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Antonius E, Kho Y, Roovers L, Wessels M. With or without biopsy in coeliac children?-Impact on dietary compliance and quality of life. Eur J Pediatr 2024; 183:4253-4258. [PMID: 39028372 DOI: 10.1007/s00431-024-05686-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 06/03/2024] [Accepted: 07/10/2024] [Indexed: 07/20/2024]
Abstract
Critics of the ESPGHAN guidelines on CD question the acceptance of the no-biopsy policy by patients and parents against the backdrop of a lifelong diagnosis. The aim of this study was to investigate the impact of the no-biopsy approach on dietary adherence and health-related quality of life (HRQOL). In this retrospective cohort study, patients ≤ 18 years diagnosed with CD between 2007 and 2017 were sent two questionnaires: a dietary interview and a CD-specific HRQOL questionnaire (CDDUX). Included patients were divided into group A (with biopsies <2012), B (with biopsies >2012) and C (without biopsies >2012). Fisher exact test and ANOVA were used to analyze the impact of the new diagnostic strategy. Forty-seven percent (82/173 patients) consented to participate in the study. Of them, 63% had a biopsy-confirmed diagnosis (40% before 2012 (group A), 23% after 2012 (group B)), and 37% were diagnosed without biopsies (group C). Dietary compliance was similar in all groups (p = 0.67). Group A scored significantly better on the subscale 'Having CD' compared to both groups diagnosed after 2012 (p = 0.003). Group A and group C seemed to score better on the total CDDUCX score when compared to group B (86 and 80% versus 61% respectively, p = 0.13). This was also observed within the subscale Diet; Group A and C scored significantly better than group B (62 and 72% versus 39% respectively, p = 0.09). CONCLUSIONS Omitting duodenal biopsies in the diagnostic approach of our CD cohort had no adverse effect on dietary adherence and HRQOL. WHAT IS KNOWN • Since the publication of the ESPGHAN guideline of 2012, duodenal biopsies are no longer obligatory in the diagnostic approach of CD if IgA-antibodies for transglutaminase 2 are ≥10× ULN, endomysial antibodies are positive in a second blood sample and the patient/family agrees with the no-biopsy approach. • Literature on the effect of the no-biopsy approach on dietary adherence and HRQOL is scarce. WHAT IS NEW • Omitting duodenal biopsies does not influence dietary adherence and quality of life. • In our cohort, lower quality of life measured with the CDDUX subscale 'Having CD' is more likely to be related to shorter disease duration than to the diagnostic approach.
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Affiliation(s)
- Evelien Antonius
- Department of Paediatrics, Rijnstate Hospital, Wagnerlaan 55, 6815 AD, Arnhem, the Netherlands
| | - Yenny Kho
- Department of Paediatrics, Rijnstate Hospital, Wagnerlaan 55, 6815 AD, Arnhem, the Netherlands
| | - Lian Roovers
- Clinical Research Center, Rijnstate Hospital, Arnhem, the Netherlands
| | - Margreet Wessels
- Department of Paediatrics, Rijnstate Hospital, Wagnerlaan 55, 6815 AD, Arnhem, the Netherlands.
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Kivelä L, Lindfors K, Lundin KEA, Størdal K. Review article: Faecal biomarkers for assessing small intestinal damage in coeliac disease and environmental enteropathy. Aliment Pharmacol Ther 2024; 60:988-1004. [PMID: 39233618 DOI: 10.1111/apt.18234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 06/19/2024] [Accepted: 08/20/2024] [Indexed: 09/06/2024]
Abstract
BACKGROUND In coeliac disease and environmental enteropathy, dietary gluten and enteric infections cause reversible inflammation and morphological changes to the small intestinal mucosa that can be detected in biopsy samples obtained by endoscopy. However, there is a clear need for non-invasive biomarkers. Constant shedding of mucosal material into the bowel lumen and faeces, together with easy availability of stool, makes it an interesting sample matrix. AIMS To conduct a systematic literature search and summarize the existing evidence for host mucosa-derived faecal biomarkers in evaluating small intestinal damage. METHODS We searched for studies on PubMed (MEDLINE) until 1 March 2024. RESULTS We identified 494 studies and included 35 original case-control and cohort studies. These assessed host mucosal transcripts and 14 other markers aiming specifically to reflect inflammation and cell-mediated, innate and gluten-induced immune responses. In coeliac disease, faecal calprotectin and anti-gliadin, tissue transglutaminase, endomysium and deamidated gliadin peptide antibodies were the most studied but with inconsistent results. Single studies reported positive findings about microRNA transcripts, β-defensin-2, lipocalin-2, zonulin-related proteins and angiotensin-converting enzyme. In environmental enteropathy, a non-significant association was reported between calprotectin and urine lactulose/mannitol ratio; there were conflicting results for neopterin, myeloperoxidase and host transcripts. Single studies reported a positive association for lactoferrin, and a negative association for regenerating islet-derived protein 1. Studies comparing faecal markers against small intestinal biopsy findings were not identified in environmental enteropathy. CONCLUSIONS Further studies are needed to determine reliable faecal markers as a proxy for small intestinal mucosal damage.
