Pediatric Celiac Disease Research Articles

Factors Associated With Adherence to a Gluten-Free Diet in Celiac Patients Diagnosed in Childhood as Compared to Adulthood.

Past studies have reported differences between pediatric and adult celiac disease patients. We aimed to compare factors associated with adherence to a gluten-free diet between these groups. An anonymous online questionnaire was sent via the Israeli Celiac Association and social networks to celiac patients. The Biagi questionnaire was used to assess dietary adherence. A total of 445 subjects participated. Mean age was 25.7 ± 17.5 years and 71.9% were female. Subjects were divided into six groups according to age at diagnosis: younger than 6 years (134 patients, 30.7%), 6-12 (79 patients, 18.1%), 12-18 (41 patients, 9.4%), 18-30 (81 patients, 18.5%), 30-45 (79 patients, 18.1%), and 45 years and above (23 patients, 5.3%). There were several significant differences between childhood- and adulthood-diagnosed patients. Pediatric patients were less likely to be noncompliant with a gluten-free diet (3.7% vs. 9.4%, p < .001). They were also more frequently followed by a gastroenterologist ( p < .001), a dietitian ( p < .001), and participated in a celiac support group ( p = .002). In logistic regression analyses, longer duration of disease was associated with poor compliance. In conclusion, pediatric-diagnosed celiac patients are more adherent to a gluten-free diet than those diagnosed in adulthood, with better social support and nutritional follow-up possibly contributing.

Doporučení ESPGHAN stran sledování celiakie u dětí

Doporučení ESPGHAN stran sledování celiakie u dětí

Role of age in dynamics of autoantibodies in pediatric Celiac disease

BackgroundCeliac disease (CD) is characterized by elevated serum titers of autoantibodies IgA anti-tissue transglutaminase 2 (TGA-IgA) and IgA anti-endomysial (EMA), with small bowel mucosa atrophy. We evaluated age differences between CD children exhibiting variable antibody titers at diagnosis.MethodsCD children diagnosed between January 2014 and June 2019, according to 2012 ESPGHAN guidelines were studied. All had EMA and TGA-IgA measurements, while a proportion of them underwent esophagogastroduodenoscopy (EGD). Patients were grouped based on serum TGA-IgA titers normalized to the upper limit of normal (ULN) and differences in median age (years) assessed by analysis of variance (ANOVA) and creation of orthogonal contrasts.ResultsCD was diagnosed in 295 subjects (median age: 4.4 [IQR: 2.60–8.52]) with a biopsy sparing protocol (high titer: ≥ 10xULN) and in 204 by EGD biopsy. Of the latter, 142 (median age: 8.5 [IQR: 5.81–11.06]) and 62 (median age: 9.5 [IQR: 6.26–12.76]) had a low (< 5xULN) and a moderate (≥ 5 < 10xULN) TGA-IgA titer, respectively. Potential CD was diagnosed in 20 patients (median age: 3.6 [IQR: 2.47–6.91]). The median age was significantly lower in the no-biopsy group (ANOVA: F(3, 516) = 25.98, p < .001) than in low- and moderate titer groups (p < 0.0001), while there was no statistical difference between biopsy-sparing and potential CD groups.ConclusionCD patients with greatly elevated antibody titers (≥ 10xULN) were diagnosed at an earlier age than those with lower titers. This may indicate that an increase in TGA-IgA is independent of age and suggests a polarization of autoimmunity in younger individuals with higher serum antibody levels.

Serum immune profiling in pediatric Crohn's disease demonstrates stronger immune modulation with first-line infliximab than conventional therapy and pre-treatment profiles predict clinical response to both treatments.

Despite its efficacy, rational guidance for starting/stopping first-line biologic treatment in individual pediatric Crohn's disease (CD) patients is needed. We assessed how serum immune profiles before and after first-line infliximab (FL-IFX) or conventional (CONV) induction therapy associate with disease remission at week 52. pre- (n=86), and 10-14 week post-treatment (n=84) sera were collected from patients with moderate-to-severe paediatric CD in the TISKids trial, randomised to FL-IFX (n=48; five 5mg/kg infusions over 22 weeks) or CONV (n=43; exclusive enteral nutrition or oral prednisolone); both groups received azathioprine maintenance. The relative concentrations of 92 inflammatory proteins were determined with Olink Proteomics; fold changes (FC) with |Log2FC|>0.5 after FDR adjustment were considered significant. FL-IFX modulated a larger number of inflammatory proteins and induced stronger suppression than CONV; 18/30 proteins modulated by FL-IFX were not regulated by CONV. Hierarchical clustering based on IFX-modulated proteins at baseline revealed two clusters of patients: CD-hi patients had significantly higher concentrations of 23/30 IFX-modulated proteins (including oncostatin-M, TNFSF14, HGF, TGF-α) and higher clinical disease activity, CRP and blood neutrophils at baseline than CD-lo patients. Only 24% of CD-hi FL-IFX-treated patients maintained remission without escalation at week 52 vs 58% of CD-lo FL-IFX-treated patients. Similarly, 6% of CD-hi CONV-treated patients achieved remission vs 20% of CONV-treated CD-lo patients. Clustering based on immune profiles post-induction therapy did not relate to remission at week 52. FL-IFX leads to stronger reductions and modulates more immune proteins than CONV. Stratification on pre-treatment profiles of IFX-modulated proteins directly relates to maintenance of remission without treatment escalation.

