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Celis-Andrade M, Morales-González V, Rojas M, Monsalve DM, Acosta-Ampudia Y, Rodríguez-Jiménez M, Rodríguez Y, Ramírez-Santana C. Prevalence of latent and overt polyautoimmunity in type 1 diabetes: A systematic review and meta-analysis. Diabetes Metab Syndr 2024; 18:103087. [PMID: 39074403 DOI: 10.1016/j.dsx.2024.103087] [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: 02/28/2024] [Revised: 07/15/2024] [Accepted: 07/20/2024] [Indexed: 07/31/2024]
Abstract
BACKGROUND Patients afflicted by type 1 diabetes (T1D) exhibit polyautoimmunity (PolyA). However, the frequency and distribution of PolyA in T1D is still unknown. OBJECTIVE We conducted a systematic review and meta-analysis to define the prevalence of latent and overt PolyA in individuals with T1D. METHODS Following PRISMA guidelines, a comprehensive search across medical databases identified studies on latent and overt PolyA in T1D. Two researchers independently screened, extracted data, and assessed study quality. A random effects model was utilized to calculate the pooled prevalence, along with its corresponding 95 % confidence interval (CI), for latent PolyA and overt PolyA. Meta-regression analysis was conducted to study the effect of study designs, age, sex, and duration of disease on pooled prevalence. RESULTS A total of 158 articles, encompassing a diverse composition of study designs were scrutinized. The analysis included 270,890 individuals with a confirmed diagnosis of T1D. The gender was evenly distributed (50.30 % male). Notably, our analysis unveiled an overt PolyA prevalence rate of 8.50 % (95 % CI, 6.77 to 10.62), with North America having the highest rates (14.50 %, 95 % CI, 7.58 to 24.89). This PolyA profile was further characterized by a substantial incidence of concurrent autoimmune thyroid disease (7.44 %, 95 % CI, 5.65 to 9.74). Moreover, we identified a notable prevalence of latent PolyA in the T1D population, quantified at 14.45 % (95 % CI, 11.17 to 18.49) being most frequent in Asia (23.29 %, 95 % CI, 16.29 to 32.15) and Oceania (21.53 %, 95 % CI, 16.48 to 27.62). Remarkably, this latent PolyA phenomenon primarily featured an array of autoantibodies, including rheumatoid factor, followed by Ro52, thyroid peroxidase antibodies, and thyroglobulin antibodies. Duration of the disease was associated with a highest frequency of latent (β: 0.0456, P-value: 0.0140) and overt PolyA (β: 0.0373, P-value: 0.0152). No difference in the pooled prevalence by study design was observed. CONCLUSION This meta-analysis constitutes a substantial advancement in the realm of early detection of PolyA in the context of T1D. Individuals with T1D should regularly undergo assessments to identify potential concurrent autoimmune diseases, especially as they age.
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Affiliation(s)
- Mariana Celis-Andrade
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad Del Rosario, Bogotá D.C., Colombia
| | - Victoria Morales-González
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad Del Rosario, Bogotá D.C., Colombia
| | - Manuel Rojas
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad Del Rosario, Bogotá D.C., Colombia; Division of Rheumatology, Allergy and Clinical Immunology, University of California, Davis, CA, 95616, USA
| | - Diana M Monsalve
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad Del Rosario, Bogotá D.C., Colombia
| | - Yeny Acosta-Ampudia
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad Del Rosario, Bogotá D.C., Colombia
| | - Mónica Rodríguez-Jiménez
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad Del Rosario, Bogotá D.C., Colombia
| | - Yhojan Rodríguez
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad Del Rosario, Bogotá D.C., Colombia; Department of Internal Medicine, University Hospital, Fundación Santa Fe de Bogotá, Bogotá D.C., Colombia
| | - Carolina Ramírez-Santana
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad Del Rosario, Bogotá D.C., Colombia.
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Raicevic M, Rosanio FM, Dos Santos TJ, Chobot A, Piona C, Cudizio L, Alsaffar H, Dumic K, Aftab S, Shaunak M, Mozzillo E, Vukovic R. Managing Children and Adolescents with Type 1 Diabetes and Coexisting Celiac Disease: Real-World Data from a Global Survey. Horm Res Paediatr 2024:1-8. [PMID: 38952115 DOI: 10.1159/000540054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 06/19/2024] [Indexed: 07/03/2024] Open
Abstract
INTRODUCTION Celiac disease (CD) is among the diseases most commonly associated with type 1 diabetes (T1D). This study aimed to evaluate the worldwide practices and attitudes of physicians involved in pediatric diabetes care regarding diagnosing and managing CD in children with T1D. METHODS The 30-item survey was conducted between July and December 2023 aimed at targeting pediatricians with special interest in T1D and CD. It was shared by the JENIOUS - young investigators group of the International Society of Pediatric and Adolescent Diabetes (ISPAD) - and the YES - early career group of the European Society for Pediatric Endocrinology (ESPE). RESULTS Overall, 180 physicians (67.8% female) from 25 countries responded. Among respondents, 62.2% expected sustaining optimal glycemic control in children with T1D and CD (T1D + CD) to be more difficult than in children with T1D alone. Majority (81.1%) agreed that more specific guidelines are needed. The follow-up routine for patients with T1D + CD differed, and one-quarter of physicians scheduled more frequent follow-up checkups for these patients. Seventy percent agreed multidisciplinary outpatient clinics for their follow-up is needed. In the multivariate ordinal logistic regression model, a statistically significant predictor of a higher degree of practice according to ISPAD 2022 guidelines was a higher level of country income (OR = 3.34; p < 0.001). CONCLUSIONS These results showed variations in physicians' practices regarding managing CD in children with T1D, emphasizing the need for more specific guidelines and intensive education of physicians in managing this population, especially in lower-income countries. Our data also suggest the implementation of multidisciplinary outpatient clinics for their follow-up.