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Affiliation(s)
- Laura Kivelä
- Department of Pediatric Research, Faculty of Medicine, University of Oslo, Oslo, Norway
- Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Children's Hospital, Helsinki University Hospital, Helsinki, Finland
- Department of Pediatrics, Tampere University Hospital, Wellbeing Services County of Pirkanmaa, Tampere, Finland
| | - Katri Lindfors
- Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Knut E A Lundin
- Department of Gastroenterology, Oslo University Hospital Rikshospitalet, Oslo, Norway
- Norwegian Coeliac Disease Research Centre, Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Ketil Størdal
- Department of Pediatric Research, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
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3
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Gan J, Nazarian S, Teare J, Darzi A, Ashrafian H, Thompson AJ. A case for improved assessment of gut permeability: a meta-analysis quantifying the lactulose:mannitol ratio in coeliac and Crohn's disease. BMC Gastroenterol 2022; 22:16. [PMID: 35012471 PMCID: PMC8751358 DOI: 10.1186/s12876-021-02082-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 12/23/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND A widely used method in assessing small bowel permeability is the lactulose:mannitol test, where the lactulose:mannitol ratio (LMR) is measured. However, there is discrepancy in how the test is conducted and in the values of LMR obtained across studies. This meta-analysis aims to determine LMR in healthy subjects, coeliac and Crohn's disease. METHODS A literature search was performed using PRISMA guidance to identify studies assessing LMR in coeliac or Crohn's disease. 19 studies included in the meta-analysis measured gut permeability in coeliac disease, 17 studies in Crohn's disease. Outcomes of interest were LMR values and comparisons of standard mean difference (SMD) and weighted mean difference (WMD) in healthy controls, inactive Crohn's, active Crohn's, treated coeliac and untreated coeliac. Pooled estimates of differences in LMR were calculated using the random effects model. RESULTS Pooled LMR in healthy controls was 0.014 (95% CI: 0.006-0.022) while pooled LMRs in untreated and treated coeliac were 0.133 (95% CI: 0.089-0.178) and 0.037 (95% CI: 0.019-0.055). In active and inactive Crohn's disease, pooled LMRs were 0.093 (95% CI: 0.031-0.156) and 0.028 (95% CI: 0.015-0.041). Significant differences were observed in LMR between: (1) healthy controls and treated coeliacs (SMD = 0.409 95% CI 0.034 to 0.783, p = 0.032), (2) healthy controls and untreated coeliacs (SMD = 1.362 95% CI: 0.740 to 1.984, p < 0.001), (3) treated coeliacs and untreated coeliacs (SMD = 0.722 95% CI: 0.286 to 1.157, p = 0.001), (4) healthy controls and inactive Crohn's (SMD = 1.265 95% CI: 0.845 to 1.686, p < 0.001), (5) healthy controls and active Crohn's (SMD = 2.868 95% CI: 2.112 to 3.623, p < 0.001), and (6) active Crohn's and inactive Crohn's (SMD = 1.429 (95% CI: 0.580 to 2.278, p = 0.001). High heterogeneity was observed, which was attributed to variability in protocols used across different studies. CONCLUSION The use of gut permeability measurements in screening and monitoring of coeliac and Crohn's disease is promising. LMR is useful in performing this function with significant limitations. More robust alternative tests with higher degrees of clinical evidence are needed if measurements of gut permeability are to find widespread clinical use.
