with the remaining child showing seroconversion within 6 months. Hence, all the children with both diseases had anti-tTG at or before diabetes diagnosis, and the prevalence of coeliac disease was 10.1%. Moreover, 6.8% of the siblings and 3.1% of the control children had elevated levels of anti-tTG. None of the siblings reported any coeliac-related symptoms, despite being positive for anti-tTG, and coeliac disease has so far been biopsy confirmed in 4.5%. CONCLUSION Silent coeliac disease is over-represented in children with type 1 diabetes and their siblings. All diabetes children and their siblings should be tested and followed for the presence of anti-tTG and coeliac disease.
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Affiliation(s)
- Tony Hansson
- Department of Women's and Children's Health; Uppsala University; Uppsala Sweden
- Department of Immunology, Genetics and Pathology; Uppsala University; Uppsala Sweden
| | - Ingrid Dahlbom
- Department of Women's and Children's Health; Uppsala University; Uppsala Sweden
- Therapeutic Immune Design Unit; Department of Clinical Neuroscience; Karolinska Institute; Stockholm Sweden
| | - Torsten Tuvemo
- Department of Women's and Children's Health; Uppsala University; Uppsala Sweden
| | - Gun Frisk
- Department of Immunology, Genetics and Pathology; Uppsala University; Uppsala Sweden
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Abstract
PURPOSE OF REVIEW To summarize the recent advances in coeliac disease. RECENT FINDINGS Details of the polygenic nature of coeliac disease with the human leukocyte antigen (HLA) locus as the dominating genetic element have been uncovered. The existence of a large number of non-HLA coeliac disease genes, only partly shared by each individual patient, suggests the genetic heterogeneity of the disease. The critical role for HLA-DQ-restricted CD4 T cells recognizing antigenic gluten peptides is further substantiated. Involvement of CD8 T cells has received new attention. Other components of wheat than gluten, in particular the amylase trypsin inhibitors, may also play a role. The disease is becoming more prevalent. New guidelines state that coeliac disease diagnosis in children can be made on the basis of clinical signs, serology and genetics without the need of biopsy. The clinical entity 'noncoeliac gluten sensitivity' has received much attention, but diagnostic and pathophysiological definitions are still elusive. The risk for mortality and morbidity in coeliac disease is less than previously thought. SUMMARY Our understanding of the basic and clinical aspects of coeliac disease increases. Coeliac disease stands out as a major health problem of almost global occurrence. Case finding, distinguishing coeliac disease from other gluten-sensitive conditions, better care and balanced use of resources are the current challenges.
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Tucci F, Astarita L, Abkari A, Abu-Zekry M, Attard T, Ben Hariz M, Bilbao JR, Boudraa G, Boukthir S, Costa S, Djurisic V, Hugot JP, Irastorza I, Kansu A, Kolaček S, Magazzù G, Mičetić-Turk D, Misak Z, Roma E, Rossi P, Terzic S, Velmishi V, Arcidiaco C, Auricchio R, Greco L. Celiac disease in the Mediterranean area. BMC Gastroenterol 2014; 14:24. [PMID: 24517104 PMCID: PMC3922979 DOI: 10.1186/1471-230x-14-24] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 01/30/2014] [Indexed: 01/17/2023] Open
Abstract
Background The World Gastroenterology Organization recommends developing national guidelines for the diagnosis of Celiac Disease (CD): hence a profile of the diagnosis of CD in each country is required. We aim to describe a cross-sectional picture of the clinical features and diagnostic facilities in 16 countries of the Mediterranean basin. Since a new ESPGHAN diagnostic protocol was recently published, our secondary aim is to estimate how many cases in the same area could be identified without a small intestinal biopsy. Methods By a stratified cross-sectional retrospective study design, we examined clinical, histological and laboratory data from 749 consecutive unselected CD children diagnosed by national referral centers. Results The vast majority of cases were diagnosed before the age of 10 (median: 5 years), affected by diarrhea, weight loss and food refusal, as expected. Only 59 cases (7.8%) did not suffer of major complaints. Tissue transglutaminase (tTG) assay was available, but one-third of centers reported financial constraints in the regular purchase of the assay kits. 252 cases (33.6%) showed tTG values over 10 times the local normal limit. Endomysial antibodies and HLA typing were routinely available in only half of the centers. CD was mainly diagnosed from small intestinal biopsy, available in all centers. Based on these data, only 154/749 cases (20.5%) would have qualified for a diagnosis of CD without a small intestinal biopsy, according to the new ESPGHAN protocol. Conclusions This cross-sectional study of CD in the Mediterranean referral centers offers a puzzling picture of the capacities to deal with the emerging epidemic of CD in the area, giving a substantive support to the World Gastroenterology Organization guidelines.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Luigi Greco
- European Laboratory for Food Induced Diseases, University of Naples Federico II, Naples 80131, Italy.
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Fingertip rapid point-of-care test in adult case-finding in coeliac disease. BMC Gastroenterol 2013; 13:115. [PMID: 23849178 PMCID: PMC3717015 DOI: 10.1186/1471-230x-13-115] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Accepted: 07/09/2013] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Coeliac disease (CD), due to its protean clinical manifestation, is still very under diagnosed in adults and delays in diagnosis may take years and even decades. Simple tools to find cases in primary care may help to identify patients for further diagnostic tests. We have evaluated the usefulness of an on site rapid fingertip whole blood point-of-care test (POCT) for such a purpose. METHODS As CD is known to run within families, we tested 148 healthy relatives of 70 Romanian index cases with biopsy-proven CD (87% of all first-degree family members, median age 36 years) for the presence of circulating autoantibodies. In addition to performing the POCT (which measures blood erythrocyte self-TG2-autoantibody complexes) on site, blood was drawn for later evaluations of serum IgA-class endomysial antibodies (EMA). EMA-positive sera were further tested for transglutaminase 2 antibodies (TG2-IgA). All serological parameters were analyzed blindly in a centralized laboratory that had no knowledge of the on site POCT result. Endoscopic small intestinal biopsies was recommended for all POCT- or EMA-test positive subjects. RESULTS In on site testing the POCT was positive in 12/148 first-degree relatives (8%) and all these subjects were also serum EMA-positive. A positive EMA test was found only in one other subject. All remaining 135 healthy first-degree relatives were negative for both POCT and EMA. Four subjects positive for both POCT and EMA were negative for TG2-IgA. Ten out of thirteen of the antibody-positive subjects agreed to undergo endoscopy. The POCT was found to be positive in 8/9 first-degree relatives having coeliac-type mucosal lesions of grade Marsh 2 (n = 3) or Marsh 3 (n = 6). The three POCT-positive subjects not agreeing to undergo endoscopy were also both EMA- and TG2-IgA-positive. CONCLUSION The fingertip whole blood rapid POCT might fulfill the unmet need for a simple and cheap case-finding biomarker for early detection and presumptive diagnosis of CD. Confirmatory studies are warranted in adult case-finding in specialized outpatient clinics and in primary care.
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