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Affiliation(s)
- Maja Raicevic
- Institute for Children's Diseases, Clinical Centre of Montenegro, Podgorica, Montenegro
| | - Francesco Maria Rosanio
- Section of Pediatrics, Department of Translational Medical Science, Regional Center of Pediatric Diabetes, Federico II University of Naples, Naples, Italy
| | - Tiago Jeronimo Dos Santos
- Pediatrics Unit, Vithas Almería, Instituto Hispalense de Pediatría, Almería, Spain
- Faculty of Health Sciences, Department of Nursing, Physiotherapy, and Medicine, University of Almería, Almería, Spain
| | - Agata Chobot
- Department of Pediatrics, Institute of Medical Sciences, University of Opole, Opole, Poland
| | - Claudia Piona
- Pediatric Diabetes and Metabolic Disorders Unit, Regional Center for Pediatric Diabetes, University City Hospital of Verona, Verona, Italy
| | - Laura Cudizio
- Pediatric Endocrine Unit, Department of Pediatrics, Santa Casa de São Paulo, São Paulo, Brazil
| | - Hussain Alsaffar
- Paediatric Endocrine and Diabetics Unit, Department of Child Health, Sultan Qaboos University Hospital, Muscat, Oman
| | - Katja Dumic
- Department of Paediatric Endocrinology and Diabetes, University Hospital Centre Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Sommayya Aftab
- Department of Paediatric Endocrinology and Diabetes, University of Child Health Sciences, The Children's Hospital, Lahore, Pakistan
| | - Meera Shaunak
- Department of Paediatric Endocrinology, Great Ormond Street Hospital, London, UK
| | - Enza Mozzillo
- Section of Pediatrics, Department of Translational Medical Science, Regional Center of Pediatric Diabetes, Federico II University of Naples, Naples, Italy
| | - Rade Vukovic
- Department of Pediatric Endocrinology, Mother and Child Health Care Institute of Serbia "Dr. Vukan Cupic", Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
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Singh A, Kleinhenz J, Brill H, Fahey L, Silvester JA, Sparks B, Verma R, Lee D, Mallon D, Leonard MM. A Clinician's Guide to Gluten Challenge. J Pediatr Gastroenterol Nutr 2023; 77:698-702. [PMID: 37608439 PMCID: PMC10872809 DOI: 10.1097/mpg.0000000000003923] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Gluten challenge is an essential clinical tool that involves reintroducing or increasing the amount of gluten in the diet to facilitate diagnostic testing in celiac disease (CD). Nevertheless, there is no consensus regarding the applications of gluten timing, dosing, and duration in children. This review aims to summarize the current evidence, discuss practical considerations, and proposes a clinical algorithm to help guide testing in pediatric patients. Childhood development, social circumstances, and long-term health concerns must be considered when identifying a candidate for gluten challenge. Based on previous studies, the authors suggest baseline serology followed by a minimum of 3-6 grams of gluten per day for over 12 weeks to optimize diagnostic accuracy for evaluation of CD. A formal provider check-in at 4-6 weeks is essential so the provider and family can adjust dosing or duration as needed. Increasing the dose of gluten further may improve diagnostic yield if tolerated, although in select cases a lower dose and shorter course (6-12 weeks) may be sufficient. There is consensus that mild elevations in celiac serology (<10 times the upper limit of normal) or symptoms, while supportive are not diagnostic for CD. Current North American Society for Pediatric Gastroenterology, Hepatology and Nutrition guidelines recommend histologic findings of intraepithelial lymphocytosis, crypt hyperplasia, and villous atrophy as the accurate and most appropriate endpoint for gluten challenge.