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Affiliation(s)
- Jonathan Gan
- Department of Surgery and Cancer, Institute of Global Health Innovation, St Mary's Hospital, Imperial College London, 10th Floor, Queen Elizabeth the Queen Mother WingSouth Wharf Road, London, W2 1NY, UK.
| | - Scarlet Nazarian
- Department of Surgery and Cancer, Institute of Global Health Innovation, St Mary's Hospital, Imperial College London, 10th Floor, Queen Elizabeth the Queen Mother WingSouth Wharf Road, London, W2 1NY, UK
| | - Julian Teare
- Department of Surgery and Cancer, Institute of Global Health Innovation, St Mary's Hospital, Imperial College London, 10th Floor, Queen Elizabeth the Queen Mother WingSouth Wharf Road, London, W2 1NY, UK
| | - Ara Darzi
- Department of Surgery and Cancer, Institute of Global Health Innovation, St Mary's Hospital, Imperial College London, 10th Floor, Queen Elizabeth the Queen Mother WingSouth Wharf Road, London, W2 1NY, UK
| | - Hutan Ashrafian
- Department of Surgery and Cancer, Institute of Global Health Innovation, St Mary's Hospital, Imperial College London, 10th Floor, Queen Elizabeth the Queen Mother WingSouth Wharf Road, London, W2 1NY, UK
| | - Alex J Thompson
- Department of Surgery and Cancer, Institute of Global Health Innovation, St Mary's Hospital, Imperial College London, 10th Floor, Queen Elizabeth the Queen Mother WingSouth Wharf Road, London, W2 1NY, UK
- Hamlyn Centre for Robotic Surgery, St Mary's Hospital, Imperial College London, Level 3 Paterson BuildingSouth Wharf Road, London, W2 1NY, UK
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Kamilova AT, Azizova GK, Umarnazarova ZE, Abdullaeva DA, Geller SI. The Activity of Antimicrobial Peptides in Pediatric Celiac Disease. Front Pediatr 2022; 10:873793. [PMID: 35733815 PMCID: PMC9208658 DOI: 10.3389/fped.2022.873793] [Citation(s) in RCA: 3] [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: 02/11/2022] [Accepted: 04/27/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Celiac disease (CD) is an immune-mediated disorder of the gut in which innate and adaptive responses are involved. Antimicrobial peptides (AMPs) constitute an arsenal of innate immunity regulators of paramount importance in the gut. However, the role of AMPs in CD is unclear. AIMS To evaluate the levels of fecal β-defensin-2, fecal calprotectin (FC), and antibodies against bactericidal/permeability-increasing protein (BPI) in the serum of children with active CD and to compare them with those of healthy controls (HCs). METHODS We examined 76 children with recently diagnosed CD between the age of 2-10 years (average age: 6.1 ± 1.2 years) and 32 HC (average age: 6.2 ± 3.8 years) in this study. We evaluated the level of fecal β-defensin-2 and FC levels in coprofiltrates, and the level of anti-BPI antibodies in blood serum. Correlation relationships between the parameters were assessed according to Pearson correlation coefficient. RESULTS Fecal β-defensin-2 concentration was greater in the CD group than in HC group, amounting to 99.6 ± 15.5 ng/mL and 64.0 ± 2.4 ng/mL, respectively (p < 0.02). The level of FC in the CD children was 35.4 ± 8.1 μg/g, while that in the control group was 19.1 ± 1.1 μg/g, (p < 0.05), representing a slightly increase. The concentration of anti-BPI antibodies in the CD and HC groups was 35.9 ± 10.1 U/mL and 5.2 ± 3.2 U/mL, respectively (p < 0.002). There was a strong and direct correlation between fecal β-defensin-2 and FC (r = 0.69), as well as a direct but weak relationship between fecal β-defensin-2 and anti-BPI antibodies (r = 0.35). CONCLUSIONS Our data reinforce that fecal β-defensin-2 and anti-BPI antibodies are greatly increased in patients with active CD. These biomarkers may be components of epithelial innate immunity in the intestine, with each having a distinct functional role in intestinal6 mucosal defense.