Retrospective analyses of antibody titers in the diagnosis of pediatric Celiac Disease

Objective: We aimed to evaluate the relationship between Tissue Transglutaminase IgA titer (tTGIgA) and Endomisium antibody (EMA) positivity and the stage of duodenal mucosal damage at Celiac disease (CD). Material and Methods: The study group consisted of 233 children (2-18 years old) who were diagnosed with CD and admitted to our XXX Hospital, Pediatric Gastroenterology Outpatient Clinic, between September 2017 and November 2022. All patients underwent an endoscopy, and a histopathological diagnosis was made. In upper gastrointestinal endoscopy, one biopsy sample were taken from the duodenum bulb and four samples from the second part of the duodenum. Histological patterns were evaluated according to the Marsh-Oberhuber classification. Results: A total 233 patients with CD were included in the study. The mean age of the patients at the time of diagnosis was 97.0 ± 57.1 months. The patients' mean tissue transglutaminase (tTG) IgA value was 172 ± 133. The most common Marsh-Oberhuber classification was found to be Marsh 3b (47.6%) in CD patients. According to the Marsh-Oberhuber classification, the mean tTGIgA values were significantly different compared to the groups. Conclusion: We recommend starting a diet with a diagnosis of CD without endoscopy for patients with a tTGIgA value of 10 X ULN (upper limit of normal) or more recommended by ESPGAN, and we even support randomized prospective studies to reduce this value to 7-10 times or less.

Nutrient intakes in adult and pediatric coeliac disease patients on gluten-free diet: a systematic review and meta-analysis.

Celiac Disease (CD) continues to require a strict lifetime gluten-free diet (GFD) to maintain healthy status. Many studies have assessed the GFD nutritional adequacy in their cohorts, but an overall picture in adults and children would offer a lifetime vision to identify actionable areas of change. We aimed at assessing the nutrient intakes of adult and pediatric CD patients following a GFD diet and identifying potential areas of improvement. Systematic review was carried out across PubMed, Scopus and Scholar up to October 2022, including full-text studies that assessed the nutrient intakes of CD patients on GFD, in terms of macro- and/or micronutrients (absolute or percentage daily average). Random-effect meta-analysis and univariable meta-regression were applied to obtain pooled estimates for proportions and influencing variables on the outcome, respectively. Thirty-eight studies with a total of 2114 patients were included. Overall, the daily energy intake was 1995 (CI 1884-2106) Kcal with 47.8% (CI 45.7-49.8%) from carbohydrates, 15.5% (CI 14.8-16.2%) from proteins, and 35.8% (CI 34.5-37.0%) from fats. Of total fats, 13.2% (CI 12.4-14.0%) were saturated fats. Teenagers had the highest consumption of fats (94.9, CI 54.8-134.9 g/day), and adults presented insufficient dietary fiber intake (18.9 g, CI 16.5-21.4 g). Calcium, magnesium, and iron intakes were particularly insufficient in adolescence, whereas vitamin D was insufficient in all age groups. In conclusion, GFD may expose CD patients to high fat and low essential micronutrient intakes. Given GFD is a lifelong therapy, to prevent the occurrence of diseases (e.g. cardiovascular or bone disorders) dietary intakes need to be assessed on long-term follow-ups.

Celiac Disease and the Gluten Free Diet during the COVID-19 Pandemic: Experiences of Children and Parents.

