Transglutaminase antibodies and celiac disease in children with type 1 diabetes and in their family members

Predictors of celiac disease in patients with type 1 diabetes and positive tissue transglutaminase immunoglobulin A

OBJECTIVES

Identify clinical and serologic features that more accurately predict a diagnosis of celiac disease (CD) in children with type 1 diabetes mellitus (T1DM), particularly focusing on the degree of elevation of tissue transglutaminase immunoglobulin A (TTG IgA) and dilution of positive endomysial antibody (EMA).

METHODS

We performed a single-center retrospective review of patients with T1DM who underwent endoscopy from 2016 to 2022 for evaluation of CD. We compared demographic, anthropometric, and laboratory data as well as symptoms and endoscopy findings for subjects with and without CD.

RESULTS

Of 123 subjects who underwent esophagogastroduodenoscopy, 74 (60%) were diagnosed with CD. Univariate logistic regression analysis revealed the factors associated with CD were degree of TTG IgA elevation, EMA positivity, and degree of EMA dilution. For every 10-fold increase in TTG IgA, there was a 4.7× increased risk of CD. TTG IgA ≥10 times the upper limit of normal (ULN) provided a positive predictive value (PPV) of 85% (confidence interval [CI]: [0.76-92]) in all subjects and 91% in asymptomatic subjects (CI: [0.75-0.98]). Of 66 subjects with EMA data, 41 (62%) were positive and 32 had CD (PPV = 0.78). Of 12 asymptomatic subjects with positive EMA, eight had CD (PPV = 0.67). For subjects with EMA ≥ 1:80, all were diagnosed with CD, and all had TTG IgA ≥10 times the ULN.

CONCLUSIONS

Among patients with T1DM, symptoms, adjunct labs, and anthropometrics do not help predict CD, but the degree of elevation of TTG IgA and dilution of a positive EMA result do.

Diabetic endothelial microangiopathy and pulmonary dysfunction

Type 2 diabetes mellitus (T2DM) is a widespread metabolic condition with a high global morbidity and mortality rate that affects the whole body. Their primary consequences are mostly caused by the macrovascular and microvascular bed degradation brought on by metabolic, hemodynamic, and inflammatory variables. However, research in recent years has expanded the target organ in T2DM to include the lung. Inflammatory lung diseases also impose a severe financial burden on global healthcare. T2DM has long been recognized as a significant comorbidity that influences the course of various respiratory disorders and their disease progress. The pathogenesis of the glycemic metabolic problem and endothelial microangiopathy of the respiratory disorders have garnered more attention lately, indicating that the two ailments have a shared history. This review aims to outline the connection between T2DM related endothelial cell dysfunction and concomitant respiratory diseases, including Coronavirus disease 2019 (COVID-19), asthma, chronic obstructive pulmonary disease (COPD) and idiopathic pulmonary fibrosis (IPF).

Infectious diseases associated with pediatric type 1 diabetes mellitus: A narrative review

Diabetes mellitus (DM) has been frequently associated with an impaired immune response against infectious agents, making affected patients at risk for more severe disease and sometimes causing worse outcomes. The recent COVID-19 pandemic has seriously affected patients with both diabetes, in particular those carrying comorbidities or with poor glycemic control. As regards pediatric diabetes mellitus, the availability of more accurate and technological tools for glycemic management and the improved markers of metabolic control might mitigate the negative impact of infections. Notably, good metabolic control of diabetes since its diagnosis reduces not only the risk of microangiopathic complications but also of impaired immune response to infectious diseases. Therefore, vaccinations are strongly recommended. Our paper aims to provide the most updated evidence regarding infectious diseases in type 1 pediatric DM.