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Affiliation(s)
- Altinoy T Kamilova
- Gastroenterology Department of Republican Specialized Scientific-Practical Medical Center of Pediatrics Ministry of Health of Republic of Uzbekistan, Tashkent, Uzbekistan
| | - Gulnoza K Azizova
- Gastroenterology Department of Republican Specialized Scientific-Practical Medical Center of Pediatrics Ministry of Health of Republic of Uzbekistan, Tashkent, Uzbekistan
| | - Zulkhumar E Umarnazarova
- Gastroenterology Department of Republican Specialized Scientific-Practical Medical Center of Pediatrics Ministry of Health of Republic of Uzbekistan, Tashkent, Uzbekistan
| | - Dilrabo A Abdullaeva
- Gastroenterology Department of Republican Specialized Scientific-Practical Medical Center of Pediatrics Ministry of Health of Republic of Uzbekistan, Tashkent, Uzbekistan
| | - Svetlana I Geller
- Gastroenterology Department of Republican Specialized Scientific-Practical Medical Center of Pediatrics Ministry of Health of Republic of Uzbekistan, Tashkent, Uzbekistan
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Sample D, Fouhse J, King S, Huynh HQ, Dieleman LA, Willing BP, Turner J. Baseline Fecal Microbiota in Pediatric Patients With Celiac Disease Is Similar to Controls But Dissimilar After 1 Year on the Gluten-Free Diet. JPGN REPORTS 2021; 2:e127. [PMID: 37206457 PMCID: PMC10191547 DOI: 10.1097/pg9.0000000000000127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 08/02/2021] [Indexed: 05/21/2023]
Abstract
The objectives of this pilot study were to examine fecal microbiota composition of pediatric patients with celiac disease (CD) before and after a 1-year gluten-free diet (GFD) and to determine the association with symptoms and anti-tissue transglutaminase (aTTG) antibody. Methods Stool samples were obtained from pediatric patients with CD and from healthy controls. Patients were classified by the presence (diarrhea, abdominal pain, weight loss) or absence (asymptomatic, headache, fatigue, etc.) of typical CD gastrointestinal symptoms and by aTTG normalization post-GFD intervention (< 7 U/mL). Fecal microbial composition was measured using 16S ribosomal RNA gene amplicon sequencing of the V3-V4 region. Results At diagnosis, 13 of 22 patients with CD had typical gastrointestinal symptoms, the remaining patients having atypical or asymptomatic presentations. After a 1-year GFD, all symptomatic patients improved and 9 of 19 had normalized aTTG. Prior to GFD, no distinct microbial signature was observed between patients and controls (P = 0.39). Post-GFD, patients with CD had a unique microbial signature with reductions in known fiber-degrading bacteria, including Blautia, Dorea, Lactobacillus, and Prevotella compared with controls. Within the patients with CD, microbial composition was not associated with reported symptom presentation or aTTG normalization. Conclusions Pediatric patients with CD only had a unique microbial signature compared with healthy controls when placed on the GFD. These results suggest that pediatric patients with CD may not have a unique fecal microbial signature indicative of inherent dysbiosis, in contrast to that suggested for older patients. In children with CD, diet may play a role in shaping microbial composition more so than disease status.
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Affiliation(s)
- Dory Sample
- From the Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Janelle Fouhse
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, AB, Canada
| | - Seema King
- Department of Medicine, Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Hien Q. Huynh
- From the Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Levinus A. Dieleman
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Benjamin P. Willing
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, AB, Canada
| | - Justine Turner
- From the Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
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6
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The Multiomics Analyses of Fecal Matrix and Its Significance to Coeliac Disease Gut Profiling. Int J Mol Sci 2021; 22:ijms22041965. [PMID: 33671197 PMCID: PMC7922330 DOI: 10.3390/ijms22041965] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 02/08/2021] [Accepted: 02/11/2021] [Indexed: 12/15/2022] Open
Abstract
Gastrointestinal (GIT) diseases have risen globally in recent years, and early detection of the host’s gut microbiota, typically through fecal material, has become a crucial component for rapid diagnosis of such diseases. Human fecal material is a complex substance composed of undigested macromolecules and particles, and the processing of such matter is a challenge due to the unstable nature of its products and the complexity of the matrix. The identification of these products can be used as an indication for present and future diseases; however, many researchers focus on one variable or marker looking for specific biomarkers of disease. Therefore, the combination of genomics, transcriptomics, proteomics and metabonomics can give a detailed and complete insight into the gut environment. The proper sample collection, sample preparation and accurate analytical methods play a crucial role in generating precise microbial data and hypotheses in gut microbiome research, as well as multivariate data analysis in determining the gut microbiome functionality in regard to diseases. This review summarizes fecal sample protocols involved in profiling coeliac disease.