The COVID-19 pandemic perturbed the everyday life of children and those with chronic illnesses, along with the lives of their families. Patients with celiac disease (CD) follow a strict gluten-free diet (GFD), and gluten ingestion is associated with negative health outcomes. The aim of this study was to investigate the experiences of children with CD and their families concerning their GFD, symptoms and CD management during the first period of the COVID-19 pandemic. A cross-sectional questionnaire-based study was performed including 37 Dutch pediatric patients with CD, along with their parents. The majority reported good compliance to the GFD and stated that the diet was easier to follow during the pandemic, mainly due to eating more meals in the home. Some discovered a greater variety of GF products by utilizing online shopping, potentially increasing the financial burden of the GFD. Concerning general dietary habits, 21.6% reported a healthier eating pattern, in contrast to 37.8% and 10.8% who consumed more unhealthy snacks and fewer fruits and vegetables, respectively, than normal during the pandemic. The natural experiment of the COVID-19 pandemic provides valuable information regarding the management of pediatric CD. Education on healthy dietary patterns is important, especially for children with restrictive diets, and the findings of this study show that there is room for improvement in this respect, regardless of the current pandemic.

Peroxiredoxins and Hypoxia-Inducible Factor-1α in Duodenal Tissue: Emerging Factors in the Pathophysiology of Pediatric Celiac Disease Patients.

Celiac disease (CD) is an autoimmune enteropathy. Peroxiredoxins (PRDXs) are powerful antioxidant enzymes having an important role in significant cellular pathways including cell survival, apoptosis, and inflammation. This study aimed at investigating the expression levels of all PRDX isoforms (1-6) and their possible relationships with a transcription factor, HIF-1α, in the small intestinal tissue samples of pediatric CD patients. The study groups consisted of first-diagnosed CD patients (n = 7) and non-CD patients with functional gastrointestinal tract disorders as the controls (n = 7). The PRDXs and HIF-1α expression levels were determined by using real-time PCR and Western blotting in duodenal biopsy samples. It was observed that the mRNA and protein expression levels of PRDX 5 were significantly higher in the CD patients, whereas the PRDX 1, -2, and -4 expressions were decreased in each case compared to the control group. No significant differences were detected in the PRDX 3 and PRDX 6 expressions. The expression of HIF-1α was also significantly elevated in CD patients. These findings indicate, for the first time, that PRDXs, particularly PRDX 5, may play a significant role in the pathogenesis of CD. Furthermore, our results suggest that HIF-1α may upregulate PRDX-5 transcription in the duodenal tissue of CD.

Taking a "Second Look" at the Incidence of Pediatric Celiac Disease.

Department of Pediatrics, Division of Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. Correspondence: Matthew D. Egberg, MD, MPH, MMSc. E-mail: [email protected].

Gluten-free diet affects fecal small non-coding RNA profiles and microbiome composition in celiac disease supporting a host-gut microbiota crosstalk

ABSTRACT Current treatment for celiac disease (CD) is adhering to a gluten-free diet (GFD), although its long-term molecular effects are still undescribed. New molecular features detectable in stool may improve and facilitate noninvasive clinical management of CD. For this purpose, fecal small non-coding RNAs (sncRNAs) and gut microbiome profiles were concomitantly explored in CD subjects in relation to strict (or not) GFD adherence over time. In this observational study, we performed small RNA and shotgun metagenomic sequencing in stool from 63 treated CD (tCD) and 3 untreated subjects as well as 66 sex- and age-matched healthy controls. tCD included 51 individuals on strict GFD and with negative transglutaminase (TG) serology (tCD-TG-) and 12 symptomatic with not strict/short-time of GFD adherence and positive TG serology (tCD-TG+). Samples from additional 40 healthy adult individuals and a cohort of 19 untreated pediatric CD subjects and 19 sex/age matched controls were analyzed to further test the outcomes. Several miRNA and microbial profiles were altered in tCD subjects (adj. p < .05). Findings were validated in the external group of adult controls. In tCD-TG-, GFD duration correlated with five miRNA levels (p < .05): for miR-4533-3p and miR-2681-3p, the longer the diet adherence, the less the expression differed from controls. tCD-TG+ and untreated pediatric CD patients showed a similar miRNA dysregulation. Immune-response, trans-membrane transport and cell death pathways were enriched in targets of identified miRNAs. Bifidobacterium longum, Ruminococcus bicirculans, and Haemophilus parainfluenzae abundances shifted (adj. p < .05) with a progressive reduction of denitrification pathways with GFD length. Integrative analysis highlighted 121 miRNA-bacterial relationships (adj. p < .05). Specific molecular patterns in stool characterize CD subjects, reflecting either the long-term GFD effects or the gut inflammatory status, in case of a not strict/short-time adherence. Our findings suggest novel host-microbial interplays and could help the discovery of biomarkers for GFD monitoring over time.

