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Deane KD, Van Hoovels L, Joy VE, Olschowka N, Bossuyt X. From autoantibody test results to decision making: Incorporating likelihood ratios within medical practice. Autoimmun Rev 2024; 23:103537. [PMID: 38565401 DOI: 10.1016/j.autrev.2024.103537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 03/27/2024] [Accepted: 03/28/2024] [Indexed: 04/04/2024]
Abstract
Autoantibodies are important laboratory markers to support diagnosis of autoimmune diseases. Interpretation of autoantibodies is classically done in a dichotomous way (positive versus negative). Yet, interpretation of autoantibody test results can be improved by reporting likelihood ratios. Likelihood ratios convey information on how much more/less likely a test result is in individuals with the disease compared to individuals without the disease. It incorporates information on the antibody level (the higher the antibody level, the higher the association with the disease), which is helpful for (differential) diagnosis. Likelihood ratios are unit-independent and allow users to harmonize test result interpretation. When the likelihood ratio is combined with information on the pre-test probability, post-test probability can be appraised. In this review, the applicability of likelihood ratio in autoimmune diagnostics will be reviewed from the perspective of the clinician, the laboratory professional and the in vitro diagnostic industry.
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Affiliation(s)
- Kevin D Deane
- University of Colorado, Anschutz Medical Campus, Aurora, CO, USA.
| | - Lieve Van Hoovels
- Department of Laboratory Medicine, OLV Hospital, Aalst, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium.
| | | | | | - Xavier Bossuyt
- Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium; Department of Laboratory Medicine, UZ Leuven, Leuven, Belgium.
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Shiha MG, Nandi N, Raju SA, Wild G, Cross SS, Singh P, Elli L, Makharia GK, Sanders DS, Penny HA. Accuracy of the No-Biopsy Approach for the Diagnosis of Celiac Disease in Adults: A Systematic Review and Meta-Analysis. Gastroenterology 2024; 166:620-630. [PMID: 38176661 DOI: 10.1053/j.gastro.2023.12.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 11/26/2023] [Accepted: 12/19/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND & AIMS Current international guidelines recommend duodenal biopsies to confirm the diagnosis of celiac disease in adult patients. However, growing evidence suggests that immunoglobulin A (IgA) anti-tissue transglutaminase (tTg) antibody levels ≥10 times the upper limit of normal (ULN) can accurately predict celiac disease, eliminating the need for biopsy. We performed a systematic review and meta-analysis to evaluate the accuracy of the no-biopsy approach to confirm the diagnosis of celiac disease in adults. METHODS We systematically searched MEDLINE, EMBASE, Cochrane Library, and Web of Science from January 1998 to October 2023 for studies reporting the sensitivity and specificity of IgA-tTG ≥10×ULN against duodenal biopsies (Marsh grade ≥2) in adults with suspected celiac disease. We used a bivariate random effects model to calculate the summary estimates of sensitivity, specificity, and positive and negative likelihood ratios. The positive and negative likelihood ratios were used to calculate the positive predictive value of the no-biopsy approach across different pretest probabilities of celiac disease. The methodological quality of the included studies was evaluated using the QUADAS-2 tool. This study was registered with PROSPERO, number CRD42023398812. RESULTS A total of 18 studies comprising 12,103 participants from 15 countries were included. The pooled prevalence of biopsy-proven celiac disease in the included studies was 62% (95% confidence interval [CI], 40%-83%). The proportion of patients with IgA-tTG ≥10×ULN was 32% (95% CI, 24%-40%). The summary sensitivity of IgA-tTG ≥10×ULN was 51% (95% CI, 42%-60%), and the summary specificity was 100% (95% CI, 98%-100%). The area under the summary receiver operating characteristic curve was 0.83 (95% CI, 0.77 - 0.89). The positive predictive value of the no-biopsy approach to identify patients with celiac disease was 65%, 88%, 95%, and 99% if celiac disease prevalence was 1%, 4%, 10%, and 40%, respectively. Between-study heterogeneity was moderate (I2 =30.3%), and additional sensitivity analyses did not significantly alter our findings. Only 1 study had a low risk of bias across all domains. CONCLUSION The results of this meta-analysis suggest that selected adult patients with IgA-tTG ≥10×ULN and a moderate to high pretest probability of celiac disease could be diagnosed without undergoing invasive endoscopy and duodenal biopsy.
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Affiliation(s)
- Mohamed G Shiha
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, United Kingdom; Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom.
| | - Nicoletta Nandi
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, United Kingdom; Center for Prevention and Diagnosis of Celiac Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Suneil A Raju
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, United Kingdom; Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom
| | - Graeme Wild
- Department of Immunology, Sheffield Teaching Hospitals, Sheffield, United Kingdom
| | - Simon S Cross
- Department of Histopathology, Sheffield Teaching Hospitals, Sheffield, United Kingdom
| | - Prashant Singh
- Division of Gastroenterology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Luca Elli
- Center for Prevention and Diagnosis of Celiac Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Govind K Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - David S Sanders
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, United Kingdom; Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom
| | - Hugo A Penny
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, United Kingdom; Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom
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Bossuyt X, Van Hoovels L. Reporting Likelihood Ratio in Autoimmune Serology: Just a Theory or Feasible in Practice? Clin Chem 2024; 70:482-485. [PMID: 38300842 DOI: 10.1093/clinchem/hvad222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 11/28/2023] [Indexed: 02/03/2024]
Affiliation(s)
- Xavier Bossuyt
- Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, Clinical and Diagnostic Immunology, KU Leuven, Leuven, Belgium
| | - Lieve Van Hoovels
- Department of Microbiology, Immunology and Transplantation, Clinical and Diagnostic Immunology, KU Leuven, Leuven, Belgium
- Laboratory Medicine, OLV Hospital, Aalst, Belgium
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Güell N, Mozas P, Jimenez-Rueda A, Miljkovic M, Juncà J, Sorigue M. Methodological and conceptual challenges to the flow cytometric classification of leukemic lymphoproliferative disorders. Crit Rev Clin Lab Sci 2023; 60:83-100. [PMID: 36066070 DOI: 10.1080/10408363.2022.2114418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The diagnosis of leukemic B-cell lymphoproliferative disorders (B-LPDs) is made by integrating clinical, cytological, cytometric, cytogenetic, and molecular data. This leaves room for differences and inconsistencies between experts. In this study, we examine methodological and conceptual aspects of the flow cytometric classification of leukemic B-LPDs that could explain them. Among methodological aspects, we discuss (1) the different statistical tests used to select and evaluate markers, (2) how these markers are analyzed, (3) how scores are interpreted, (4) different degrees to which diagnostic information is used, and (5) and the impact of differences in study populations. Among conceptual aspects, we discuss (1) challenges to integrating different biological data points, (2) the under examination of the costs of misclassification (false positives and false negatives), and finally, (3) we delve into the impact of the lack of a true diagnostic gold standard and the indirect evidence suggesting poor reproducibility in the diagnosis of leukemic B-LPDs. We then outline current harmonization efforts and our personal approach. We conclude that numerous flow cytometry scores and diagnostic systems are now available; however, as long as the considerations discussed remain unaddressed, external reproducibility and interobserver agreement will not be achieved, and the field will not be able to move forward if a true gold standard is not found.
