Original article 721
Improving detection of celiac disease patients: a prospective study in iron-deficient blood donors without anemia in north Italy Renato Cannizzaroa, Alessandro Da Ponteb, Maria Tabusoa, Mario Mazzucatob, Valli De Rec, Laura Caggiaric, Mara Fornasariga, Stefania Maieroa, Enrico Orzesa and Vincenzo Canzonierid Objective To evaluate the prevalence of celiac disease in asymptomatic iron-deficient blood donors without anemia. Material and methods Between the period February 2004 and January 2006, iron-deficient male donors with serum ferritin less than 30 ng/ml and female donors with serum ferritin less than 10 ng/ml were screened for immunoglobulin A (IgA) and IgG antitissue transglutaminase antibodies and donors with positive antibody titers were referred for endoscopy with multiple biopsies of the second/third part of duodenum. The frequency of celiac disease in iron-deficient blood donors without anemia and the predictive value of ferritin levels were analyzed. Results Of the 1679 blood donors, 579 (34.4%) were identified as iron deficient and screened for celiac disease. 290 (50%) were men (mean age: 39 years; range: 19–65) and 289 (50%) were women (mean age: 37 years; range: 19–63). Thirteen donors (2.2%) were positive for serum IgA antitissue transglutaminase antibodies, of whom six were men (2.0%) and seven were women (2.4%). 10 donors of 13 (1.7%) at histology presented alterations in the mucosal architecture according to the modified Marsh classification (Marsh I–III). Low ferritin level was not predictive for celiac disease (median serum ferritin level in celiac donors
Introduction Celiac disease (CD) is an immune-mediated enteropathy triggered by the ingestion of gluten in genetically susceptible individuals, causing injury to the small intestine. Mustalahti et al. [1] found a large variability in the prevalence of CD between European nations, ranging from 0.4 to 2.3%. The prevalence of CD is increasing not only among European populations but also in Eastern populations [2–5], but still many patients remain undiagnosed. Many studies have used blood donors as a population to study the prevalence of CD among healthy individuals, with a prevalence ranging from 0.1 to 1% [4–9]. Clinical presentations of CD include gastrointestinal symptoms such as abdominal pain, diarrhea, weight loss, vomiting, constipation, and nongastrointestinal signs and symptoms such as iron deficiency with or without anemia, osteoporosis, neurological disorders, abnormal liver tests, and skin disorders [10,11]. Gluten-related disorders have been classified as symptomatic, silent, and potential [12]. c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 0954-691X
14.7 ng/ml and in nonceliac donors 15.8 ng/ml, Wilcoxon test: P not significant). The prevalence of celiac disease among iron-deficient blood donors without anemia was 1.7%. Conclusion The prevalence of celiac disease in our population of asymptomatic iron-deficient blood donors without anemia was 1.7%. We suggest screening for celiac disease in iron-deficient individuals without anemia to increase diagnosis of asymptomatic celiac disease. Eur J c 2014 Wolters Kluwer Gastroenterol Hepatol 26:721–724 Health | Lippincott Williams & Wilkins. European Journal of Gastroenterology & Hepatology 2014, 26:721–724 Keywords: blood donors, celiac disease, iron deficiency, prevalence, screening a Department of Gastroenterology, bTranslational Research Department, Stem Cell Unit, cDepartment of Translational Research, Faculty of Bioproteomic and d Department of Pathology, Centro di Riferimento Oncologico, National Cancer Institute, IRCCS, Aviano (PN), Italy
Correspondence to Renato Cannizzaro, MD, Department of Gastroenterology, Centro di Riferimento Oncologico, National Cancer Institute, Via Franco Gallini, 2 33081 Aviano (PN) Italy Tel: + 39 0434 659281; fax: + 39 0434659515; e-mail: [email protected] Received 20 December 2013 Accepted 14 March 2014