P248 The diagnostic accuracy of Intestinal ultrasound for assessing disease activity in the proximal ileum and jejunum in children with Crohn’s disease: Preliminary results of a prospective study

Abstract Background Crohn’s disease (CD) is an inflammatory bowel disease (IBD) involving mainly the small intestine and the colon. Current imaging modalities such as magnetic resonance enterography (MRE) to assess disease activity in the small bowel are expensive and are often poorly tolerated by children. Intestinal ultrasound (IUS) is a non-invasive and well tolerated monitoring tool for assessing disease activity in colon and terminal ileum. In children the diagnostic accuracy of IUS for proximal bowel has not been systematically studied. In this study we assess the diagnostic accuracy of IUS compared to MRE for the proximal ileum and jejunum in the paediatric population. Furthermore we aim to establish which IUS features are the best predictors for IBD activity in the proximal ileum and jejunum. Methods Paediatric CD patients were prospectively enrolled and underwent MRE and IUS within 7 days. MRE-images were scored using the segmental grading system by Tielbeek et al. The ultrasonographer was blinded for the MRE results and the paediatric radiologist who assessed the MRE images was blinded for IUS results. Results Forty-two paediatric CD patients underwent IUS paired with MRE until now. Eighty-four bowel segments were available for analyses. In total 24 bowel segments had mild (n=12) to moderate severe (n=12) disease activity based on MRE. The AUROC of BWT for moderate severe disease was 0.78 (95% CI 0.61-0.95). A cut-off value of BWT &amp;gt;2.5 mm showed had a specificity of 90%. A cut-off value of BWT &amp;lt;1.7 mm showed had a sensitivity of 91%. Of the affected segments 12 had increased Doppler signal and 13 showed mesenteric fat proliferation. No regression analysis was performed since the number of inflamed segments was too low. Conclusion IUS is an promising tool to non-invasively assess disease activity in the proximal ileum and jejunum. Our preliminary results suggest that a cut-off for BWT &amp;lt; 2,5mm IUS can be used to demonstrate disease activity. A lager sample size to perform regression analysis and to assess other IUS features for disease activity is currently being collected.

P448 Long term effectiveness of first-line infliximab treatment compared to conventional treatment in paediatric moderate-to-severe Crohn’s disease – an update from the TISKids study

Abstract Background Current guidelines recommend first-line anti-TNF therapy (start at diagnosis) only in children with high risk for a complicated disease course. However, previous results of the TISKids study showed that first-line infliximab (FL-IFX) treatment (5 infusions in total) combined with azathioprine (AZA) was more effective to achieve clinical remission without treatment escalation at week 52 compared to conventional induction treatment (CONV) with AZA in therapy-naïve children with moderate-to-severe CD, irrespective of having high risk for development of complications1. The aim of our study was to investigate the effects at 3-year follow-up of the TISKids cohort. Methods The TISKids study is a multicentre, open-label randomised controlled trial in which untreated patients with a new diagnosis of CD (3–17 years old, weighted paediatric CD activity index score &amp;gt;40) were included. Patients were randomised to FL-IFX (5 infusions of 5 mg/kg infliximab at weeks 0, 2, 6, 14, 22) or CONV (EEN or prednisolone). Both treatment groups were combined with AZA maintenance. The primary outcome was biochemical remission (faecal calprotectin &amp;lt;250 ug/g) without need for additional biological treatment at 3 years. Secondary outcomes were time to additional biological treatment and number of patients with luminal surgery until 3 years. Additional biological treatment in the FL-IFX group included intensification, continuation or restart of IFX. Differences in proportions were tested using the Chi-square or Fisher-exact test, time to additional biological was analysed using Kaplan-Meier method with log-rank test. Results In total, 50 patients received FL-IFX and 47 CONV. One patient from each group was lost to follow-up, data at 3 years was available in 89/97 patients. At 3 years, 5/43 (12%) FL-IFX patients were in biochemical remission without need for additional biological treatment compared to 4/42 (10%) CONV patients (p=1.00). The time to additional biological treatment was significantly longer for the FL-IFX patients (median 63 weeks) compared to CONV patients (median 32 weeks), p=0.019. The number of luminal surgeries (all ileocaecal resections) until 3 years was not significantly different between FL-IFX (n=2/46, 4%) compared to CONV (n=5/43, 12%), p=0.256. Conclusion These results imply that there still is a significant benefit of FL-IFX during 3 years of follow-up (longer time to additional biological treatment compared to CONV), demonstrating durability of providing effective induction treatment. Further research should identify in which patient and when IFX may be stopped and which maintenance treatment would be appropriate in order to sustain and further optimize the benefits of FL-IFX treatment. 1. Jongsma MME et al. Gut. 2020. PMID: 33384335