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Affiliation(s)
- Nadia Güell
- Hematology Laboratory, Unitat de citometria ICO-Badalona (CITICOB), Hospital Germans Trias i Pujol, IJC, LUMN, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Pablo Mozas
- Department of Hematology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Alba Jimenez-Rueda
- Hematology Laboratory, Unitat de citometria ICO-Badalona (CITICOB), Hospital Germans Trias i Pujol, IJC, LUMN, Universitat Autònoma de Barcelona, Badalona, Spain.,Facultat de Biologia, Universitat de Barcelona, Barcelona, Spain
| | | | - Jordi Juncà
- Hematology Laboratory, Unitat de citometria ICO-Badalona (CITICOB), Hospital Germans Trias i Pujol, IJC, LUMN, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Marc Sorigue
- Hematology Laboratory, Unitat de citometria ICO-Badalona (CITICOB), Hospital Germans Trias i Pujol, IJC, LUMN, Universitat Autònoma de Barcelona, Badalona, Spain
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Stefanolo JP, Zingone F, Gizzi C, Marsilio I, Espinet ML, Smecuol EG, Khaouli M, Moreno ML, Pinto-Sánchez MI, Niveloni SI, Verdú EF, Ciacci C, Bai JC. Upper gastrointestinal endoscopic findings in celiac disease at diagnosis: A multicenter international retrospective study. World J Gastroenterol 2022; 28:6157-6167. [PMID: 36483156 PMCID: PMC9724482 DOI: 10.3748/wjg.v28.i43.6157] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/22/2022] [Accepted: 11/07/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Gastroduodenal endoscopy and biopsy following positive specific serology is considered the gold standard to diagnose celiac disease (CeD) in adults. Whether upper endoscopy helps detect comorbid conditions is unknown.
AIM To investigate the prevalence of non-celiac endoscopic findings in patients in whom endoscopy was performed to confirm CeD diagnosis.
METHODS This is an observational, descriptive, multicenter, retrospective study that reports endoscopic findings obtained in adult patients enrolled in local registries from four tertiary centers. We collected data reported on first endoscopy, indicated for investigation of CeD. Diagnosis of CeD was performed by histology (≥ Marsh 2 type mucosal damage) and specific serology. Two European and one North American center included biopsy-confirmed CeD following positive serology. A fourth center (South America) included symptomatic patients undergoing endoscopy, irrespective of CeD serology. The latter cohort included a non-CeD control group.
RESULTS A total of 1328 patients (80% female; 35 years median age) were enrolled, of whom 95.6% had positive specific serology. In 135 patients, endoscopy revealed 163 abnormalities unrelated to CeD (prevalence: 10.1%). Erosive reflux esophagitis (6.4%), gastric erosions (2.0%), and suspicion of esophageal metaplasia (1.2%) were the most common findings. Biopsy-confirmed Barrett’s esophagus was infrequent (0.2%). No endoscopic cancer was detected. Older patients (≥ 51 years of age) had a higher prevalence of endoscopic findings than those ≤ 50 (P < 0.01). Within the South American cohort, CeD was associated with a lower rate (8.2%) of comorbid endoscopic findings compared with controls (29.1%; P < 0.001). In the adjusted multivariate analysis of this cohort, having CeD was associated with a 72% reduction in the risk of any endoscopic abnormality (P < 0.0001), and having alarm symptoms was associated with a 37% reduction in the risk of finding at least one endoscopic lesion (P < 0.02).
CONCLUSION In this large multicenter study, young adults with positive CeD serology had few comorbid endoscopic findings. Although patients over 51 years had a high prevalence of non-CeD gastroduodenal mucosal damage, no malignancy or premalignant lesions were found.
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Affiliation(s)
- Juan Pablo Stefanolo
- Small Bowel Section, Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires 1264, Argentina
| | - Fabiana Zingone
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padova 35124, Italy
- Gastroenterology Unit, Azienda Ospedale Università, Padova 35128, Italy
| | - Carolina Gizzi
- Department of Medicine, Surgery, Dentistry, Scuola Medica Salernitana, University of Salerno, Salerno 84081, Italy
| | - Ilaria Marsilio
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padova 35124, Italy
| | - María Luján Espinet
- Small Bowel Section, Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires 1264, Argentina
| | - Edgardo Gustavo Smecuol
- Small Bowel Section, Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires 1264, Argentina
| | - Mark Khaouli
- Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton L8S 4K1, Canada
| | - María Laura Moreno
- Small Bowel Section, Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires 1264, Argentina
| | - María I Pinto-Sánchez
- Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton L8S 4K1, Canada
| | - Sonia Isabel Niveloni
- Small Bowel Section, Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires 1264, Argentina
| | - Elena F Verdú
- Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton L8S 4K1, Canada
| | - Carolina Ciacci
- Department of Medicine, Surgery, Dentistry, Scuola Medica Salernitana, University of Salerno, Salerno 84081, Italy
| | - Julio César Bai
- Small Bowel Section, Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires 1264, Argentina
- Research Institutes, Universidad del Salvador, Buenos Aires 1020, Argentina
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Anbardar MH, Haghighi FG, Honar N, Zahmatkeshan M. Diagnostic Value of Immunoglobulin G Anti-Deamidated Gliadin Peptide Antibody for Diagnosis of Pediatric Celiac Disease: A Study from Shiraz, Iran. Pediatr Gastroenterol Hepatol Nutr 2022; 25:312-320. [PMID: 35903491 PMCID: PMC9284110 DOI: 10.5223/pghn.2022.25.4.312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 01/13/2022] [Accepted: 05/18/2022] [Indexed: 11/14/2022] Open
Abstract
PURPOSE Screening serologic tests are important tools for the diagnosis of celiac disease (CD). Immunoglobulin (Ig)G anti-deamidated gliadin peptide (anti-DGP) is a relatively new autoantibody thought to have good diagnostic accuracy, comparable to that of anti-tissue transglutaminase (anti-tTG) antibody. METHODS Pediatric patients (n=86) with a clinical suspicion of CD were included. Duodenal biopsy, anti-tTG, and IgG anti-DGP antibody tests were performed. The patients were divided into CD and control groups based on the pathological evaluation of duodenal biopsies. The diagnostic accuracy of serological tests was determined. RESULTS IgA anti-tTG and IgG anti-DGP antibodies were positive in 86.3% and 95.4% of patients, respectively. The sensitivity, specificity, and diagnostic accuracy of the IgA anti-tTG test were 86.3%, 50.0%, and 68.6%, respectively, and those of the IgG anti-DGP test were 95.4%, 85.7%, and 90.7%, respectively. The area under the receiver operating characteristic (ROC) curve was 0.84 (95% confidence interval [CI], 0.74-0.91) for IgA anti-tTG test and 0.93 (95% CI, 0.86-0.97) for IgG anti-DGP test. The comparison of IgA anti-tTG and IgG anti-DGP ROC curves showed a higher sensitivity and specificity of the IgG anti-DGP test. CONCLUSION IgG anti-DGP is a reliable serological test for CD diagnosis in children. High tTG and DGP titers in the serum are suggestive of severe duodenal atrophy. The combined use of IgA anti-tTG and IgG anti-DGP tests for the initial screening of CD can improve diagnostic sensitivity.