Increased Frequency of Diabetic Ketoacidosis: The Link With COVID-19 Pandemic

AIMS

Diabetic ketoacidosis is the most severe metabolic derangement due to prolonged insulin deficiency as in type 1 diabetes. Diabetic ketoacidosis, a life-threatening condition, is often diagnosed late. A timely diagnosis is mandatory to prevent its consequences, mainly neurological. The COVID-19 pandemic and lockdown have reduced the availability of medical care and access to hospitals. The aim of our retrospective study was to compare the frequency of ketoacidosis at the diagnosis of type 1 diabetes between the lockdown-post lockdown period and the previous two calendar years, in order to evaluate the impact of the COVID-19 pandemic.

PATIENTS AND METHODS

We retrospectively assessed the clinical and metabolic data at the diagnosis of type 1 diabetes in children in the Liguria Region during 3 different time periods: calendar year 2018 (Period A), calendar year 2019 until February 23,2020 (Period B) and from February 24, 2020 onwards to March 31, 2021 (Period C).

RESULTS

We analyzed 99 patients with newly-diagnosed T1DM from 01/01/2018 to 31/03/2021. Briefly, a younger age at diagnosis of T1DM was observed in Period 2 compared to Period 1 (p = 0.03). The frequency of DKA at clinical onset of T1DM was similar in Period A (32.3%) and Period B (37.5%), while it significantly increased in Period C (61.1%) compared to Period B (37.5%) (p = 0.03). PH values were similar in Period A (7.29 ± 0.14) and Period B (7.27 ± 0.17), while they were significantly lower in Period C (7.21 ± 0.17) compared to Period B (p = 0.04).

CONCLUSIONS

An increase in the frequency of diabetic ketoacidosis has been documented in newly diagnosed pediatric patients in the Liguria Region during and after the lockdown period compared to previous calendar years. This increase could have been caused by the delay in diagnosis following the restrictions imposed by the lockdown with consequently reduced access to health care facilities. More information on the risks of ketoacidosis is desirable by means of social and medical awareness campaigns.

Wait-and-See Approach or Gluten-Free Diet Administration-The Rational Management of Potential Coeliac Disease

Potential celiac disease (PCD) is a heterogeneous disease; only some patients develop full celiac disease (CD), characterised by advanced atrophic changes in the small intestine. Few accurate prognostic factors exist for the progression of PCD; therefore, therapeutic decisions should be made on an individual basis in each case. Patients with clinical gastroenterological or parenteral symptoms often benefit from a gluten-free diet, and those left on a diet containing gluten should receive clinical, serological and histopathological supervision.

Prevalence of celiac disease in Iranian patients with type 1 diabetes: A systematic review and meta-analysis

Patients with type 1 diabetes mellitus (T1DM) are at high risk for celiac disease (CD) due to the common genetic background and interaction between environmental and immunological factors. The purpose of this systematic review and meta-analysis was to estimate the prevalence of CD among Iranian patients with type 1 diabetes. The search for articles was conducted using the following keywords: "celiac disease," "celiac," "coeliac disease," "diabetes," "Iran," and all other possible combinations of these terms. The following databases were searched from inception to June 2019: Scientific Information Database (SID), MagIran, Web of Science, PubMed, and Scopus. Meta-analysis was performed using the random-effects models, and the heterogeneity of results across the studies was assessed using the Cochran's Q test and quantified by the I² statistic. Data analysis was performed by Stata version 14. A total of 14 papers were included in the meta-analysis, involving 2030 Iranian patients with T1DM. The pooled prevalence of CD in patients with T1DM was 5% (95% CI 3-7). The prevalence of CD in Tehran (4%; 95% CI 1-6) was lower than in other provinces of the country (6%; 95% CI 4-8). Meta-regression analysis showed that, with increasing sample size, the prevalence of  CD was significantly reduced (p = 0.018).Given the adverse effects of CD , such as osteoporosis and malignancy (especially lymphoma), patients with T1DM must be screened for CD .

Age, HLA, and Sex Define a Marked Risk of Organ-Specific Autoimmunity in First-Degree Relatives of Patients With Type 1 Diabetes

OBJECTIVE

Autoimmune diseases can be diagnosed early through the detection of autoantibodies. The aim of this study was to determine the risk of organ-specific autoimmunity in individuals with a family history of type 1 diabetes.

