Celiac.com 07/12/2021 - When doctors test symptomatic children for celiac disease, they currently order biopsy confirmation only for children whose anti-transglutaminase IgA (TGA-IgA) titers exceed the upper limit of normal (ULN), and below 10 times the upper limit of normal. Any results below the ULN do not normally get referred for a biopsy.
Now, this works pretty well in the sense that a high percentage of biopsies for such patients come up positive. However, the management of children with lower TGA-IgA values presents a clinical challenge. What about children who test just under the ULN cut off? Especially those with symptoms, however mild.
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Do persistently low positive TGA-IgA titers have any diagnostic value for predicting celiac disease in children? A team of researchers recently looked into this question.
The research team included Chiara Marja Trovato; Monica Montuori; Annalisa Morelli; Danilo Alunni Fegatelli; Annarita Vestri; Carla Giordano; Salvatore Cucchiara; Giocomo Caio; and Salvatore Oliva. They are variously affiliated with the Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department; the Department of Statistical Science; and the Department of Radiological, Oncological and Pathological Sciences at Sapienza University of Rome; along with the Department of Medical Sciences at the University of Ferrara in Ferrara, Italy.
The team retrospectively analyzed children with symptoms or signs of celiac disease, not eligible for a no-biopsy approach.
Their study included children with at least two TGA-IgA measurements, endomysial antibody (EMA) assessment and esophagogastroduodenoscopy with biopsies. TGA-IgA values were provided as multiples of ULN. The team grouped patients according to median TGA-IgA values: Group A included TGA-IgA>1 ≤ 5 × ULN; defined as “low-positive”, Group B (TGA-IgA > 5 < 10 × ULN; “moderate-positive”), and Group C, the controls).
They were able to analyze the data of 281 children. Of 162 children in group A, they diagnosed celiac disease in 142 (nearly 90%), whereas they found normal duodenal mucosa in 20 group A children.
The team diagnosed all 62 children (100%) in group B with celiac disease. Group C included 57 control subjects. EMA were undetectable in 31 (15%) of mucosal atrophy cases.
On the receiver-operating characteristic curve, with the area under the curve equal to 0.910, a mean value of 1.7 ULN predicted mucosal damage with nearly 82% sensitivity and specificity.
Based on their data, the team concludes that repeated low or moderate TGA-IgA values, under 5 ULN or 10 ULN, are good predictors of a celiac disease diagnosis. The team advises doctors treating symptomatic children with persistently low positive TGA-IgA titers to conduct an esophagogastroduodenoscopy, regardless of the patient's EMA status.
Read more in the Journal of Pediatric Gastroenterology and Nutrition
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