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Affiliation(s)
- Mohammad Hossein Anbardar
- Department of Pathology, Shiraz Medical School, Namazi Teaching Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Fatemeh Golbon Haghighi
- Department of Pathology, Shiraz Medical School, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Naser Honar
- Department of Pediatric Hepatology and Gastroenterology, Shiraz Medical School, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mozhgan Zahmatkeshan
- Gastroenterohepatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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The global burden of coeliac disease: opportunities and challenges. Nat Rev Gastroenterol Hepatol 2022; 19:313-327. [PMID: 34980921 DOI: 10.1038/s41575-021-00552-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/08/2021] [Indexed: 02/06/2023]
Abstract
Coeliac disease is a systemic disorder characterized by immune-mediated enteropathy, which is caused by gluten ingestion in genetically susceptible individuals. The clinical presentation of coeliac disease is highly variable and ranges from malabsorption through solely extra-intestinal manifestations to asymptomatic. As a result, the majority of patients with coeliac disease remain undiagnosed, misdiagnosed or experience a substantial delay in diagnosis. Coeliac disease is diagnosed by a combination of serological findings of disease-related antibodies and histological evidence of villous abnormalities in duodenal biopsy samples. However, variability in histological grading and in the diagnostic performance of some commercially available serological tests remains unacceptably high and confirmatory assays are not readily available in many parts of the world. Currently, the only effective treatment for coeliac disease is a lifelong, strict, gluten-free diet. However, many barriers impede patients' adherence to this diet, including lack of widespread availability, high cost, cross-contamination and its overall restrictive nature. Routine follow-up is necessary to ensure adherence to a gluten-free diet but considerable variation is evident in follow-up protocols and the optimal disease management strategy is not clear. However, these challenges in the diagnosis and management of coeliac disease suggest opportunities for future research.
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Evaluation of Celiac Disease by Minimally Invasive Biomarkers in a Spanish Pediatric Population. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19095020. [PMID: 35564413 PMCID: PMC9100138 DOI: 10.3390/ijerph19095020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 04/13/2022] [Accepted: 04/14/2022] [Indexed: 02/04/2023]
Abstract
Background: The diagnosis of celiac disease (CD) has been substantially improved with the availability of highly sensitive CD-specific IgA-TG2, Ig-GDP, and IgA-EMA. The European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) published (2012) and updated (2020) diagnostic criteria for CD in order to simplify CD diagnosis and to avoid biopsies in selected patients. Methods: A prospective study including 5641 pediatric patients (0–16 years old) from January 2012 to January 2019 was performed. CD diagnosis was made according to the ESPGHAN algorithm. The objective of this study was to evaluate the utility of biomarkers and the relationship between TGA-IgA and EMA titers. Results: CD diagnoses were confirmed in 113 patients, 110 were IgA-TG2-positive and 3 (2.7%) had IgA deficiency. The diagnosis was made by serologic tests in 95 (84.1%) patients. Only 18 (15.9%) patients underwent intestinal biopsy. We obtained 100% concordance between IgA-EMA and positive results for IgA-TG2 ≥ 10 ULN with IgA-EMA antibody titer ≥ 1:80. Conclusions: This study provides evidence of a positive correlation between IgA-TG2 antibody serum levels and IgA-EMA. The diagnosis could be guaranteed with strict application of IgA-TG2 values ≥ 10 ULN (confirmed by subsequent testing) plus the serological response to the gluten-free diet (GFD).
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Upper Gastrointestinal Tract Associated Lesions in Patients with Newly Diagnosed Celiac Disease. GASTROENTEROLOGY INSIGHTS 2022. [DOI: 10.3390/gastroent13010009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
(1) Background: Currently available guidelines require upper gastrointestinal (GI) endoscopy with biopsy sampling for adult celiac disease (CD) diagnosis. Based on the pediatric experience, there has been a growing interest if serology-based diagnosis would be possible for adult CD also. Our aim was to analyze the associated upper GI tract lesions in newly diagnosed CD patients, to see if significant associated pathology is detected during index endoscopy, which might impact patient management not related to CD. (2) Methods: We performed a retrospective analysis of newly diagnosed CD cases diagnosed over a period of 7 years (2014–2020). Demographic, clinical, laboratory, endoscopy and histopathology data were collected from the patients’ charts. Diagnosis was set according to ACG Guideline 2013. (3) Results: Altogether 79 patients were recruited for this study purpose, 75.9% female, median age 39 years. All patients had positive CD-specific serology and atrophic mucosal injury in duodenal biopsy samples. Besides villous atrophy, associated endoscopic findings were detected in 42/79 (53.16%) of patients. Most of the gastric lesions were minor endoscopic findings—small sliding hiatal hernias, non-specific chronic gastritis, but we also found two cases of peptic ulcers, one case of metaplastic gastritis, six cases of atrophic gastritis and one subepithelial lesion. Only one patient had changes in the duodenum except CD-related findings—an inflammatory polyp in the duodenal bulb. No malignancies were found. (4) Conclusions: In our cohort, there was a significant number of newly diagnosed CD patients who had associated lesions during the index upper GI endoscopy, but most of them were minor endoscopic findings.