P052 IL-12p70 as a potential driver of pathogenic IL-17+IFNγ+ mucosal memory TIGITneg T cells in a subgroup of severe CD patients

Abstract Background Crohn’s disease (CD) is a chronic disease driven by inflammatory memory CD4+ T cells. Deciphering heterogeneity in underlying immune disease is required for predicting the individual patients’ disease course. We have shown that analysis of circulating CD38+ memory CD4+ T cells, which are enriched for gut-homing, identifies therapy-naïve pediatric CD patients with a more severe disease course. At diagnosis, these patients have increased frequencies of circulating CD38+ memory T cells that do not express TIGIT (TIGITneg). TIGIT (T-cell immunoreceptor with immunoglobulin and ITIM domains), is a coinhibitory receptor selectively induced on CD4+ T cells with a memory phenotype. In healthy controls, TIGIT+CD38+ memory T cells have an inhibitory function while TIGITnegCD38+ memory T cells are enriched in inflammatory cells. In our cohort of CD patients, circulating inflammatory TIGITnegCD38+ memory T cells had increased frequencies of pathogenic IFNγ +IL-17+-double-producing or Th1* cells. We hypothesize that in these severe CD patients, CD-related inflammatory cytokines selectively increase frequencies of Th1* TIGITnegCD38+ memory T cells. Methods We cultured peripheral blood memory CD4+ T cells from healthy individuals in vitro with TCR- and co-stimulation together with different cocktails of CD-related inflammatory cytokines during 72h. Results Of all cytokines tested, only cocktails containing IL-12p70 increased TIGITneg cell frequencies within gut-homing CD38+ memory T cells, but not CD38neg memory T cells that are enriched in skin-homing. As hypothesized, IL-12p70-stimulated cultures contained higher frequencies of Th1* cells, expressing both hallmark transcription factors T-bet and RORgt, in TIGITnegCD38+ T cells but not within TIGIT+CD38+ T cells. This selective IL-12p70 responsiveness in TIGITneg cells agreed with the higher expression of the IL-12 receptor b2 subunit in TIGITnegCD38+ compared to TIGIT+CD38+ memory T cells. These data argue that IL12p70 initiates reprogramming of the TIGITnegCD38+ memory T cells to the Th1* phenotype. To assess whether IL-12p70 causes expansion of TIGITnegCD38+ cells or downregulates TIGIT expression on TIGIT+CD38+ cells, we traced fluorescently-labelled TIGIT+ cells during culture. TIGIT+ cells did not downregulate TIGIT, indicating that IL-12p70 increased proliferation of TIGITnegCD38+ cells. Conclusion The finding that IL-12p70 drives expansion of TIGITnegCD38+ memory T cells with a pathogenic Th1* phenotype argues that this cytokine may enforce chronic inflammation in these severe CD patients. These analyses pave the way toward deciphering key actors involved in CD inflammation at an individual patient level, needed to tailor novel IL-12/IL-23 targeting therapeutic strategies.

TREATMENT PATTERNS OF PEDIATRIC AND ADULT PATIENTS WITH CROHN’S DISEASE

Abstract OBJECTIVE Crohn’s Disease (CD) is a chronic disease characterized by transmural inflammation and may involve any portion of the gastrointestinal tract. Children with CD are more likely to present with extensive disease and have more rapid clinical progression than adults.1 This study aimed to compare the treatment patterns between pediatric and adult patients with CD. METHODS This is a retrospective claims-based study using the Merative L.P Marketscan® Research database (January 1, 2014 through December 31, 2021). Pediatric (≤ 17 years) and adult (≥ 18 years) patients with a CD diagnosis code and ≥12 months continuous enrollment with medical and pharmacy benefits before and after the first diagnosis of CD (index date) were included. Descriptive statistics described treatment patterns for pediatric and adult CD cohorts. RESULTS There were 2810 pediatric and 25,934 adult patients with CD included in the analysis. The mean (SD) ages in years for pediatric and adult patients were 13.5 (3.1) and 46.0 (15.9), respectively (Table 1). While females (53.6%) were slightly predominant in the adult cohort, there was a numerically higher proportion of males (59.5%) in the pediatric cohort. The most common monotherapy in children was corticosteroids (22.9%) or biologics (34.9%), while adult monotherapy was primarily corticosteroids (29.6%) or aminosalicylates (32.9%). The time from diagnosis to initiation of corticosteroids and immunomodulators was numerically shorter in children than adults (median days between index and corticosteroids or immunomodulators initiations: 14 vs. 54 and 26 vs 34, respectively). Combination therapies, including biologics and/or immunomodulators with corticosteroids, were numerically more often used in children than in adults (32.4% vs 15.0%). Among all biologic users, adalimumab (18.1%) was numerically more commonly prescribed for adults while infliximab (38.2%) was numerically more common in children. Pediatric patients showed numerically higher 6-month persistence from initiation of a biologic when compared with adult patients (persistence rate: 94.6% vs 87.2%; Table 2). Notably, a small proportion of pediatric patients were on either ustekinumab or vedolizumab (0.1% and 0.2%, respectively) as add-on therapy despite those medications not being currently approved in this population. CONCLUSION The study suggests that children with newly diagnosed CD receive combination therapies more frequently than adults. This may be related to greater disease severity in children. Children treated with biologics had numerically greater persistence, suggesting similar efficacy compared to adults. REFERENCE 1. Freeman H.J., Natural history and long-term clinical course of Crohn’s disease. World J Gastroenterol. 2014 Jan 7;20(1):31-6.