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Affiliation(s)
- Arunjot Singh
- Division of Gastroenterology, Hepatology & Nutrition, Children’s Hospital of Philadelphia, Philadelphia, PA
- University of Pennsylvania – Perelman School of Medicine, Philadelphia, PA
| | - Julia Kleinhenz
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, The University of Chicago, Chicago, IL
| | - Herbert Brill
- Division of Gastroenterology and Nutrition, McMaster Children’s Hospital, Hamilton, Ontario, Canada
- Department of Pediatrics, William Osler Health System, Etobicoke, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Lisa Fahey
- Division of Gastroenterology, Hepatology & Nutrition, Children’s Hospital of Philadelphia, Philadelphia, PA
- University of Pennsylvania – Perelman School of Medicine, Philadelphia, PA
| | - Jocelyn A. Silvester
- Celiac Research Program, Harvard Medical School, Boston, MA
- Department of Medicine, Boston Children’s Hospital, Boston, MA
| | - Brandon Sparks
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Riley Hospital for Children, Indiana University, Indianapolis, IN
| | - Ritu Verma
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, The University of Chicago, Chicago, IL
| | - Dale Lee
- Department of Pediatrics, Division of Gastroenterology, Seattle Children’s Hospital and University of Washington, Seattle, WA
| | - Daniel Mallon
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center/University of Cincinnati College of Medicine, Cincinnati, OH
| | - Maureen M. Leonard
- Celiac Research Program, Harvard Medical School, Boston, MA
- Division of Pediatric Gastroenterology and Nutrition, MassGeneral Hospital for Children, Harvard Medical School, Boston, MA
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Guandalini S. The when, why and whom to biopsy of type 1 diabetes mellitus children with positive anti-tissue transglutaminase serology. Saudi J Gastroenterol 2023; 29:257-258. [PMID: 37787345 PMCID: PMC10645000 DOI: 10.4103/sjg.sjg_253_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/22/2023] Open
Affiliation(s)
- Stefano Guandalini
- Founder and Director Emeritus of the University of Chicago Celiac Disease Center, Chicago, IL, USA
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5
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Al Sarkhy A, Al Hassan A, Assiri H, Alabdulkarim H, AlAnazi N, Alshammari N, AlOtaibi N, Al Asmi M, Assiri A, Al-Khalifah R, Ahamed SS, El Mouzan M. Frequency and predictive factors for spontaneous normalization of anti-tissue transglutaminase-IgA serology among Saudi children with type 1 diabetes mellitus: A cohort study. Saudi J Gastroenterol 2023; 29:278-285. [PMID: 37282447 PMCID: PMC10645001 DOI: 10.4103/sjg.sjg_25_23] [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: 01/20/2023] [Revised: 04/25/2023] [Accepted: 04/30/2023] [Indexed: 06/08/2023] Open
Abstract
Background Celiac serology can be transiently elevated in patients with type 1 diabetes mellitus (T1DM) and normalized despite gluten consumption. This study aimed to identify the frequency and predictive factors of spontaneous normalization of anti-tissue transglutaminase (anti-TTG-IgA) antibodies in these patients. Methods The charts of all patients (≤18 years) with T1DM were retrospectively reviewed from 2012 to 2021 at a tertiary care center in Riyadh, Saudi Arabia. The following data were collected: clinical characteristics of the participants, anti-TTG-IgA-immunoglobulin (Ig) A antibody, and histological findings. The outcome of positive anti-TTG-IgA-IgA in patients with T1DM and the predictive factors for spontaneous normalization were investigated. Results Of the 1,006 patients with T1DM, 138 (13.7%) had elevated anti-TTG-IgA antibodies, celiac disease was diagnosed in 58/138 (42%) patients, spontaneous normalization of anti-TTG-IgA was observed in 65 (47.1%) patients, and fluctuating anti-TTG-IgA antibodies were seen in 15 (10.9%) patients. The patients with anti-TTG-IgA levels at 3-10 times the upper normal limits (UNL), and those with levels ≥10 times UNL were less likely to have spontaneous normalization of anti-TTG-IgA compared to patients with levels at 1-3 times UNL (hazard ratio [HR] = 0.28, 95% confidence interval [Cl] = 0.13-0.61, P = 0.001, and HR = 0.03, 95% Cl = 0.00-0.19, P < 0.001, respectively). Conclusion Asymptomatic patients with T1DM with mild elevation of anti-TTG-IgA need not be rushed for invasive endoscopy or exposed to an un-needed gluten-free diet but should rather have a regular follow-up of their celiac serology.