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Diagnostic Accuracy of IgA Anti-Transglutaminase and IgG Anti-Deamidated Gliadin for Diagnosis of Celiac Disease in Children under Two Years of Age: A Systematic Review and Meta-Analysis. Nutrients 2021; 14:nu14010007. [PMID: 35010880 PMCID: PMC8746847 DOI: 10.3390/nu14010007] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/15/2021] [Accepted: 12/16/2021] [Indexed: 01/18/2023] Open
Abstract
The need of adding the determination of anti-deamidated gliadin peptide (DGP) IgG to anti-transglutaminase (TTG) IgA antibodies for diagnosis of celiac disease (CD) in children <2 years of age is controversial. We performed a systematic review and meta-analysis to evaluate, by head-to-head comparison, the diagnostic accuracy of TTG IgA and DGP IgG antibodies. We searched PubMed, MEDLINE, and Embase databases up to January 2021. The diagnostic reference was intestinal biopsy. We calculated the sensitivity and specificity of these tests and the odds ratio (OR) between the tests. Fifteen articles were eligible for the systematic review and ten were eligible for the meta-analysis. Sensitivity and specificity were 0.96 (95% confidence interval (CI), 0.91–0.98) and 0.96 (95% CI, 0.85–0.99) for DGP IgG and 0.93 (95% CI, 0.88–0.97) and 0.98 (95% CI, 0.96–0.99) for TTG IgA, respectively. TTG IgA specificity was significantly higher (OR 9.3 (95% CI, 2.3–37.49); p < 0.001) while the sensitivity of DGP IgG was higher without reaching statistical significance (OR: 0.6 (95% CI, 0.24–1.51); p = 0.28). Both the meta-analysis and the systematic review showed that some children with early CD are missed without the DGP IgG test. In children <2 years of age, TTG IgA is the best CD screening test; however, the addition of DGP IgG may increase the diagnostic sensitivity.
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Losurdo G, Di Leo M, Santamato E, Arena M, Rendina M, Luigiano C, Ierardi E, Di Leo A. Serologic diagnosis of celiac disease: May it be suitable for adults? World J Gastroenterol 2021; 27:7233-7239. [PMID: 34876785 PMCID: PMC8611199 DOI: 10.3748/wjg.v27.i42.7233] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 05/02/2021] [Accepted: 10/25/2021] [Indexed: 02/06/2023] Open
Abstract
The diagnosis of coeliac disease (CD) in adult patients requires the simultaneous assessment of clinical presentation, serology, and typical histological picture of villous atrophy. However, several years ago, the European Society of Pediatric Gastroenterology, Hepatology, and Nutrition guidelines approved new criteria for the diagnosis in children: Biopsy could be avoided when anti-transglutaminase antibody (TGA) values exceed the cut-off of × 10 upper limit of normal (ULN) and anti-endomysium antibodies are positive, independently from value. This “no biopsy” approach is a decisive need for pediatric population, allowing to avoid stressful endoscopic procedures in children, if unnecessary. This approach relies on the correlation existing in children between TGA levels and assessment of mucosal atrophy according to Marsh’s classification. Several lines of evidence have shown that patients with villous atrophy have markedly elevated TGA levels. Therefore, we aim to perform a narrative review on the topic in adults. Despite that some studies confirmed that the × 10 ULN threshold value has a very good diagnostic performance, several lines of evidence in adults suggest that TGA cut off should be different from that of pediatric population for reaching a good correlation with histological picture. In conclusion, the heterogeneity of study reports as well as some conditions, which may hamper the serological diagnosis of CD (such as seronegative CD and non-celiac villous atrophy) and are much more common in adults than in children, could represent a limitation for the “no biopsy” approach to CD diagnosis in patients outside the pediatric age.
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Affiliation(s)
- Giuseppe Losurdo
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari 70124, Italy
| | - Milena Di Leo
- Unit of Digestive Endoscopy, San Paolo Hospital, Milan 20090, Italy
| | - Edoardo Santamato
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari 70124, Italy
| | - Monica Arena
- Unit of Digestive Endoscopy, San Paolo Hospital, Milan 20090, Italy
| | - Maria Rendina
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari 70124, Italy
| | - Carmelo Luigiano
- Unit of Digestive Endoscopy, San Paolo Hospital, Milan 20090, Italy
| | - Enzo Ierardi
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari 70124, Italy
| | - Alfredo Di Leo
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari 70124, Italy
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Losurdo G, Di Leo M, Santamato E, Giangaspero A, Rendina M, Luigiano C, Ierardi E, Di Leo A. May Antitransglutaminase Levels Predict Severity of Duodenal Lesions in Adults with Celiac Disease? Medicina (B Aires) 2021; 57:medicina57111212. [PMID: 34833430 PMCID: PMC8622174 DOI: 10.3390/medicina57111212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 11/03/2021] [Accepted: 11/04/2021] [Indexed: 01/11/2023] Open
Abstract
Background and Objective: Pediatric guidelines on celiac disease (CD) state that children with anti-transglutaminase antibodies (TGAs) >×10 upper limit of normal (ULN) may avoid endoscopy and biopsy. We aimed to evaluate whether these criteria may be suitable for villous atrophy diagnosis in CD adults. Materials and Methods: We retrospectively enrolled patients with CD aged >18 years. TGAs were expressed as xULN. Duodenal lesions were classified as atrophic or non-atrophic according to Marsh-Oberhuber. Fisher’s exact and t-test were used for variables comparison. Receiver operating characteristics (ROC) curve analysis was performed with estimation of area under the curve (AUC), sensitivity, specificity, and positive and negative predictive value (PPV/NPV). Results: One hundred and twenty-one patients were recruited. Sixty patients (49.6%) had TGA >×10 ULN, and 93 (76.8%) had villous atrophy. The cut-off of >×10 ULN had sensitivity = 53.7%, specificity = 64.3%, PPV = 83.3%, and NPV = 29.5% to predict atrophy. Therefore, considering pediatric criteria, in 50 (41.3%) patients, biopsy could have been avoided. Patient subgroup with atrophy had higher TGA levels despite being not significant (37.2 ± 15.3 vs. 8.0 ± 1.3 ULN, p = 0.06). In adults, a slightly better diagnostic performance was obtained using a cut-off of TGA >×6.2 ULN (sensitivity = 57.1%, specificity = 65.6%, and AUC = 0.62). Conclusions: Despite our confirmation that villous atrophy is linked to high TGA levels, CD and atrophy diagnosis based only on serology is not reliable in adults.