PRO-INFLAMMATORY SIRPα-EXPRESSING MONOCYTES AND MACROPHAGES MEDIATE ANTI-TNF REFRACTORY CROHN'S DISEASE IN CHILDREN

Abstract BACKGROUND Crohn’s disease (CD) is a chronic inflammatory disorder of the gastrointestinal tract with detrimental consequences on the pediatric population. Anti-tumor necrosis factor (aTNF) therapies are the only FDA-approved biologics for pediatric CD but one-third fail anti-TNF induction, and of those who initially respond, approximately 15% relapse every year. Consequently, there is a pressing need to elucidate the underlying immunogenetic mechanisms of anti-TNF refractory CD. METHODS A prospective cohort study was employed of treatment-naïve (TN-CD; n= 12), aTNF refractory (REF-CD; n=11), and endoscopic remission CD (REM-CD; n=16) along with non-IBD control (n=13) children. High dimensional flow cytometric analyses (HD FACS) of the blood, ileal and rectal biopsies were performed and analyzed by t-distributed stochastic neighbor embedding (t-SNE) clustering. Single-cell RNA sequencing (scRNA-seq) was conducted using the 10X Chromium platform with a 3’ reagent kit and sequenced on Illumina’s Novaseq600. The Seurat v4.1 workflow was used for the UMAP cell clustering algorithm. Effects of conditioned media (CM) from SIRPα cells on ileal organoids from non-IBD controls was assessed by enriching blood SIRPα+ cells from REF-CD via magnetic activated cell-sorting and stimulating with LPS (10 ng/mL) and flagellin (FLG; 10 ng/mL) for 96 hrs in culture. CM was collected and ileal organoids were treated for 72 hrs and re-stimulated with LPS+FLG followed by viability and intracellular cytokine staining. Descriptive statistics, one-way ANOVA with multiple comparisons testing, and univariate linear regression were utilized. RESULTS HD FACS revealed significant enrichment of SIRPα+CD11c+HLA-DR+CD64+ (SIRPα) cells in the ileum, rectum, and blood of REF-CD (P&amp;lt; 0.05). These cells expressed pro-inflammatory cytokines, IL-1β, IL-6, and TNFα. Deeper characterization with scRNA-seq revealed SIRPα cells to be macrophages based on expression of: CD14, FCGR3A, CD68, CD163, FCGR1A, and MRC1. In addition to pro-inflammatory cytokines detected by HD FACS, SIRPα macrophages expressed TGFB1 and CXCL8. There were significant positive correlations of intestinal SIRPα macrophages with fecal calprotectin (P&amp;lt;0.05) and CRP (P&amp;lt;0.05). CM from SIRPα+ cells of REF-CD induced significant cell death and intracellular cytokine expression of TNFα and IL-1β from non-IBD ileal organoids. CONCLUSION SIRPα cells are a distinct pro-inflammatory macrophage population enriched in the blood and intestinal lamina propria of REF-CD that may mediate resistance to anti-TNF therapy via secretion of pro-inflammatory cytokines and disruption of the intestinal epithelial barrier. These findings provide mechanistic insight into pathogenesis of anti-TNF refractory CD in children and highlight these cells to be a potential therapeutic target.