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Meijer CR, Schweizer JJ, Peeters A, Putter H, Mearin ML. Efficient implementation of the 'non-biopsy approach' for the diagnosis of childhood celiac disease in the Netherlands: a national prospective evaluation 2010-2013. Eur J Pediatr 2021; 180:2485-2492. [PMID: 33856540 PMCID: PMC8285331 DOI: 10.1007/s00431-021-04068-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/11/2021] [Accepted: 04/04/2021] [Indexed: 01/11/2023]
Abstract
The aim of this study was (1) to prospectively evaluate the nationwide implementation of the ESPGHAN-guidelines for the diagnosis of celiac disease (CD), (2) to investigate the incidence and clinical presentation of diagnosed childhood CD (0-14 years) in the Netherlands, and (3) to compare the findings with national survey data from 1975 to 1990 and 1993 to 2000 using the same approach. From 2010 to 2013, all practicing paediatricians were invited to report new celiac diagnoses to the Dutch Pediatric Surveillance Unit. Data were collected via questionnaires. A total of 1107 children with newly diagnosed CD were reported (mean age, 5.8 years; range, 10 months-14.9 years; 60.5% female). After the introduction of the non-biopsy approach in 2012, 75% of the diagnoses were made according to the guideline with a significant decrease of 46.3% in biopsies. The use of EMA and HLA-typing significantly increased with 25.8% and 62.1%, respectively. The overall incidence rate of childhood CD was 8.8-fold higher than in 1975-1990 and 2.0-fold higher than in 1993-2000. During the study period, the prevalence of diagnosed CD was 0.14%, far below 0.7% of CD identified via screening in the general Dutch paediatric population. Clinical presentation has shifted towards less severe and extra-intestinal symptoms.Conclusion: ESPGHAN guidelines for CD diagnosis in children were effectively and rapidly implemented in the Netherlands. Incidence of diagnosed CD among children is still significantly rising with a continuous changing clinical presentation. Despite the increasing incidence of diagnoses, significant underdiagnosis still remains. What is Known: • Since 2000 the incidence of diagnosed childhood CD in the Netherlands has shown a steady rise. • The rise in incidence has been accompanied by a changing clinical presentation at diagnosis. What is New: • The ESPGHAN guidelines 2012 for CD diagnosis were effectively and rapidly implemented in the Netherlands. • The incidence of diagnosed childhood CD in the Netherlands has continued to rise significantly during the reported period.