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Affiliation(s)
- Ahmed Al Sarkhy
- Department of Pediatrics, Gastroenterology Unit, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Department of Pediatrics, Prince Abdullah Bin Khalid Celiac Disease Research Chair, King Saud University, Riyadh, Saudi Arabia
| | - Ali Al Hassan
- Department of Pediatrics, Gastroenterology Unit, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Department of Pediatrics, Maternity and Childhood Hospital, Ahsa, Saudi Arabia
| | - Heba Assiri
- Department of Pediatrics, Gastroenterology Unit, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Hayfa Alabdulkarim
- Department of Pediatrics, Gastroenterology Unit, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Noor AlAnazi
- Department of Pediatrics, Gastroenterology Unit, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Nawaf Alshammari
- Department of Pediatrics, Gastroenterology Unit, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Najla AlOtaibi
- Department of Pediatrics, Gastroenterology Unit, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Department of Pediatrics, College of Medicine, Majmaah University, Majmaah, Saudi Arabia
| | - Mona Al Asmi
- Department of Pediatrics, Gastroenterology Unit, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Department of Pediatrics, Prince Abdullah Bin Khalid Celiac Disease Research Chair, King Saud University, Riyadh, Saudi Arabia
| | - Asaad Assiri
- Department of Pediatrics, Gastroenterology Unit, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Department of Pediatrics, Prince Abdullah Bin Khalid Celiac Disease Research Chair, King Saud University, Riyadh, Saudi Arabia
| | - Reem Al-Khalifah
- Department of Pediatrics, Division of Endocrinology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Shaik Shaffi Ahamed
- Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mohammad El Mouzan
- Department of Pediatrics, Gastroenterology Unit, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Department of Pediatrics, Prince Abdullah Bin Khalid Celiac Disease Research Chair, King Saud University, Riyadh, Saudi Arabia
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Shiha MG, Raju SA, Sidhu R, Penny HA. The debate in the diagnosis of coeliac disease - time to go 'no-biopsy'? Curr Opin Gastroenterol 2023; 39:192-199. [PMID: 37144537 DOI: 10.1097/mog.0000000000000929] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
PURPOSE OF REVIEW Duodenal biopsies have been central to making a diagnosis of coeliac disease for the last 70 years. Recent paediatric guidelines have reduced the emphasis on duodenal biopsies with the incorporation of a 'no-biopsy' arm to the diagnostic pathway. This review discusses the no-biopsy approach in adults and highlights advances in alternative (non-biopsy) diagnostic modalities in coeliac disease. RECENT FINDINGS Evidence suggests that a no-biopsy approach for the diagnosis of adult coeliac disease is accurate. However, a number of factors still favour duodenal biopsy sampling in specific patient groups. Moreover, several factors need to be considered if this pathway is implemented into local gastroenterology services. SUMMARY Duodenal biopsies remain an important step in the diagnosis of adult coeliac disease. However, an alternative approach that removes the necessity for biopsies may be an option in selected adults. If further guidelines incorporate this pathway, then efforts should focus on supporting a dialogue between primary and secondary care to facilitate the appropriate implementation of this approach.
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Affiliation(s)
- Mohamed G Shiha
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust
- Academic Unit of Gastroenterology, Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Suneil A Raju
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust
- Academic Unit of Gastroenterology, Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Reena Sidhu
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust
- Academic Unit of Gastroenterology, Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Hugo A Penny
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust
- Academic Unit of Gastroenterology, Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
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Tamai T, Ihara K. Celiac Disease Genetics, Pathogenesis, and Standard Therapy for Japanese Patients. Int J Mol Sci 2023; 24:ijms24032075. [PMID: 36768398 PMCID: PMC9916540 DOI: 10.3390/ijms24032075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/14/2023] [Accepted: 01/17/2023] [Indexed: 01/21/2023] Open
Abstract
Celiac disease is an autoimmune disease primarily affecting the small intestine that is caused by the ingestion of gluten in genetically susceptible individuals. The development of celiac disease is based on a complex immune response to gluten proteins. The global average prevalence in the general population is about 1%. In recent years, it has become clear that celiac disease is not less common in Asian countries than in Western countries but often remains undiagnosed. Although the number of patients with celiac disease in Asia is expected to increase with improving disease recognition and advances in diagnostic techniques, there remain few reports of celiac disease in the Far East region of Asia, especially in Japan. In this paper, we outline the epidemiology, diagnosis, and treatment of celiac disease. In addition, we summarize the reported Japanese cases of celiac disease with an overview in Japan.
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Lal R, Bhardwaj R, Minz RW, Prasad KK, Lal S, Dayal D, Kumar Y. Usefulness of a double immunofluorescence technique for detection of intestinal tTG-IgA deposits in diabetic and non-diabetic children with celiac disease. Pediatr Neonatol 2022:S1875-9572(22)00269-8. [PMID: 36610914 DOI: 10.1016/j.pedneo.2022.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 12/30/2021] [Accepted: 01/18/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Celiac disease (CD) is frequently associated with type I diabetes mellitus (T1D), where its diagnosis may be a challenging task. This study aims to test the usefulness of the double staining immunofluorescence (dsIF) technique for the detection of intestinal anti-tissue transglutaminase specific IgA antibody (tTG-IgA) deposits in CD and T1D children with coexisting CD. METHODS A total of 46 patients (30 cases of CD and 16 cases of T1D with CD) and 16 non-diabetic, non-celiac children were recruited. Endoscopic biopsies were taken and analyzed by light microscopy, quantitative histology (QH), and a dsIF technique. RESULTS Histologically, villous atrophy was most severe in CD, followed by T1D with CD, while all control biopsies except 1 were normal. QH showed a statistically significant difference in villous height (Vh), crypt depth (CrD), and Vh:CrD ratio between diabetic and non-diabetic patients with CD. dsIF technique could detect tTG-IgA deposits in 85.7% of cases of CD alone and 93.8% of biopsies from diabetic children. Surprisingly, deposits were more extensive in biopsies with minimal villous shortening. Also, all 5 biopsies from T1D patients with normal histology were dsIF positive. CONCLUSION In-situ analysis of tTG-IgA immune deposits facilitates the detection of positive serology early-onset CD. Quantitative analysis may be used as an ancillary tool to increase the reliability of histological findings in these patients.