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Affiliation(s)
- Giuseppe Losurdo
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University “Aldo Moro” of Bari, 70124 Bari, Italy; (E.S.); (A.G.); (M.R.); (E.I.); (A.D.L.)
- Ph.D. Course in Organs and Tissues Transplantation and Cellular Therapies, Department of Emergency and Organ Transplantation, University “Aldo Moro” of Bari, 70124 Bari, Italy
- Correspondence: ; Tel.: +39-080-559-4430
| | - Milena Di Leo
- Unit of Digestive Endoscopy, San Paolo Hospital, 20142 Milano, Italy; (M.D.L.); (C.L.)
| | - Edoardo Santamato
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University “Aldo Moro” of Bari, 70124 Bari, Italy; (E.S.); (A.G.); (M.R.); (E.I.); (A.D.L.)
| | - Antonio Giangaspero
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University “Aldo Moro” of Bari, 70124 Bari, Italy; (E.S.); (A.G.); (M.R.); (E.I.); (A.D.L.)
| | - Maria Rendina
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University “Aldo Moro” of Bari, 70124 Bari, Italy; (E.S.); (A.G.); (M.R.); (E.I.); (A.D.L.)
| | - Carmelo Luigiano
- Unit of Digestive Endoscopy, San Paolo Hospital, 20142 Milano, Italy; (M.D.L.); (C.L.)
| | - Enzo Ierardi
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University “Aldo Moro” of Bari, 70124 Bari, Italy; (E.S.); (A.G.); (M.R.); (E.I.); (A.D.L.)
| | - Alfredo Di Leo
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University “Aldo Moro” of Bari, 70124 Bari, Italy; (E.S.); (A.G.); (M.R.); (E.I.); (A.D.L.)
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Beig J, Rostami K, Hayman DTS, Hassan S, Gerred S, Ogra R. Is duodenal biopsy always necessary for the diagnosis of coeliac disease in adult patients with high anti-tissue transglutaminase (TTG) antibody titres? Frontline Gastroenterol 2021; 13:287-294. [PMID: 35722610 PMCID: PMC9186042 DOI: 10.1136/flgastro-2020-101728] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 06/08/2021] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Avoiding duodenal biopsy in adults for coeliac disease (CD) diagnosis is controversial. Some retrospective and prospective studies have shown that CD can be reliably diagnosed in adults with serology rather than duodenal biopsies. This study aimed to check the accuracy of a cut-off value of ≥10 upper limit of normal of anti-tissue transglutaminase antibody (anti-TTG IgA) titres for CD diagnosis in adult patients. METHOD We retrospectively analysed adult patients (≥16 years) who underwent gastroscopy from 2013 to 2018 for positive coeliac serology. The relationship between titres and disease was determined by using linear models, whereas sensitivity and specificity were assessed by receiver operator curve. RESULTS We analysed 144 newly anti-TTG antibody-positive adult patients with a median age of 48.5 years (IQR 32-62); among them, 86 (60%) patients had CD (Marsh III: n=68 and Marsh II and I: n=18) with a higher prevalence in females (n=59 (69%)) and Europeans (n=60 (70%)). Fifty (58%) patients with CD had colonoscopy and five (6%) had imaging; only six patients were diagnosed with additional conditions. An anti-TTG IgA titre cut-off value of 150 U/L was 100% specific for CD in our dataset, with 70% (95% CI: 60% to 88%) sensitivity for this patient group. CONCLUSION Coeliac serology using anti-TTG IgA with titres ≥10× normal value is an excellent predictor of CD, irrespective of age, gender and ethnicity. Duodenal biopsy may not be necessary in selected adult patients with CD, especially younger than 50 years of age without additional gastrointestinal red-flag signs and symptoms.
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Affiliation(s)
- Junaid Beig
- Gastroenterology and Hepatology, Middlemore Hospital - Counties Manukau DIstrict Health Board (CMDH), Auckland, New Zealand
| | - Kamran Rostami
- Gastroenterology and Hepatology, MidCentral District Health Board, Palmerston North, New Zealand
| | - David T S Hayman
- Molecular Epidemiology and Public Health Laboratory, School of Veterinary Science, Massey University, Palmerston North, New Zealand
| | - Summer Hassan
- Gastroenterology and Hepatology, Middlemore Hospital - Counties Manukau DIstrict Health Board (CMDH), Auckland, New Zealand
| | - Stephen Gerred
- Gastroenterology and Hepatology, Middlemore Hospital - Counties Manukau DIstrict Health Board (CMDH), Auckland, New Zealand
| | - Ravinder Ogra
- Gastroenterology and Hepatology, Middlemore Hospital - Counties Manukau DIstrict Health Board (CMDH), Auckland, New Zealand
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14
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Penny HA, Raju SA, Lau MS, Marks LJS, Baggus EMR, Bai JC, Bassotti G, Bontkes HJ, Carroccio A, Danciu M, Derakhshan MH, Ensari A, Ganji A, Green PHR, Johnson MW, Ishaq S, Lebwohl B, Levene A, Maxim R, Mohaghegh Shalmani H, Rostami-Nejad M, Rowlands D, Spiridon IA, Srivastava A, Volta U, Villanacci V, Wild G, Cross SS, Rostami K, Sanders DS. Accuracy of a no-biopsy approach for the diagnosis of coeliac disease across different adult cohorts. Gut 2021; 70:876-883. [PMID: 33139268 PMCID: PMC8040155 DOI: 10.1136/gutjnl-2020-320913] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 06/29/2020] [Accepted: 07/18/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE We aimed to determine the predictive capacity and diagnostic yield of a 10-fold increase in serum IgA antitissue transglutaminase (tTG) antibody levels for detecting small intestinal injury diagnostic of coeliac disease (CD) in adult patients. DESIGN The study comprised three adult cohorts. Cohort 1: 740 patients assessed in the specialist CD clinic at a UK centre; cohort 2: 532 patients with low suspicion for CD referred for upper GI endoscopy at a UK centre; cohort 3: 145 patients with raised tTG titres from multiple international sites. Marsh 3 histology was used as a reference standard against which we determined the performance characteristics of an IgA tTG titre of ≥10×ULN for a diagnosis of CD. RESULTS Cohort 1: the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for IgA tTG levels of ≥10×ULN at identifying individuals with Marsh 3 lesions were 54.0%, 90.0%, 98.7% and 12.5%, respectively. Cohort 2: the sensitivity, specificity, PPV and NPV for IgA tTG levels of ≥10×ULN at identifying individuals with Marsh 3 lesions were 50.0%, 100.0%, 100.0% and 98.3%, respectively. Cohort 3: the sensitivity, specificity, PPV and NPV for IgA tTG levels of ≥10×ULN at identifying individuals with Marsh 3 lesions were 30.0%, 83.0%, 95.2% and 9.5%, respectively. CONCLUSION Our results show that IgA tTG titres of ≥10×ULN have a strong predictive value at identifying adults with intestinal changes diagnostic of CD. This study supports the use of a no-biopsy approach for the diagnosis of adult CD.