RESEARCH DESIGN AND METHODS

The study cohort included 2,441 first-degree relatives of patients with type 1 diabetes who were prospectively followed from birth to a maximum of 29.4 years (median 13.2 years). All were tested regularly for the development of autoantibodies associated with type 1 diabetes (islet), celiac disease (transglutaminase), or thyroid autoimmunity (thyroid peroxidase). The outcome was defined as an autoantibody-positive status on two consecutive samples.

RESULTS

In total, 394 relatives developed one (n = 353) or more (n = 41) of the three disease-associated autoantibodies during follow-up. The risk by age 20 years was 8.0% (95% CI 6.8-9.2%) for islet autoantibodies, 6.3% (5.1-7.5%) for transglutaminase autoantibodies, 10.7% (8.9-12.5%) for thyroid peroxidase autoantibodies, and 21.5% (19.5-23.5%) for any of these autoantibodies. Each of the three disease-associated autoantibodies was defined by distinct HLA, sex, genetic, and age profiles. The risk of developing any of these autoantibodies was 56.5% (40.8-72.2%) in relatives with HLA DR3/DR3 and 44.4% (36.6-52.2%) in relatives with HLA DR3/DR4-DQ8.

CONCLUSIONS

Relatives of patients with type 1 diabetes have a very high risk of organ-specific autoimmunity. Appropriate counseling and genetic and autoantibody testing for multiple autoimmune diseases may be warranted for relatives of patients with type 1 diabetes.

Remission phase in children diagnosed with type 1 diabetes in years 2012 to 2013 in Silesia, Poland: An observational study

BACKGROUND/OBJECTIVE

The study aimed to analyze the frequency of partial remission (PR) and its association with chosen clinical and laboratory factors among pediatric patients with newly diagnosed type 1 diabetes (T1D). The long-term effect of PR on chosen parameters was also investigated.

METHODS

In 194 patients (95 girls) aged 8.1 ± 4.3 years, we analyzed data at T1D onset: glycemia, pH, C-peptide, antibodies, weight, and concomitant autoimmune diseases. Anthropometric parameters, daily insulin requirement (DIR), and HbA1c 2 and 4 years after T1D diagnosis were also analyzed. We determined PR based on HbA1c and DIR measurements at least every 3 months.

RESULTS

PR occurred in 59% of patients. Remitters had significantly higher pH (7.33 vs 7.28, P = 0.03), weight SD score (SDS) (0.25 vs -0.24, P = 0.002), and body mass index SDS (0.19 vs -0.66, P = 0.02) compared with non-remitters. Concomitant diseases correlated negatively with PR. Multivariate analysis indicated only pH at onset was an independent predictor of PR. pH was the most important factor associated with the beginning of PR. There was a positive correlation between the start and duration of PR. Four years after T1D onset remitters had lower HbA1c (7.24% vs 8.05%, 53 vs 63.9 mmol/mol, P < 0.001) and DIR (0.81 vs 1.08, P = 0.005).

CONCLUSIONS

PR occurred quite often and developed more frequently in children with higher: weight and BMI SDS, but the main factor influencing PR presence and duration was higher pH at T1D onset. There was a beneficial impact of PR on HbA1c and DIR after 4 years of treatment.

Targeted genotyping for the prediction of celiac disease autoimmunity development in patients with type 1 diabetes and their family members

BACKGROUND

Patients with type 1 diabetes (T1D) and their first-degree relatives (FDRs) have an increased risk of developing celiac disease (CD) compared to the general population. This is largely explained by the shared association with major histocompatibility class II human leukocyte antigen (HLA) DQ2 and/or DQ8 between the two disease states.