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Affiliation(s)
- Raghav Lal
- Department of Immunopathology, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Ranjeet Bhardwaj
- Department of Immunopathology, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Ranjana Walker Minz
- Department of Immunopathology, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Kaushal Kishore Prasad
- Department of Gastroenterology, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Sadhna Lal
- Department of Pediatric Gastroenterology, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Devi Dayal
- Department of Pediatric Endocrinology, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Yashwant Kumar
- Department of Immunopathology, Post Graduate Institute of Medical Education & Research, Chandigarh, India.
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Fröhlich-Reiterer E, Elbarbary NS, Simmons K, Buckingham B, Humayun KN, Johannsen J, Holl RW, Betz S, Mahmud FH. ISPAD Clinical Practice Consensus Guidelines 2022: Other complications and associated conditions in children and adolescents with type 1 diabetes. Pediatr Diabetes 2022; 23:1451-1467. [PMID: 36537532 DOI: 10.1111/pedi.13445] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Elke Fröhlich-Reiterer
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | | | - Kimber Simmons
- Barbara Davis Center for Diabetes, University of Colorado, Denver, Colorado, USA
| | - Bruce Buckingham
- Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford University Medical Center, Stanford, California, USA
| | - Khadija N Humayun
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Jesper Johannsen
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital, Herlev and Steno Diabetes Center Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany
| | - Shana Betz
- Parent/Advocate for people with diabetes, Markham, Canada
| | - Farid H Mahmud
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Özalkak Ş, Yıldırım R, Tunç S, Ünal E, Taş FF, Demirbilek H, Özbek MN. Revisiting the Annual Incidence of Type 1 Diabetes Mellitus in Children from the Southeastern Anatolian Region of Turkey: A Regional Report. J Clin Res Pediatr Endocrinol 2022; 14:172-178. [PMID: 35014245 PMCID: PMC9176090 DOI: 10.4274/jcrpe.galenos.2021.2021-10-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 12/15/2021] [Indexed: 12/01/2022] Open
Abstract
Objective The incidence of type 1 diabetes mellitus (T1D) in children has an increasing trend globally, with a variable rate depending on region and ethnicity. Our group first reported T1D incidence in Diyarbakır in 2011. The aim of this study was to evaluate the current incidence rate of pediatric T1D in Diyarbakır, and compare the incidence, and clinical and presenting characteristics of more recent cases with those reported in our first report. Methods Hospital records of patients diagnosed with T1D in Diyarbakır city between 1st January 2020 and 31st December 2020 and aged under 18 years old were retrieved, and their medical data was extracted. Demographic population data were obtained from address-based census records of the Turkish Statistical Institution (TSI). Results Fifty-seven children and adolescents were diagnosed with T1D. Of those, 34 were female (59.6%), indicating a male/female ratio of 1.47. The mean age at diagnosis was 9.5±3.9 years (0.8-17.9). TSI data indicated a population count of 709,803 for the 0-18 years age group. Thus the T1D incidence was 8.03/105 in the 0-18 age group and was higher in the 0-14 age group at 9.14/105. The cumulative increase in the incidence of T1D in the 0-14 age group was 26.9% suggesting an increasing rate of 2.7% per year. The frequency of presentation with diabetic ketoacidosis was 64.9%. Conclusion The annual incidence of pediatric T1D in Diyarbakır city increased from 7.2/105 to 9.14/105 within the last decade. The rate of annual increase was 2.7% in the 0-14 age group comparing this study with our earlier report, with a predominance in male subjects and a shift of peak incidence from the 5-9 year age group in the first study to the 10-14 year age group in this one.
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Affiliation(s)
- Şervan Özalkak
- Diyarbakır Gazi Yaşargil Training and Research Hospital, Clinic of Pediatric Endocrinology, Diyarbakır, Turkey
| | - Ruken Yıldırım
- Diyarbakır Child Diseases Hospital, Clinic of Pediatric Endocrinology, Diyarbakır, Turkey
| | - Selma Tunç
- Diyarbakır Child Diseases Hospital, Clinic of Pediatric Endocrinology, Diyarbakır, Turkey
| | - Edip Ünal
- Dicle University Faculty of Medicine, Department of Pediatric Endocrinology, Diyarbakır, Turkey
| | - Funda Feryal Taş
- Diyarbakır Gazi Yaşargil Training and Research Hospital, Clinic of Pediatric Endocrinology, Diyarbakır, Turkey
| | - Huseyin Demirbilek
- Hacettepe University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Mehmet Nuri Özbek
- Diyarbakır Gazi Yaşargil Training and Research Hospital, Clinic of Pediatric Endocrinology, Diyarbakır, Turkey
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Oliveira DR, Rebelo JF, Maximiano C, Gomes MM, Martins V, Meireles C, Antunes H, Martins S. HLA DQ2/DQ8 haplotypes and anti-transglutaminase antibodies as celiac disease markers in a pediatric population with type 1 diabetes mellitus. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2022; 66:229-236. [PMID: 35420265 PMCID: PMC9832899 DOI: 10.20945/2359-3997000000457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Objective Evaluate the celiac disease (CD) markers, within the scope of its screening, in a pediatric population with diagnosis of type 1 diabetes (T1D) at Hospital de Braga (HB) and determine the prevalence of CD in the sample. Reflect on CD screening algorithm applied in this pediatric population. Methods Retrospective observational study with 94 patients diagnosed with T1D at age 10 years or younger, followed up at the HB Outpatient Diabetology Consultation, including those referred from other hospitals. Record of clinical information, IgA anti-transglutaminase and anti-endomysium and HLA DQ2/DQ8 haplotypes. Results We obtained positive serological test for CD in 4 patients. This test had 100% sensitivity and specificity. The prevalence of CD was 4.3% (n = 4). Positive HLA screening in 84.6% of patients, with both sensitivity and negative predictive value of 100% and specificity of 16.67%. Diagnosis of CD was made on average 3.40 ± 3.32 years after the diagnosis of TD1. All cases of CD registered non-gastrointestinal manifestations, none had gastrointestinal symptoms. Conclusion This study proved that there is a higher prevalence of CD in pediatric population with TD1, when compared to general population, and clarified the importance of CD screening. Furthermore, it was observed that serological screening for CD antibodies is an excellent screening test and HLA typing, although not the most suitable first line test, can be useful in excluding the possibility of patients with T1D developing CD.