Dynamics of the gut microbiome, IgA response, and plasma metabolome in the development of pediatric celiac disease

BackgroundCeliac disease (CD) is an autoimmune disorder triggered by gluten consumption. Almost all CD patients possess human leukocyte antigen (HLA) DQ2/DQ8 haplotypes; however, only a small subset of individuals carrying these alleles develop CD, indicating the role of environmental factors in CD pathogenesis. The main objective of this study was to determine the contributory role of gut microbiota and microbial metabolites in CD onset. To this end, we obtained fecal samples from a prospective cohort study (ABIS) at ages 2.5 and 5 years. Samples were collected from children who developed CD after the final sample collection (CD progressors) and healthy children matched by age, HLA genotype, breastfeeding duration, and gluten-exposure time (n=15–16). We first used 16S sequencing and immunoglobulin-A sequencing (IgA-seq) using fecal samples obtained from the same children (i) 16 controls and 15 CD progressors at age 2.5 and (ii) 13 controls and 9 CD progressors at age 5. We completed the cytokine profiling, and plasma metabolomics using plasma samples obtained at age 5 (n=7–9). We also determined the effects of one microbiota-derived metabolite, taurodeoxycholic acid (TDCA), on the small intestines and immune cell composition in vivo.ResultsCD progressors have a distinct gut microbiota composition, an increased IgA response, and unique IgA targets compared to healthy subjects. Notably, 26 plasma metabolites, five cytokines, and one chemokine were significantly altered in CD progressors at age 5. Among 26 metabolites, we identified a 2-fold increase in TDCA. TDCA treatment alone caused villous atrophy, increased CD4+ T cells, Natural Killer cells, and two important immunoregulatory proteins, Qa-1 and NKG2D expression on T cells while decreasing T-regulatory cells in intraepithelial lymphocytes (IELs) in C57BL/6J mice.ConclusionsPediatric CD progressors have a distinct gut microbiota composition, plasma metabolome, and cytokine profile before diagnosis. Furthermore, CD progressors have more IgA-coated bacteria and unique targets of IgA in their gut microbiota. TDCA feeding alone stimulates an inflammatory immune response in the small intestines of C57BJ/6 mice and causes villous atrophy, the hallmark of CD. Thus, a microbiota-derived metabolite, TDCA, enriched in CD progressors’ plasma, has the potential to drive inflammation in the small intestines and enhance CD pathogenesis.8KKUiKqzQG1iyio8Fngon2Video

Prevalence of Malnutrition among Pediatric Celiac Disease

Purpose: Celiac Disease (CD) is an autoimmune systemic disorder triggered by gluten in genetically susceptible individuals, which can lead to chronic malabsorption. Considering the changes in the manifestations of CD.The present study was designed to determine the nutritional status and prevalence of malnutrition of celiac disease in children and to investigate the nutritional markers, anthropometric parameters such as body mass index (BMI), meal patterns ,and routine laboratory in celiac disease children&#x0D; Methodology: This cross-sectional study aimed to evaluate the children with CD who had referred to Pediatric gastroenterology Clinic between 2021 and 2022. Totally, 40 children were eligible, and their weight, height, and Body Mass Index (BMI) were extracted by interview. The anthropometric indices were presented based on the criteria of the Center for Disease Control and Prevention (CDC) and World Health Organization (WHO). Biochemical tests were obtained during the study period from medical files of the studied patients. Data were analyzed using descriptive statistics. The Chi-Square test was applied to examine the study data.&#x0D; Findings: Data shows that 52% of CD children were well-nourished while the remaining 45%, 3%had moderate -to-severe malnutrition. Regarding the height for age and weight for age 20% of the participants had short stature, 80% were normal stature, in addition ,40% of the patients had sever wasting for age and 43% had normal weight for age. Based on the CDC’s criteria 20%,65%, 10%, and 20% low BMI, normal BMI, overweight, and obese for age respectively. In addition, results show that most of CD children had normal hemoglobin level with low level of vitamin D. Regarding to meals pattern of CD children result revealed that the most kind of food daily intake was milk and white bread while there was not daily consumed of ice cream and whole wheat bread.&#x0D; Conclusion: To sum up, the results clearly indicated that growth failure and low height, weight, and BMI were less prevalent among the studied group of children with CD. Early diagnosis of celiac disease is very important to prevent long-term complications, early initiation of nutritional intervention and treatment is important. Currently, the only effective treatment is a lifelong gluten-free diet.