Untreated CD may lead to complications such as impaired splenic function, infertility or recurrent abortion, ulcerative jejunoileitis, enteropathy-associated T-cell lymphoma, and adenocarcinoma of the jejunum [13–15]. Moreover, Silano et al. [16] have reported that delayed diagnosis of CD increases the risk of cancer. Iron-deficient anemia is now the most common clinical presentation of CD [10]. A recent study by Wierdsma et al. [17] has shown that 46% of early-diagnosed CD patients have decreased iron storage. Nevertheless, the prevalence of CD in an iron-deficient but not anemic population is not known. Recent guidelines recommend testing for CD in patients with unexplained iron-deficiency anemia, but there is no consensus on weather patients with iron deficiency without anemia should be investigated, and further research is needed. Subclinical iron deficiency is a common feature in periodic blood donors not deferred for low hemoglobin levels [18,19]. Therefore, we focused on evaluating the prevalence of CD in asymptomatic iron-deficient blood donors without anemia. DOI: 10.1097/MEG.0000000000000100
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
722 European Journal of Gastroenterology & Hepatology 2014, Vol 26 No 7
Patients and methods
Results
During the period February 2004–January 2006, all periodic blood donors of the National Cancer Institute Transfusion Department of Aviano were annually tested for serum ferritin concentration, a test recommended for a long time by the Italian Transfusional Scientific Community and mandatory since March 2005. A ferritin value lower than 30 ng/ml for men and 10 ng/ml for women is considered an index of iron deficiency. Serum samples were kept refrigerated at – 301C and checked within a month for tissue transglutaminase antibodies (tTG Ab), both immunoglobulin A (IgA) and IgG (Eurospital Eu-tTG IgG and IgA; Eurospital, Trieste, Italy), considering positive all results above 7 and 26 U/l for IgA and IgG anti-tTG Ab, respectively. All donors positive for anti-tTG Ab were recalled and advised for counseling with a gastroenterologist for further investigation. All tTG-positive donors were seen in outpatient gastroenterology clinics. Signs and symptoms specific for CD, such as diarrhea, abdominal pain, bloating, weight loss, recurrent aphtosis, and skin lesions, were evaluated by a gastroenterologist. All tTG-positive donors were also evaluated for rectal bleeding and were tested for occult blood in the stool. All tTG-positive patients underwent human leukocyte antigen typing. Gastric and duodenal endoscopic examinations with four biopsies of the second/third part of the duodenum were performed in all donors with positive IgA tTG Ab titers using a videogastroscope Olympus GIF-Q165 (Olympus, Tokyo, Japan). Histological analysis of the biopsies was carried out by an expert pathologist (V.C.). The severity of intestinal mucosal damage was scored according to the modified Marsh classification [20] as follows: increase in intraepithelial lymphocytes (IEL) (type I), increase in IEL with crypt hyperplasia (type II), mild villous flattening (type IIIA), marked villous flattening (grade IIIB), and total villous flattening (grade IIIC). Patients with Marsh I–III changes and positive serology were considered positive for CD. All 10 CD patients underwent re-examination. The first follow-up assessment was scheduled at 3–6 months after diagnosis, at 12 months from diagnosis, and then every 12–24 months. At each follow-up assessment, IgA and IgG tTG antibody levels and ferritin levels were rechecked. All patients underwent esophagogastroduodenoscopy with biopsies of the second/third part of the duodenum after 2–3 years from diagnosis. None of the enrolled donors reported typical gastrointestinal symptoms or extragastrointestinal signs or symptoms of CD. All enrolled healthy blood donors were on a normal diet with no restrictions.