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Affiliation(s)
| | | | | | - Maria Miguel Gomes
- Faculdade de Medicina da Universidade do Minho, Braga, Portugal.,Unidade de Endocrinologia e Diabetologia Pediátrica, Departamento de Pediatria, Hospital de Braga, Braga, Portugal
| | - Vânia Martins
- Serviço de Pediatria, Centro Hospitalar Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Carla Meireles
- Serviço de Pediatria, Hospital Senhora da Oliveira-Guimarães, Guimarães, Portugal
| | - Henedina Antunes
- Unidade de Gastroenterologia, Hepatologia e Nutrição, Serviço de Pediatria e Centro Académico Clínico Hospital de Braga, Braga, Portugal.,Instituto de Investigação em Ciências da Vida e da Saúde (ICVS), ICVS/3B's-PT Laboratório Associado do Governo e Faculdade de Medicina da Universidade do Minho, Braga, Portugal
| | - Sofia Martins
- Unidade de Endocrinologia e Diabetologia Pediátrica, Departamento de Pediatria, Hospital de Braga, Braga, Portugal
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Flores Monar GV, Islam H, Puttagunta SM, Islam R, Kundu S, Jha SB, Rivera AP, Sange I. Association Between Type 1 Diabetes Mellitus and Celiac Disease: Autoimmune Disorders With a Shared Genetic Background. Cureus 2022; 14:e22912. [PMID: 35399440 PMCID: PMC8986520 DOI: 10.7759/cureus.22912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2022] [Indexed: 11/05/2022] Open
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13
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Sbravati F, Cosentino A, Lenzi J, Fiorentino M, Ambrosi F, Salerno A, Di Biase A, Righi B, Brusa S, Valin PS, Bruni L, Battistini B, Pagano S, Grondona AG, Labriola F, Alvisi P. Antitissue transglutaminase antibodies' normalization after starting a gluten-free diet in a large population of celiac children-a real-life experience. Dig Liver Dis 2022; 54:336-342. [PMID: 34274255 DOI: 10.1016/j.dld.2021.06.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/24/2021] [Accepted: 06/24/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Few data are available regarding the trend of IgA anti-transglutaminase antibodies (TGA-IgA) in children with celiac disease (CD) on a gluten-free diet (GFD). Our aim is to examine the normalization time of CD serology in a large pediatric population, and its predictors. MATERIAL AND METHODS We retrospectively evaluated the normalization time of TGA-IgA and its predictive factors (age, sex, ethnicity, symptoms, associated diabetes/thyroiditis, Marsh stage, TGA-IgA and endomysial antibody levels at diagnosis, diet adherence), in 1024 children diagnosed from 2000 to 2019 in three pediatric Italian centers, on a GFD. RESULTS TGA-IgA remission was reached in 67,3%, 80,7%, 89,8% and 94,9% after 12, 18, 24 and 36 months from starting a GFD, respectively (median time = 9 months). TGA-IgA >10´upper limit of normal at diagnosis (HR = 0.56), age 7-12 years old (HR = 0.83), poor compliance to diet (HR = 0.69), female sex (HR = 0.82), non-Caucasian ethnicity (HR = 0.75), and comorbidities (HR = 0.72) were independent factors significantly associated with longer time to normalization. CONCLUSIONS Our population is the largest in the literature, with the majority of patients normalizing CD serology within 24 months from starting a GFD. We suggest a special attention to patients with comorbidities, language barriers or age 7-12 years for a proper management and follow-up.