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Affiliation(s)
- Caroline R. Meijer
- Department of Paediatrics, Willem Alexander Children’s Hospital, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Joachim J. Schweizer
- Department of Paediatrics, Willem Alexander Children’s Hospital, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Anne Peeters
- Department of Paediatrics, Willem Alexander Children’s Hospital, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Hein Putter
- Department of Medical Statistics, Leiden University Medical Centre, Leiden, The Netherlands
| | - M. Luisa Mearin
- Department of Paediatrics, Willem Alexander Children’s Hospital, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
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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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Sharp SA, Jones SE, Kimmitt RA, Weedon MN, Halpin AM, Wood AR, Beaumont RN, King S, van Heel DA, Campbell PM, Hagopian WA, Turner JM, Oram RA. A single nucleotide polymorphism genetic risk score to aid diagnosis of coeliac disease: a pilot study in clinical care. Aliment Pharmacol Ther 2020; 52:1165-1173. [PMID: 32790217 DOI: 10.1111/apt.15826] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/05/2020] [Accepted: 05/10/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Single nucleotide polymorphism-based genetic risk scores (GRS) model genetic risk as a continuum and can discriminate coeliac disease but have not been validated in clinic. Human leukocyte antigen (HLA) DQ gene testing is available in clinic but does not include non-HLA attributed risk and is limited by discrete risk stratification. AIMS To accurately characterise both HLA and non-HLA coeliac disease genetic risk as a single nucleotide polymorphism-based GRS and evaluate diagnostic utility. METHODS We developed a 42 single nucleotide polymorphism coeliac disease GRS from a European case-control study (12 041 cases vs 12 228 controls) using HLA-DQ imputation and published genome-wide association studies. We validated the GRS in UK Biobank (1237 cases) and developed direct genotyping assays. We tested the coeliac disease GRS in a pilot clinical cohort of 128 children presenting with suspected coeliac disease. RESULTS The GRS was more discriminative of coeliac disease than HLA-DQ stratification in UK Biobank (receiver operating characteristic area under the curve [ROC-AUC] = 0.88 [95% CIs: 0.87-0.89] vs 0.82 [95% CIs: 0.80-0.83]). We demonstrated similar discrimination in the pilot clinical cohort (114 cases vs 40 controls, ROC-AUC = 0.84 [95% CIs: 0.76-0.91]). As a rule-out test, no children with coeliac disease in the clinical cohort had a GRS below 38th population centile. CONCLUSIONS A single nucleotide polymorphism-based GRS may offer more effective and cost-efficient testing of coeliac disease genetic risk in comparison to HLA-DQ stratification. As a comparatively inexpensive test it could facilitate non-invasive coeliac disease diagnosis but needs detailed assessment in the context of other diagnostic tests and against current diagnostic algorithms.
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Affiliation(s)
- Seth A Sharp
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Samuel E Jones
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | | | - Michael N Weedon
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Anne M Halpin
- Division of Nephrology and Transplant Immunology, University of Alberta, Edmonton, AB, Canada
| | - Andrew R Wood
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Robin N Beaumont
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Seema King
- Faculty of Medicine and Dentistry, Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - David A van Heel
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Patricia M Campbell
- Division of Nephrology and Transplant Immunology, University of Alberta, Edmonton, AB, Canada
| | | | - Justine M Turner
- Faculty of Medicine and Dentistry, Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Richard A Oram
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK.,Royal Devon & Exeter, NHS Foundation Trust, Exeter, UK
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11
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A Survey of Fecal Calprotectin in Children with Newly Diagnosed Celiac Disease with Villous Atrophy. ACTA ACUST UNITED AC 2019. [DOI: 10.5812/semj.84514] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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12
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Abstract
Celiac disease is a common autoimmune disorder of the small intestine, triggered by an immunological response to the gluten present in wheat, barley, and rye in individuals who are genetically at risk. A key to reducing the complications of this disease is early diagnosis, preferably in childhood, and consuming a lifelong gluten-free diet once diagnosis is confirmed. Yet, the diagnosis of celiac disease is often considerably delayed, exposing patients to needless suffering and morbidity. It is also difficult to confirm histologically if dietary gluten has been restricted prior to obtaining a diagnostic biopsy, a significant problem given the current growing popularity of gluten-free diets. Furthermore, failure to understand or follow current guidelines means physicians may recommend patients commence the gluten-free diet before initiating referral to a gastroenterologist. Finally, adding further confusion, pediatric guidelines in Europe support a diagnosis based on serology rather than on histology, whereas those based in North America do not. The purpose of this review is to discuss these issues and other controversies in the diagnosis of celiac disease and to consider ways to optimize diagnosis across the lifespan.
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Affiliation(s)
- Justine M Turner
- Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, University of Alberta, 11405-87 Avenue, Edmonton, AB, T6G 1C9, Canada.