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Affiliation(s)
- Hugo A Penny
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Suneil A Raju
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Michelle S Lau
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Lauren JS Marks
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Elisabeth MR Baggus
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Julio C Bai
- Medicine, Gastroenterology Hospital 'Dr C Bonorino Udaondo', Buenos Aires, Argentina
| | - Gabrio Bassotti
- Gastroenterology & Hepatology Section, Department of Medicine, University of Perugia Medical School, Perugia, Italy
| | - Hetty J Bontkes
- Department Clinical Chemistry, Amsterdam Gastroenterology and Metabolism and Infection and Immunity Institutes, Amsterdam UMC, Amsterdam, The Netherlands
| | - Antonio Carroccio
- Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Mihai Danciu
- Pathology Department, Grigore T. Popa University of Medicine and Pharmacy Iasi, Iasi, Romania
| | | | - Arzu Ensari
- Department of Pathology, Ankara University Medical School, Ankara, Turkey
| | - Azita Ganji
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Peter H R Green
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Matt W Johnson
- Gastroenterology, Luton and Dunstable Hospital NHS Foundation Trust, Luton, UK
| | - Sauid Ishaq
- Department of Gastroenterology, Dudley Group NHS Foundation Trust, Birmingham City University, Birmingham, UK
| | - Benjamin Lebwohl
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Adam Levene
- Gastroenterology, Luton and Dunstable Hospital NHS Foundation Trust, Luton, UK
| | - Roxana Maxim
- Gastroenterology Department, Grigore T. Popa University of Medicine and Pharmacy Iasi, Iasi, Romania
| | - Hamid Mohaghegh Shalmani
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Rostami-Nejad
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - David Rowlands
- Department of Gastroenterology, Queen Elizabeth II Hospital, Hertfordshire, UK
| | - Irene A Spiridon
- Pathology Department, Grigore T. Popa University of Medicine and Pharmacy Iasi, Iasi, Romania
| | | | - Umberto Volta
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | | | - Graeme Wild
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Simon S Cross
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Kamran Rostami
- Department of Gastroenterology, MidCentral District Health Board, Palmerston North, New Zealand
| | - David S Sanders
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
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15
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Ben Houmich T, Admou B. Celiac disease: Understandings in diagnostic, nutritional, and medicinal aspects. Int J Immunopathol Pharmacol 2021; 35:20587384211008709. [PMID: 33878915 PMCID: PMC8064516 DOI: 10.1177/20587384211008709] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Celiac disease (CD) is characterized by clinical polymorphism, with classic, asymptomatic or oligosymptomatic, and extra-intestinal forms, which may lead to diagnostic delay and exposure to serious complications. CD is a multidisciplinary health concern involving general medicine, pediatric, and adult gastroenterology, among other disciplines. Immunology and pathology laboratories have a fundamental role in diagnosing and monitoring CD. The diagnosis consists of serological testing based on IgA anti-transglutaminase (TG2) antibodies combined with IgA quantification to rule out IgA deficiency, a potential misleading factor of CD diagnosis. Positive TG2 serology should be corroborated by anti-endomysium antibody testing before considering an intestinal biopsy. Owing to multiple differential diagnoses, celiac disease cannot be confirmed based on serological positivity alone, nor on isolated villous atrophy. In children with classical signs or even when asymptomatic, with high levels of CD-linked markers and positive HLA DQ2 and/or DQ8 molecules, the current trend is to confirm the diagnosis on basis of the non-systematic use of the biopsy, which remains obligatory in adults. The main challenge in managing CD is the implementation and compliance with a gluten-free diet (GFD). This explains the key role of the dietitian and the active participation of patients and their families throughout the disease-management process. The presence of the gluten in several forms of medicine requires the sensitization of physicians when prescribing, and particularly when dispensing gluten-containing formulations by pharmacists. This underlines the importance of the contribution of the pharmacist in the care of patients with CD within the framework of close collaboration with physicians and nutritionists.
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Affiliation(s)
- Taoufik Ben Houmich
- Laboratory of Immunology, Center of Clinical Research, University Hospital Mohammed VI, Marrakech, Morocco
| | - Brahim Admou
- Laboratory of Immunology, Center of Clinical Research, University Hospital Mohammed VI, Marrakech, Morocco.,Bioscience Research Laboratory, Faculty of Medicine and Pharmacy, Cadi Ayyad University, Marrakech, Morocco
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Fierz W, Bossuyt X. Likelihood Ratio Approach and Clinical Interpretation of Laboratory Tests. Front Immunol 2021; 12:655262. [PMID: 33936083 PMCID: PMC8086426 DOI: 10.3389/fimmu.2021.655262] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 03/23/2021] [Indexed: 12/12/2022] Open
Affiliation(s)
- Walter Fierz
- Schweizerischer Verband der Diagnostikindustrie (SVDI), Bern, Switzerland
| | - Xavier Bossuyt
- Clinical and Diagnostic Immunology, Department of Microbiology, Immunology and Transplantation, KU, Leuven, Belgium.,Immunology Service, Department of Laboratory Medicine, University Hospitals, Leuven, Belgium
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17
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Thompson G, Grover Z, Loh R, Mews C, Ravikumara M, Jevon G, D'Orsogna L, McLean-Tooke A. Assessment of European Society of Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) guidelines in an Australian paediatric population. Pathology 2020; 52:568-575. [PMID: 32586687 DOI: 10.1016/j.pathol.2020.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 05/07/2020] [Accepted: 05/11/2020] [Indexed: 12/20/2022]
Abstract
Coeliac disease (CD) diagnosis is based on clinical assessment, detection of specific autoantibodies and histological examination of small intestinal biopsies. The European Society of Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) guidelines have recently been updated and recommend CD may be diagnosed without a biopsy or HLA typing in symptomatic patients with high titre IgA tissue transglutaminase antibodies (aTTG) and positive endomysial antibodies (EMA). However, the need for EMA in patients with high level aTTG has been questioned. We aimed to determine the diagnostic benefit of HLA typing, EMA and IgG antibodies to deamidated gliadin (DGP) in children with high level aTTG. We prospectively evaluated children presenting for assessment of possible CD. All patients underwent small bowel biopsy, serological testing and HLA typing. Results were analysed and correlated with histopathological diagnosis. A total of 209 children were assessed; 61.5% were found to have CD and 29% could have avoided biopsy as per 2020 ESPGHAN guidelines. Titres of aTTG ≥60 U/mL or DGP ≥28 U/mL gave 100% specificity and 100% positive predictive value (PPV) for CD. HLA typing and EMA did not improve the PPV of patients with aTTG ≥60 U/mL, but addition of DGP ≥28 U/mL improved diagnostic sensitivity whilst retaining 100% specificity. Addition of HLA and EMA testing in patients with high titre aTTG antibodies does not improve diagnostic performance and may possibly be omitted from the serological workup in these patients. Our data support combining aTTG and DGP testing and optimising cut-offs to maximise specificity as an alternative biopsy-free diagnostic approach.