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Affiliation(s)
- Francesca Sbravati
- Pediatric Gastroenterology Unit, Department of Pediatrics, Maggiore Hospital, Largo B. Nigrisoli 2, Bologna 40132, Italy
| | - Anita Cosentino
- Specialty School of Pediatrics-Alma Mater Studiorum, Università di Bologna, Italy
| | - Jacopo Lenzi
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum-University of Bologna, Bologna 40138, Italy
| | - Michelangelo Fiorentino
- Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, Bologna 40138, Italy
| | - Francesca Ambrosi
- Bologna Metropolitan Department of Pathology, Maggiore Hospital, Bologna 40132, Italy
| | - Angela Salerno
- Department of Pediatrics, University of Modena, Modena 41125, Italy
| | - Annarita Di Biase
- Pediatric Unit, Santa Maria della Scaletta Hospital, Imola 40026, Italy
| | - Beatrice Righi
- Department of Pediatrics, University of Modena, Modena 41125, Italy
| | - Sandra Brusa
- Pediatric Unit, Santa Maria della Scaletta Hospital, Imola 40026, Italy
| | - Paola Sogno Valin
- Pediatric Unit, Santa Maria della Scaletta Hospital, Imola 40026, Italy
| | - Laura Bruni
- Specialty School of Pediatrics-Alma Mater Studiorum, Università di Bologna, Italy
| | | | - Sara Pagano
- Pediatric Gastroenterology Unit, Department of Pediatrics, Maggiore Hospital, Largo B. Nigrisoli 2, Bologna 40132, Italy
| | - Ana Gabriela Grondona
- Unified Metropolitan Laboratory, Autoimmunity and Allergy, Maggiore Hospital, Bologna 40132, Italy
| | - Flavio Labriola
- Pediatric Gastroenterology Unit, Department of Pediatrics, Maggiore Hospital, Largo B. Nigrisoli 2, Bologna 40132, Italy
| | - Patrizia Alvisi
- Pediatric Gastroenterology Unit, Department of Pediatrics, Maggiore Hospital, Largo B. Nigrisoli 2, Bologna 40132, Italy.
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Could I-FABP Be an Early Marker of Celiac Disease in Children with Type 1 Diabetes? Retrospective Study from the Tertiary Reference Centre. Nutrients 2022; 14:nu14030414. [PMID: 35276772 PMCID: PMC8840733 DOI: 10.3390/nu14030414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/09/2022] [Accepted: 01/16/2022] [Indexed: 02/05/2023] Open
Abstract
Patients with type 1 diabetes (T1D) are at higher risk of celiac disease (CD). Recently, intestinal fatty acid binding protein (I-FABP) has been shown to be a serological biomarker of impaired intestinal barrier in CD. Thus, the aim of this study was to verify whether I-FABP could be an early marker of CD in pediatric T1D patients. I-FABP was measured in sera of patients with T1D (n = 156), active CD (n = 38), T1D with active CD (T1D-CD, n= 51), and age-matched healthy children (n = 55). Additionally, I-FABP was determined in T1D patients with negative CD serology at least one year before CD diagnosis (T1D-CD-1, n = 22), in CD patients on a gluten-free diet (CD-GFD, n = 36), and T1D-CD patients on GFD (T1D-CD-GFD, n = 39). Sera were tested using immunoenzymatic assay. Significantly increased levels of I-FABP were found in the T1D, active CD, and T1D-CD groups (1153 ± 665, 1104 ± 916, and 1208 ± 878, respectively) in comparison to healthy with controls (485 ± 416, p < 0.05). GFD induced a significant decrease in I-FABP levels in CD and T1D-CD groups (510 ± 492 and 548 ± 439, respectively). Interestingly, in T1D-CD-1 and T1D, I-FABP levels were comparable (833 ± 369 vs. 1153 ± 665), and significantly increased in relation to healthy controls and T1D-CD values on GFD. The results indicate that the epithelial barrier is disrupted in T1D patients independently of CD development; therefore, I-FABP cannot serve as an early marker of CD in T1D patients. Although GFD can improve epithelial recovery, the question remains as to whether GFD could exert beneficial effects on the intestinal barrier in early stages of T1D.
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Zhang JJ, Wang JQ, Xu X, Zhang LD, Zhang CP, Lu WL, Gu WQ, Dong ZY, Xiao Y, Xia ZW. Circulating circular RNA profiles associated with celiac disease seropositivity in children with type 1 diabetes. Front Pediatr 2022; 10:960825. [PMID: 36210930 PMCID: PMC9537605 DOI: 10.3389/fped.2022.960825] [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: 06/03/2022] [Accepted: 09/07/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The frequency of celiac disease autoantibody (CDAb) positivity in type 1 diabetes (T1D) has increased due to unclear mechanisms, including autoimmune injury. Circular ribonucleic acids (circRNAs) participate in autoimmune diseases, but the roles of circRNAs in T1D with CDAbs are currently unknown. This study aimed to determine the frequency of CDAbs in Chinese children with T1D and describe the relationship between CDAbs and circRNAs. MATERIALS AND METHODS Eighty patients diagnosed with T1D were screened for CDAbs and CD-predisposing genes, and circRNAs in peripheral blood mononuclear cells (PBMCs) were collected from 47 patients. The Gene Expression Omnibus (GEO) database was searched for candidate circRNAs in related studies on T1D PBMCs. Data on clinical characteristics (i.e., blood glucose control, residual islet function, and daily insulin dosage) and immunophenotypes (i.e., islet autoantibodies and immune cell subsets) were collected. RESULTS In total, 35.0% of patients were positive for CDAbs. CD-predisposing genes accounted for 52.5% of the genes, and no significant difference in frequency was found between the CDAb-positive (CDAb+) and CDAb-negative (CDAb-) groups. In addition, among the differentially expressed circRNAs from the GEO database, five highly conserved circRNAs homologous to humans and mice were screened, and only the expression of hsa_circ_0004564 in the CDAb+ group significantly decreased (CDAb+ vs. CDAb-:1.72 ± 1.92 vs. 11.12 ± 8.59, p = 6.0 × 10-6), while the expression of hsa_circ_0004564 was upregulated in the general T1D population. Moreover, its parental gene RAPH1 was significantly upregulated (CDAb+ vs. CDAb-:1.26 ± 0.99 vs. 0.61 ± 0.46, p = 0.011). Importantly, the positive correlation between hsa_circ_0004564 and CD3+ cells was validated in children with T1D after adjustments for CDAbs (p = 0.029), while there were no correlations between hsa_circ_0004564 and clinical characteristics or other immune cell subsets (i.e., CD4+ T cells, CD8+ T cells, and natural killer cells). CONCLUSION This study highlights the importance of screening for CD in Chinese children with T1D, considering the high prevalence of CDAb positivity and CD-predisposing genes. The profile of candidate circRNAs in children with T1D with CDAbs was different from that in previous reports on general T1D patients from the GEO database. Moreover, hsa_circ_0004564 and its parental gene RAPH1 may be new targets for studying immune mechanisms in children with T1D and CD.
