Raising the Cut-Off Level of Anti-Tissue Transglutaminase Antibodies to Detect Celiac Disease Reduces the Number of Small Bowel Biopsies in Children with Type 1 Diabetes: A Retrospective Study

Celiac disease can be predicted by high levels of tissue transglutaminase antibodies in children and adolescents with type 1 diabetes

“…The ESPGHAN 2020 guidelines state that biopsies can be omitted in screened, asymptomatic children if their anti‐tTG levels are ≥10x ULN, but the guidelines excluded T1D due to insufficient data 23 . In the same line as the Brazilian, 2 the Dutch 22 and the Australian 21 studies mentioned above, our study addressed this lack of data and we propose that children and adolescents with T1D should be included in any future revisions of the guidelines.…”

“…The authors reported that 35 children had high levels of anti‐tTG and confirmed CD, but the association with the degree of enteropathy was not studied or presented 21 . In addition, a multicenter study including children from the Netherlands, recently showed that high levels of CD biomarkers could give accurate CD diagnosis 22 . This Dutch cooperation, included a retrospective evaluation on 63 children with T1D and CD, using six different types of tTG assays, and showed that the cut‐off value 11 times the ULN had a sensitivity of 96%, and a positive predictive value of 94%.…”

“…Some of these children had T1D, but they were not assessed separately 18,19 . A small Finnish study, 20 a retrospective Australian study 21 and a Dutch collaboration 22 confirmed that anti‐tTG had a good positive predictive value for biopsy‐proven CD in children with T1D. Nevertheless, the 2020 European Society for Pediatric Gastroenterology, Hepatology and Nutrition guidelines for diagnosing celiac disease (CD), without a biopsy, do not include type 1 diabetes (T1D) due to lack of data 23 …”

Type 1 Diabetes and Celiac Disease: Can (and Should) We Raise the Cut-off of Tissue Transglutaminase Immunoglobulin A to Decide Whether to Biopsy?

“…This issue is precisely what the article published in this volume of The Journal by Wessels et al aims to clarify. 16 By following the European Society for Pediatric Gastroenterology, Hepatology and Nutrition guidelines that recommend endoscopy with biopsies in those patients with T1DM who have a TTG >3 times the upper limit of normal (ULN), they hypothesize an excessive number of patients will be subject to an unnecessary invasive procedure. 11 Their aim was, therefore, to determine a TTG cut-off level that would optimize specificity while minimizing loss of sensitivity.…”

“…18 In the series from Wessels et al, however, surprisingly "50% of EMA positive patients had normal duodenal histology." 16 One wonders in how many of these patients a search for intestinal deposits of anti-TTG IgA might have identified them as having celiac disease, because these antibodies are considered "a constant presence and appear very early in the natural history of disease." 19 This report focuses on the value of TTG only.…”