AIM

To describe the frequency of CD autoimmunity (CDA) and the distribution of HLA and haptoglobin genotypes in patients with T1D and their FDRs. Additionally, we aimed at identifying predictors associated with an increased risk of developing CDA in patients with T1D and their family members.

METHODS

We obtained clinical information and blood samples from 1027 participants (302 with T1D and 725 FDRs) over a five-year period. Samples were tested for autoantibodies associated with CD, HLA-DQ alleles, and haptoglobin genotype. We fit univariate and multiple logistic regression models for CDA separately for subjects with T1D and for FDRs of subjects with T1D.

RESULTS

Implementation of a screening program increased the frequency of CDA by 2-fold in participants with T1D and 2.8-fold in their FDRs. Multivariate analysis found that, in participants with T1D, having both DR7-DQ2 and DR4-DQ8 was associated with an increased frequency of CDA. In FDRs of T1D patients, reported CD in the family was associated with an increased frequency of CDA during screening. Haptoglobin 2 genotype was not associated with developing CDA in the multivariate analysis.

CONCLUSION

Patients with T1D and their FDRs have a high frequency of CDA. Carrying both DR7-DQ2 and DR4-DQ8 was associated with development of CDA in patients with T1D.

Environmental Factors Associated With Type 1 Diabetes

Type 1 diabetes (T1D) is a chronic autoimmune disorder that leads to progressive pancreatic ß-cell destruction and culminates in absolute insulin deficiency and stable hyperglycaemia. It is very likely that environmental factors play a role in triggering islet autoimmunity. Knowing whether they have true relevance in favoring T1D development is essential for the effective prevention of the disease. Moreover, prevention could be obtained directly interfering with the development of autoimmunity through autoantigen-based immunotherapy. In this narrative review, the present possibilities for the prevention of T1D are discussed. Presently, interventions to prevent T1D are generally made in subjects in whom autoimmunity is already activated and autoantibodies against pancreatic cell components have been detected. Practically, the goal is to slow down the immune process by preserving the normal structure of the pancreatic islets for as long as possible. Unfortunately, presently methods able to avoid the risk of autoimmune activation are not available. Elimination of environmental factors associated with T1D development, reverse of epigenetic modifications that favor initiation of autoimmunity in subjects exposed to environmental factors and use of autoantigen-based immunotherapy are possible approaches, although for all these measures definitive conclusions cannot be drawn. However, the road is traced and it is possible that in a not so distant future an effective prevention of the disease to all the subjects at risk can be offered.

HLA and non-HLA genes and familial predisposition to autoimmune diseases in families with a child affected by type 1 diabetes

Genetic predisposition could be assumed to be causing clustering of autoimmunity in individuals and families. We tested whether HLA and non-HLA loci associate with such clustering of autoimmunity. We included 1,745 children with type 1 diabetes from the Finnish Pediatric Diabetes Register. Data on personal or family history of autoimmune diseases were collected with a structured questionnaire and, for a subset, with a detailed search for celiac disease and autoimmune thyroid disease. Children with multiple autoimmune diseases or with multiple affected first- or second-degree relatives were identified. We analysed type 1 diabetes related HLA class II haplotypes and genotyped 41 single nucleotide polymorphisms (SNPs) outside the HLA region. The HLA-DR4-DQ8 haplotype was associated with having type 1 diabetes only whereas the HLA-DR3-DQ2 haplotype was more common in children with multiple autoimmune diseases. Children with multiple autoimmune diseases showed nominal association with RGS1 (rs2816316), and children coming from an autoimmune family with rs11711054 (CCR3-CCR5). In multivariate analyses, the overall effect of non-HLA SNPs on both phenotypes was evident, associations with RGS1 and CCR3-CCR5 region were confirmed and additional associations were implicated: NRP1, FUT2, and CD69 for children with multiple autoimmune diseases. In conclusion, HLA-DR3-DQ2 haplotype and some non-HLA SNPs contribute to the clustering of autoimmune diseases in children with type 1 diabetes and in their families.