1679 consecutive periodic donors between February 2004 and January 2006 were screened for iron deficiency, considered as a serum ferritin level below 30 ng/ml for men and 10 ng/ml for women. There were 1092 men and 587 women, mean age 41 years (range: 19–65). 579 (34.4%) blood donors were iron deficient and were screened for CD. Two hundred and ninety (50%) were men, with a mean age of 39 years (range: 19–65), and 289 (50%) were women, with a mean age of 37 years (range: 19–63). Thirteen (2.2%) donors, seven men and six women, tested positive for IgA tTG Ab. Two women tested positive for both IgA and IgG tTG Ab. The mean value of IgA tTG Ab in the 13 donors was 16.2 AU/ml (range: 7–24). The mean value of IgG Ab in the two donors was 31.7 AU/ml (range: 26.2–37.2). All tTG positive individuals were positive for DQ2 and DQ8 at human leukocyte antigen typing. All donors tested negative for occult blood in the stool. Ten donors (1.7%), six men and four women, had histological changes on duodenal biopsies according to the modified Marsh classification. Four donors had Marsh I changes, three had Marsh III A changes, two had Marsh III B changes, and one had Marsh III C changes. Three patients were classified as Marsh 0 type. In the three patients with Marsh 0, the mean level of IgA tTG Ab was 10 AU/ml (range: 7–16). In the four patients with Marsh I, the mean level of IgA tTG Ab was 14.8 AU/ml (range: 7.5–21.4). In the six patients with Marsh III lesions, the mean level of IgA tTG Ab was 21.1 AU/ml (range: 16.1–24). No statistically significant association was observed between tTG Ab levels and duodenal lesions (P = 0.84). Patients with positive serology and Marsh I–III changes were considered positive for CD. Between the male and the female groups, there were no statistically significant differences with respect to the mean age, prevalence of positivity for IgA tTG Ab (2.0 vs. 2.4% for men and women, respectively, P = 0.84), and prevalence of CD (2.1 vs. 1.4% for men and women, respectively, P = 0.64). Two of the four women were also positive for IgG tTG Ab. Low ferritin level was not predictive for CD (median serum ferritin level in celiac donors 14.7 ng/ml, range: 3–37, in nonceliac donors 15.8 ng/ml, range: 1–40, Wilcoxon test: P not significant). The prevalence of CD was 1.7%. All celiac patients started a gluten-free diet. All patients with Marsh I–III lesions responded to a gluten-free diet, with normalization of ferritin values and a normalization of the mucosal architecture at follow-up (Figs 1 and 2).
Statistical analysis
Data are presented as absolute numbers and percentages. Differences between groups were tested for significance using the Wilcoxon test. Statistical significance was considered at P less than 0.05.
Discussion In the present study, the prevalence of iron deficiency without anemia was 34.4%, with a prevalence of 50% for male and female populations. The prevalence of CD in asymptomatic iron-deficient blood donors without anemia was 1.7%, two-fold higher than the general Italian population, which is 0.7%, as reported by Mustalahti et al. [1]. The prevalence of CD was 2.1% in men and 1.4% in women, indicating a higher prevalence in male donors, in
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Celiac disease in iron-deficient blood donors Cannizzaro et al. 723
Fig. 1
A duodenal biopsy specimen showing intraepithelial lymphocytes, crypt hyperplasia, and villous flattening (Marsh III).
Fig. 2
not evaluated as we incorporated IgG tTG into the serology testing. The diagnosis was made on the basis of positivity of serum IgA tTG Ab combined with a positive histology of biopsies from the second/third part of the duodenum with characteristic histological changes according to the modified Marsh classification (IEL, crypt hyperplasia, and villous atrophy). All patients with Marsh I–III lesions were considered positive for CD. A limitation of our study is that biopsies of the bulb were not taken; therefore, the actual prevalence of CD may have been underestimated. All patients with Marsh I–III lesions responded to a gluten-free diet, with normalization of ferritin values and a normalization of the mucosal architecture. The three patients with positive IgA tTG Ab levels and no histological changes according to the Marsh–Oberhuber classification showed normalized IgA tTG Ab levels during follow-up. Early recognition and treatment of CD is important to prevent severe complications and neoplasia. Recent guidelines for the diagnosis and management for CD recommend celiac serology in all patients with unexplained iron-deficiency anemia [21,22]. Despite the lack of firm evidence, celiac serology has also been recommended in patients with iron deficiency without anemia [22]. In our study, the prevalence of CD in iron deficiency without anemia was almost two-fold higher than that in the general Italian population [1]. Therefore, the findings of our study strongly support such a recommendation. Iron deficiency without anemia should not be underestimated because it could be the only initial sign of CD. Greater clinical awareness could lead to early recognition and treatment of CD, with prevention of related complications. In conclusion, all asymptomatic individuals with iron deficiency without anemia should be investigated for CD for improved detection of nonclassical forms of CD and prevention of severe complications.