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Avoiding Small Intestinal Biopsies for Diagnosis of Celiac Disease in Children: A Reliable Strategy for All Patients? J Pediatr Gastroenterol Nutr 2018; 66:785-788. [PMID: 29135820 DOI: 10.1097/mpg.0000000000001834] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Current reports applying ESPGHAN exception criteria (EEC) to diagnose celiac disease (CD) without duodenal biopsies indicate that a high percentage of patients with CD may be identified when applied correctly in specialized settings. Application of the EEC, however, in "daily life conditions" at the different levels of medical services is not clear. METHODS EEC was applied to 130 pediatric patients evaluated for CD at 5 public hospitals in Santiago, Chile, during 2010 to 2015. Clinical presentation, serum anti-tissue transglutaminase 2 and anti-endomysium antibodies (EMA), genotyping, and small intestinal histology were obtained from clinical charts. RESULTS A total of 78 of 130 patients reviewed had some of the data required for analysis, but EMA was determined in 54% and genotyping in 2.3% of patients, limiting the study. After offering free genotyping, only 12 of 78 (15%) had all data required for EEC application. In this small group, 10 of 12 (83.3%) patients could avoid duodenal biopsies and 2 (16.7%) with potential CD were misdiagnosed. Main reasons for not doing EMA and genotyping were that they are expensive, unavailable in the local health care center, and considered "not necessary" for diagnosis. CONCLUSION Limited resources in clinical settings reduce availability of EMA and genotyping, making application of EEC criteria difficult and only possible only in 15% of our patients. Within this subgroup, biopsies could be avoided in 83.3%, and 16.7% of patients with potential CD were misdiagnosed. Insufficient studies and incorrect interpretation of EEC contributed to incomplete assessment in 52 of 130 (40%) patients. The Chilean public health system is likely representative of several others present in developing and developed countries.
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Tissue Transglutaminase Levels Are Not Sufficient to Diagnose Celiac Disease in North America Without Intestinal Biopsies: Don't Throw the Baby Out with the Bathwater. Dig Dis Sci 2017; 62:3256-3258. [PMID: 28916977 DOI: 10.1007/s10620-017-4744-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 08/30/2017] [Indexed: 12/09/2022]
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Paul SP, Harries SL, Basude D. Barriers to implementing the revised ESPGHAN guidelines for coeliac disease in children: a cross-sectional survey of coeliac screen reporting in laboratories in England. Arch Dis Child 2017; 102:942-946. [PMID: 28483757 DOI: 10.1136/archdischild-2016-312027] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 03/27/2017] [Accepted: 03/30/2017] [Indexed: 01/17/2023]
Abstract
BACKGROUND European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) guidelines for diagnosing paediatric coeliac disease (CD) were revised in 2012. This enabled serological diagnosis in a selective group of symptomatic children using anti-tissue transglutaminase (anti-tTG) titre, antiendomysial antibodies (EMA) and HLA DQ2/DQ8 status. However, observing variations in the availability of serological tests for CD within our region, we conducted a countrywide survey to explore the diversity of these tests for all paediatric centres. METHODS A nationwide telephone survey among biomedical scientists based in 139 National Health Service hospital trusts providing paediatric services in England was conducted by a single interviewer over a defined 3-week period. Respondents were asked about type of anti-tTG assay, the upper limit of normal (ULN) for anti-tTG titres, availability of EMA and reporting of IgA concentration. RESULTS Responses were available from 134 (96.4%) laboratories. Anti-tTG titres are performed by 83/134 (62.6%) laboratories and 68/83 (81.4%) of those also offered EMA testing. Four different anti-tTG assays are available in England, but there are 10 different ULN values. The range for ULN varies widely from 4 to 30 IU/mL. Automatic reporting of total IgA concentration for a coeliac serology request occurs in only 24/83 laboratories. CONCLUSIONS Significant heterogeneity exists for serological tests for CD in particular anti-tTG titre reporting even within the same regions. This potentially affects the interpretation of the results by clinicians diagnosing CD and hence harbouring diagnostic inconsistencies in their practice. Standardisation especially of the anti-tTG assays and routine reporting of IgA concentration nationally should be strongly considered to support the current diagnostic process for CD.
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Affiliation(s)
- Siba Prosad Paul
- Department of Paediatric Gastroenterology, Bristol Royal Hospital for Children, Bristol, UK
| | | | - Dharamveer Basude
- Department of Paediatric Gastroenterology, Bristol Royal Hospital for Children, Bristol, UK.,Medical School, University of Bristol, Bristol, UK
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