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Affiliation(s)
- Grace Thompson
- Department of Clinical Immunology, PathWest Laboratory Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia.
| | - Zubin Grover
- Department of Gastroenterology, Perth Children's Hospital, Perth, WA, Australia
| | - Richard Loh
- Department of Clinical Immunology, PathWest Laboratory Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Catherine Mews
- Department of Gastroenterology, Perth Children's Hospital, Perth, WA, Australia
| | - Madhur Ravikumara
- Department of Gastroenterology, Perth Children's Hospital, Perth, WA, Australia
| | - Gareth Jevon
- Department of Anatomical Pathology, PathWest Laboratory Medicine, Perth Children's Hospital, Perth, WA, Australia
| | - Lloyd D'Orsogna
- Department of Clinical Immunology, PathWest Laboratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| | - Andrew McLean-Tooke
- Department of Clinical Immunology, PathWest Laboratory Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia; Department of Immunology, Perth Children's Hospital, Perth, WA, Australia
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18
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Bogaert L, Cauchie M, Van Hoovels L, Vermeersch P, Fierz W, De Hertogh G, Hoffman I, Bossuyt X. Optimization of serologic diagnosis of celiac disease in the pediatric setting. Autoimmun Rev 2020; 19:102513. [PMID: 32173515 DOI: 10.1016/j.autrev.2020.102513] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 11/30/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND The clinical presentation of celiac disease (CD) varies between children. The objective of this study was to document the pre-test probability for CD based on symptoms and routine laboratory test and to evaluate the performance of two IgA anti-tissue transglutaminase (tTG) assays. We critically reviewed the concept of using multiples of the manufacturer's upper limit of normal (ULN), as proposed in the ESPGHAN guidelines (if IgA tTG is >10 times ULN, no biopsy is needed). METHODS The retrospective study included 91 children with newly diagnosed CD and 605 controls (<16 years). All underwent upper endoscopy with small bowel biopsies. Four laboratory parameters and 16 symptoms were registered. All patients were tested for IgA anti-tTG antibodies with assays from Inova Diagnostics and Thermo Fisher Scientific. RESULTS Some combinations of clinical symptoms and laboratory parameters had a high pre-test probability for CD, such as (combinations of) anorexia, failure to thrive, low ferritin level and elevated AST. The diagnostic performance of both IgA anti-tTG assays was excellent and comparable (no difference in ROC curve area under the curve). At a threshold that corresponds to a specificity of 100% (5 times ULN for Inova Diagnostics and 2 times ULN for Thermo Fisher), the sensitivity was 82% for both assays. At the 10 times ULN threshold, the sensitivity differed between the assays (77% vs. 57%), indicating that such threshold does not completely align interpretation across companies. CONCLUSIONS Our study showed that some combinations of symptoms and aberrant laboratory parameters had a high pre-test probability. The use of the ESPGHAN non-biopsy approach could reduce small bowel biopsies, but thresholds for IgA-tTG levels are not aligned across assays and should be based on predefined likelihood ratios or specificity.
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Affiliation(s)
- Laura Bogaert
- Department of Laboratory Medicine, OLV Hospital, Aalst, Belgium; Department of Laboratory Medicine, University Hospital Leuven, Leuven, Belgium
| | - Mathieu Cauchie
- Department of Laboratory Medicine, Europe Hospitals, Brussels, Belgium
| | - Lieve Van Hoovels
- Department of Laboratory Medicine, OLV Hospital, Aalst, Belgium; Department of Microbiology, Immunology and Transplantation, KU Leuven, Belgium
| | - Pieter Vermeersch
- Department of Laboratory Medicine, University Hospital Leuven, Leuven, Belgium
| | - Walter Fierz
- Schweizerischer Verband der Diagnostikindustrie (SVDI), Bern, Switzerland
| | - Gert De Hertogh
- Department of Pathology, University Hospital Leuven, Leuven, Belgium
| | - Ilse Hoffman
- Department of Paedriatrics, University Hospital Leuven, Leuven, Belgium
| | - Xavier Bossuyt
- Department of Laboratory Medicine, University Hospital Leuven, Leuven, Belgium; Department of Microbiology, Immunology and Transplantation, KU Leuven, Belgium.
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Penny HA, Raju SA, Sanders DS. Progress in the serology-based diagnosis and management of adult celiac disease. Expert Rev Gastroenterol Hepatol 2020; 14:147-154. [PMID: 32011187 DOI: 10.1080/17474124.2020.1725472] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Introduction: This article provides a comprehensive overview of the development and application of serological tests used routinely in clinical practice for the diagnosis and management of adult celiac disease.Areas covered: We summarize existing scientific literature related to anti-endomyseal, anti-tissue transglutaminase, and anti-deamidated gliadin peptide antibodies and detail the current and potential future applications of these tests in celiac disease.Expert commentary: Current serological tests in celiac disease have some of the best performance characteristics among disease-specific tests. However, in adult celiac disease, current diagnostic algorithms still rely on duodenal biopsies to confirm the diagnosis. A 'biopsy avoidance strategy' has been implemented in pediatric celiac disease. Future high-quality studies will help inform on whether this approach can be implemented into adult gastroenterology services. It is envisaged that the next 5 years will see an increasing reliance on serology in the diagnosis of adult celiac disease.