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Affiliation(s)
- Juan-Juan Zhang
- Department of Pediatrics, Ruijin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, China
| | - Jun-Qi Wang
- Department of Pediatrics, Ruijin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, China
| | - Xu Xu
- Department of Pediatrics, Ruijin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, China
| | - Li-Dan Zhang
- Department of Pediatrics, Ruijin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, China
| | - Cai-Ping Zhang
- Department of Pediatrics, Ruijin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, China
| | - Wen-Li Lu
- Department of Pediatrics, Ruijin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, China
| | - Wei-Qiong Gu
- Department of Endocrinology and Metabolism, Ruijin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, China
| | - Zhi-Ya Dong
- Department of Pediatrics, Ruijin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, China
| | - Yuan Xiao
- Department of Pediatrics, Ruijin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, China
| | - Zhen-Wei Xia
- Department of Pediatrics, Ruijin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, China
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Paul SP, Ranjan A, Bremner G, Gillett PM. Diagnosis and management of coeliac disease in children. ACTA ACUST UNITED AC 2021; 30:S6-S10. [PMID: 34251861 DOI: 10.12968/bjon.2021.30.13.s6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Coeliac disease (CD) is an autoimmune gluten-dependent condition with a prevalence of 1% in the population, if screened. However, approximately only a third of children with CD are diagnosed. When CD is suspected, serological screening with anti-tissue transglutaminase titres should be performed. Children with a positive result should be referred to a specialist in CD for confirmation of the diagnosis. The European Society for Paediatric Gastroenterology Hepatology and Nutrition revised their diagnostic guidance for CD in 2020 and this article discusses the current diagnostic pathways. Lifelong strict adherence to a gluten-free diet is necessary to prevent complications. Nurses and specialist paediatric dietitians have an important role in recognising and diagnosing CD early, as well as offering ongoing dietary and clinical support.
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Affiliation(s)
| | - Abeeran Ranjan
- Consultant Paediatrician, Yeovil District Hospital, Yeovil
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Jalilian M, Jalali R. Prevalence of celiac disease in children with type 1 diabetes: A review. Diabetes Metab Syndr 2021; 15:969-974. [PMID: 33946030 DOI: 10.1016/j.dsx.2021.04.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/20/2021] [Accepted: 04/22/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Diabetes mellitus is a chronic disease and a major health threat. Comorbidity of celiac disease and diabetes is associated with many complications in children, and if not diagnosed in time in diabetes children, caused complications, including gastrointestinal disorders, most importantly, growth disorders. Thus, this study aims to summarize the evidence about prevalence of celiac disease in children with type 1 diabetes through a systematic review approach. METHODS A literature review was conducted within databases. Observational studies that assessed the prevalence of celiac disease in diabetes children, were included. We assess the quality of included studies with STROBE checklist. Data extraction and assessment has guided by PRISMA checklist. Also, the data has reported by Garrard's table. RESULTS 31 studies included that assessed 63,349 children with type 1 diabetes. Anemia, osteoporosis, and neurological disorders reported. Studies showed two main type of tests for diagnosis of CD included serological and intestinal biopsy. The prevalence of CD based serologic tests was higher than of intestine biopsy (1.4%-24.5% VS 1.1%-16.6%). In addition, the prevalence of celiac disease was different between populations. CONCLUSIONS Celiac disease is an important comorbidity in children with type 1 diabetes, especially because of the similarity between CD symptoms and neuropathic and gastrointestinal symptoms of diabetes. Screening the diabetes children for celiac disease by serological tests and then intestinal biopsy is recommended.
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Affiliation(s)
- Milad Jalilian
- Nursing Department, Nursing and Midwifery School, Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran.
| | - Rostam Jalali
- Nursing Department, Nursing and Midwifery School, Kermanshah University of Medical Sciences, Kermanshah, Iran
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