Alimentary TractDynamics of celiac disease-specific serology after initiation of a gluten-free diet and use in the assessment of compliance with treatment
Introduction
Celiac disease (CD) is a chronic inflammatory disease in the gastrointestinal (GI) tract triggered by dietary gluten in susceptible individuals. Complete and lifelong adherence to a gluten-free diet (GFD) is the only accepted treatment that allows patients to lead an otherwise normal life [1], [2], [3]. The current diagnostic strategy for CD is primarily based on the demonstration of a characteristic gluten-dependent enteropathy [1], [2]. Whilst intestinal biopsy is still considered the gold standard for diagnosing CD, CD-related serological tests have been used clinically for more than 20 years as markers for screening candidates for duodenal biopsy and as a reliable surrogate marker for gluten sensitivity [3]. Two types of antibodies have been closely associated with CD: the first type are the serum antibodies against gliadin, the external antigen that triggers CD [4], [5]; the other type are the autoantibodies against connective matrix proteins (anti-reticulin, anti-endomysium [EmA], anti-transglutaminase [a-tTG] and anti-actin antibodies [AAA]) [6], [7], [8].
Although the screening and diagnosis of CD is relatively well established [1], [9], there are no reliable measurements for follow-up assessment of treatment effectiveness [10], [11], [12], [13], [14]. Clinical assessment is not particularly useful to measure outcomes because a majority of patients with CD have an atypical or silent presentation of the illness [15]. The quality-of-life measurements have been shown to be responsive to treatment, but their sensitivity to patients’ compliance with dietary treatment seems to be limited [16]. Histological evaluation of duodenal biopsy specimens is critical for diagnosis, but is not feasible for routine monitoring of treatment efficacy and remission [14]. Although CD-specific serology has an established role in screening and diagnosis, their sensitivity and accuracy as an outcome measurement tool have not been well established and continue to be debated [15], [16], [17], [18], [19], [20].
Our aims in the present study were to prospectively describe the changes of a series of CD-related antibodies over time in newly diagnosed patients who were placed on the GFD and to determine the efficacy of serologic tests in evaluating patient compliance with dietary treatment during the first year of initiating the GFD.
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Patients
From December 2004 to December 2005, 132 consecutive adults (113 female and 19 male) who were newly diagnosed for CD at the Small Bowel Diseases Clinic of the “Dr. Carlos Bonorino Udaondo” Gastroenterology Hospital were enrolled in this 1-year prospective study. IgA-deficient patients, those without biopsy-confirmed CD, and patients already on a GFD at the time of the first visit were excluded. We also excluded patients who expressed reluctance about participating to the study and those who
Baseline clinical and serologic findings
At diagnosis, most patients enrolled had classical GI symptoms, 19% had atypical presentation, and only 7% were asymptomatic. Table 1 presents demographic, clinical, and histological characteristics of patients at diagnosis.
The CD-specific serologic tests produced a range of baseline values depending on the assay used. Based on the cut-off values provided by the manufacturers, the serologic tests were categorised into assays with very high sensitivity (>92%) (IgA a-tTG, IgA, IgG a-DGP, IgA EmA,
Discussion
Avoidance of gluten exposure is crucial for CD patients to reduce the risk of complications. To achieve efficay with GFD, reliable markers are needed to monitor patient compliance with dietary restrictions. Clinical outcome, laboratory tests, quality-of-life instruments, self-reported compliance, intestinal biopsy, and others tools have been used with unsatisfactory reliability [3]. In contrast, a nutritionist's evaluation to estimate the degree of transgression from the GFD has been suggested
Conflict of interest statement
None declared.
Disclosures
This is an investigator-performed study and Inova Diagnostic Inc. had no direct or indirect involvement in the design of the study, data collection nor preparation or submission of the manuscript. Inova Diagnostic Inc. generously provided assays.
Grant/funding support
The study was supported by a grant from the Consejo de Investigaciones en Salud del Gobierno Autónomo de la Ciudad de Buenos Aires, Argentina. Reagents used in this study were generously provided by Inova Inc. San Diego, CA, USA.
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