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Affiliation(s)
- Hugo A Penny
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.,Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
| | - Suneil A Raju
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - David S Sanders
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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European Society Paediatric Gastroenterology, Hepatology and Nutrition Guidelines for Diagnosing Coeliac Disease 2020. J Pediatr Gastroenterol Nutr 2020; 70:141-156. [PMID: 31568151 DOI: 10.1097/mpg.0000000000002497] [Citation(s) in RCA: 532] [Impact Index Per Article: 133.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The ESPGHAN 2012 coeliac disease (CD) diagnostic guidelines aimed to guide physicians in accurately diagnosing CD and permit omission of duodenal biopsies in selected cases. Here, an updated and expanded evidence-based guideline is presented. METHODS Literature databases and other sources of information were searched for studies that could inform on 10 formulated questions on symptoms, serology, HLA genetics, and histopathology. Eligible articles were assessed using QUADAS2. GRADE provided a basis for statements and recommendations. RESULTS Various symptoms are suggested for case finding, with limited contribution to diagnostic accuracy. If CD is suspected, measurement of total serum IgA and IgA-antibodies against transglutaminase 2 (TGA-IgA) is superior to other combinations. We recommend against deamidated gliadin peptide antibodies (DGP-IgG/IgA) for initial testing. Only if total IgA is low/undetectable, an IgG-based test is indicated. Patients with positive results should be referred to a paediatric gastroenterologist/specialist. If TGA-IgA is ≥10 times the upper limit of normal (10× ULN) and the family agrees, the no-biopsy diagnosis may be applied, provided endomysial antibodies (EMA-IgA) will test positive in a second blood sample. HLA DQ2-/DQ8 determination and symptoms are not obligatory criteria. In children with positive TGA-IgA <10× ULN at least 4 biopsies from the distal duodenum and at least 1 from the bulb should be taken. Discordant results between TGA-IgA and histopathology may require re-evaluation of biopsies. Patients with no/mild histological changes (Marsh 0/I) but confirmed autoimmunity (TGA-IgA/EMA-IgA+) should be followed closely. CONCLUSIONS CD diagnosis can be accurately established with or without duodenal biopsies if given recommendations are followed.
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Female Patients with Dermatitis Herpetiformis Show a Reduced Diagnostic Delay and Have Higher Sensitivity Rates at Autoantibody Testing for Celiac Disease. BIOMED RESEARCH INTERNATIONAL 2019; 2019:6307035. [PMID: 32090062 PMCID: PMC7024079 DOI: 10.1155/2019/6307035] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 08/07/2019] [Indexed: 12/20/2022]
Abstract
Objective Our objective was to characterize the demographic information, clinical features, and laboratory data of patients with dermatitis herpetiformis (DH). Methods In this multicentre cross-sectional study, consecutive patients with a new diagnosis of DH that referred to nine different Italian centers between 2011 and 2016 were characterized assessing demographic, clinical and laboratory findings, and evaluating gender and age differences across selected variables. Results A total of 151 patients were included. Among them, 81 (53.6%) were males and 70 (46.4%) were females, with a male to female ratio of 1.2 : 1. The median age at the time of diagnosis was 41 years (range 0-85). Males had a significant longer diagnostic delay if compared to females (9 vs. 3 months, respectively; p = 0.01). Direct immunofluorescence was positive in 94.7% of the patients, while duodenal biopsy showed partial to total villous atrophy in 70.1% of patients. All the females resulted positive to at least one of the antibodies tested, while a total of 12 male patients (10.5%) tested negative to celiac-specific antibodies. Female patients had a high rate (14.1%) of autoimmune thyroiditis. Conclusions Our study confirmed some of the most relevant data regarding DH that have been previously reported in the literature. In addition, we found a reduced diagnostic delay in females with respect to males, possibly related to the higher sensitivity of serologic testing in females with DH compared to males. Finally, we demonstrated that intestinal involvement could be severe in patients with DH and that females should be tested for thyroiditis.
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23
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Diagnostic Yield of Isolated Deamidated Gliadin Peptide Antibody Elevation for Celiac Disease. Dig Dis Sci 2017; 62:1272-1276. [PMID: 28161854 DOI: 10.1007/s10620-017-4474-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 01/24/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Serologic testing for celiac disease includes tissue transglutaminase and endomysial antibodies. In addition to these tools, assays for deamidated gliadin peptide antibodies have been shown to have sensitivity and specificity that are comparable to tissue transglutaminase testing, and are increasingly being used for celiac disease testing. AIMS The goal of this study is to evaluate the utility of deamidated gliadin peptide (DGP) testing in the setting of a negative tissue transglutaminase (TTG) IgA test. METHODS We reviewed the records of all patients seen at two U.S. celiac disease referral centers and identified those who had an elevated DGP IgA and/or IgG in the setting of a negative TTG IgA. Of these patients, those who underwent duodenal biopsy while on a gluten-containing diet were included. Patients with prior biopsy-proven celiac disease or prior TTG IgA positivity were excluded. The results of the biopsy were used as the gold standard for celiac disease diagnosis, and patients with villous atrophy (Marsh class 3) on duodenal biopsy were considered to have celiac disease. RESULTS Between the two institutions, 84 patients were identified with negative TTG IgA and positive DGP IgA or IgG who also had duodenal biopsies performed while maintaining a gluten-containing diet. Of these patients, 13 patients (15.5%; 95% CI 8.5-25.0%) were found to have celiac disease on duodenal biopsy. CONCLUSIONS DGP antibody testing can identify cases of celiac disease in TTG-negative individuals, although the low positive predictive value suggests that the yield may be low.
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Bai JC, Verdú EF. The CD That Pays Dividends: More Than 15 Years of Deamidated Gliadin Peptide Antibodies. Dig Dis Sci 2017; 62:1110-1112. [PMID: 28315033 DOI: 10.1007/s10620-017-4528-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Julio C Bai
- Research Institute, Universidad del Salvador, Buenos Aires, Argentina. .,Hospital de Gastroenterología Dr. C. Bonorino Udaondo, Buenos Aires, Argentina.
| | - Elena F Verdú
- Farncombe Family Digestive Health Research Institute, McMaster University Health Sciences Centre, Hamilton, ON, Canada
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25
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Wolf J, Jahnke A, Fechner K, Richter T, Laass MW, Hauer A, Stern M, de Laffolie J, Flemming G, Mothes T. Primate liver tissue as an alternative substrate for endomysium antibody immunofluorescence testing in diagnostics of paediatric coeliac disease. Clin Chim Acta 2016; 460:72-7. [DOI: 10.1016/j.cca.2016.06.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 06/21/2016] [Accepted: 06/21/2016] [Indexed: 12/20/2022]
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