Assessment of diagnostic value of HLA-DQ2/DQ8 typing and anti-tissue transglutaminase antibodies as an alternative to duodenal biopsy in pediatric celiac disease

Introduction/Objective. The objective of the paper is to assess the applicability of serum anti-tissue transglutaminase (tTG) antibodies IgA and IgG concentration and HLA-DQ2/DQ8 typing as a non-invasive alternative to duodenal biopsy in diagnosing celiac disease (CD) in pediatric population. Methods. A prospective cohort study included a total of 179 pediatric patients aged 1?18 years. Determination of tTG IgA and tTG IgG antibodies and human leukocyte antigen (HLA) DQ2/DQ8 typing was performed for all patients. Histology of duodenal biopsies was interpreted by the modified Marsh scoring system. Results. The diagnosis of CD was confirmed in 101 (56%) patients of the studied population. In cases of CD, HLA-DQ2/DQ8 was positive in 100 patients (99%). The tTG IgA antibodies in concentration higher than 100 U/ml were detected in 77 (76.2%) of the CD patients and in significantly smaller number for tTG IgG [29 (28.7%)] (p &lt; 0.001). Statistically highly significant association of duodenal lesions Marsh grade 3 with concentration of tTG IgA 10-fold higher than the upper level of normal (ULN) was established (p &lt; 0.001) Conclusion. Concentration of tTG IgA 10-fold higher than ULN is significantly positively correlated with Marsh grade 3 histopathology findings. Specific antibodies determination in combination with HLA-DQ2/ DQ8 typing proves to be sufficient for a diagnosis of CD, supporting the fact that duodenal biopsy may be avoided in a significant majority of patients ? 75%.

Association of micro RNA expressions with pediatric celiac clinical findings

There is a need to determine the relationship between the function of the immune system and miRNA expression in pediatric celiac disease (pCD). We aimed to describe the expression profiles of miRNAs in Turkish pCD patients based on the clinical and pathological findings. This study was conducted on 33 pCD patients and 33 pediatric control subjects with normal biopsy results. Four most common mutations (DQA1*05, DQB1*02, DQA1*03, DQB1*03:0.2) on HLA gene in pCD were screened. Paraffin-embedded biopsy tissue samples were used in miRNA isolations followed by cDNA synthesis. Expression of miRNAs were evaluated in the groups with qRT-PCR array-method. Significant underexpression of hsa-miR-194-5p gene was detected in pCD patients compared to the control group. The hsa-miR-194-5p gene was significantly underexpressed in anemic or short stature pCD patients compared to the control. The genes of hsa-miR-29b-3p, hsa-miR-30e-5p, and hsa-miR-146a-5p were significantly overexpressed in the patients with constipated celiac patients. Significant overexpression of hsa-miR146a-5p gene was detected in the Marsh2 and Marsh3a groups. The hsa-miR-29b-3p, hsa-miR-30e-5p, hsa-let-7a-5p, hsa-miR-27a-3p, hsa-miR141-3p, hsa-miR143-3p, and hsa-miR-146a-5p miRNA genes were significantly overexpressed in the Marsh3b group. Also, the hsa-miR-194-5p and hsa-miR-26a-5p genes were significantly underexpressed in the comparison of Marsh3c group to the control. These results suggest that miRNA expressions are likely to play a role in the pathogenesis of pCD. It is believed that the current results present valuable inferences that may help understand the genetic boundaries on pCD, which might be further supported by follow up studies on other miRNAs.

The role of serology in the diagnosis of coeliac disease.

Serology has significantly revolutionized the knowledge of celiac disease (CD), leading to the identification of unsuspected patients in at-risk CD groups, thereby increasing the number of CD diagnoses compared to the pre-screening era. Several markers for CD with a progressive diagnostic accuracy have been identified over the years, but only three of them, i.e. anti-tissue transglutaminase (anti-tTG), anti-endomysial (EmA) and anti-deamidated gliadin antibodies (DGP) are currently assessed in the daily clinical practice. A thorough review of the literature identified 44 original studies published between 1998 to 2022 for a total of 5098 pediatric and adult CD patients (without selective IgA deficiency) and 11930 disease controls. The results highlighted that anti-tTG IgA exhibited a higher sensitivity for CD (93.4%) than EmA IgA (92.8%), DGP IgG (81.8%) and DGP IgA (83.8%). The specificity of EmA IgA (99%) resulted to be higher than those of anti-tTG IgA (95.8%), DGP IgG (96.4%) and DGP IgA (92.1%). In patients with selective IgA deficiency, a condition closely related to CD, serological screening should include one of the three antibodies of IgG class, since anti-tTG, DGP and EmA have a very similar diagnostic accuracy in this clinical setting. According to age, there are two main diagnostic strategies for CD detection. In children, the revised ESPGHAN 2020 guidelines established that CD could be diagnosed in both symptomatic and asymptomatic children by high anti-tTG IgA titers (>10 times the cut-off) and EmA positivity with no need to obtain duodenal biopsy and HLA typing. In adult patients, although high tTG IgA titers (confirmed by EmA IgA positivity) correlate with villous atrophy, an intestinal biopsy is still considered mandatory for confirming CD diagnosis. Currently, a case finding approach in at-risk groups is preferred to mass screening for CD detection.