Acknowledgements Special thanks are due to Eurospital, Trieste, for providing tissue transglutaminase antibodies. A duodenal biopsy specimen after 3 years of a gluten-free diet showing tall villi and sparse intraepithelial lymphocytes (Marsh 0).
agreement with previous studies [4–9], although the difference is not statistically significant (P = 0.64). As hypothesized previously by Shahbazkhani et al. [4], undiagnosed CD women may be excluded from blood donor volunteers because of anemia caused by menstrual blood loss. Most of the affected individuals were younger than 40 years of age. The most sensitive antibody tests for the diagnosis of CD are the IgA class. It is known that selective IgA deficiency is more common in patients with CD than in the general population – one case in 40 as compared with one in 400 [13]. Therefore, both IgA and IgG tTG Ab were used for screening in the present study. Total IgA serum levels were
Renato Cannizzaro was responsible for planning and conducting the study, collecting and interpreting data, and drafting the manuscript. Alessandro Da Ponte was responsible for collecting data, statistical analysis, interpretation of data, and drafting the manuscript. Maria Tabuso, Mara Fornasarig and Stefania Maiero were responsible for interpreting data and drafting the manuscript. Valli De Re was responsible for drafting the manuscript. Laura Caggiari was responsible for drafting the manuscript. Mario Mazzucato was responsible for collecting and interpreting data. Enrico Orzes was responsible for interpretation of data. Vincenzo Canzonieri was responsible for histological examination of biopsies.
Conflicts of interest
There are no conflicts of interest.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
724 European Journal of Gastroenterology & Hepatology 2014, Vol 26 No 7
References Mustalahti K, Catassi C, Reunanen A, Fabiani E, Heier M, McMillan S, et al. The prevalence of celiac disease in Europe: results of a centralized, international mass screening project. Ann Med 2010; 42:587–595. 2 Catassi C, Gobellis G. Coeliac disease epidemiology is alive and kicking, especially in the developing world. Dig Liver Dis 2007; 39:908–910. 3 Catassi C, Kryszak D, Louis-Jacques O, Deurksen DR, Hill I, Crowe SE, et al. Detection of celiac disease in primary care: a multicenter case-finding study in North America. Am J Gastroenterol 2007; 102:1454–1460. 4 Shahbazkhani B, Malekzadeh R, Sotoudeh M, Moghadam KF, Fahradi M, Ansari R, et al. High prevalence of coeliac disease in apparently healthy Iranian blood donors. Eur J Gastroenterol Hepatol 2003; 15:475–478. 5 Kochhar R, Sachdev S, Kochhar R, Aggarwal A, Sharma V, Prasad KK, et al. Prevalence of coeliac disease in healthy blood donors: a study from north India. Dig Liver Dis 2012; 44:530–532. 6 Trevisiol C, Not T, Berti I, Buratti E, Citta` A, Neri E, et al. Screening for coeliac disease in healthy blood donors at two immune-transfusion centres in north-east Italy. Ital J Gastroenterol Hepatol 1999; 31:584. 7 Menardo G, Brizzolara R, Bonassi S, Marchetti A, Dante GL, Pistone C, et al. Population screening for celiac disease in a low prevalence area in Italy. Scand J Gastroenterol 2006; 41:1414–1420. 8 Rostami K, Mulder CJ, Werre JM, van Beukelen FR, Kerchhaert J, Crusius JB, et al. High prevalence of celiac disease in apparently healthy blood donors suggests a high prevalence of undiagnosed celiac disease in the Dutch population. Scand J Gastroenterol 1999; 34:276–279. 9 Gandolfi L, Pratesi L, Cordoba JC, Tauil PL, Gasparin M, Catassi C, et al. Prevalence of celiac disease among blood donors in Brazil. Am J Gastroenterol 2000; 95:689–692. 10 Farrell RJ, Kelly CP. Celiac sprue. N Engl J Med 2002; 346:180–188. 11 Ehsani-Ardakani MJ, Rostami Nejad M, Villanacci V, Volta U, Manenti S, Caio G, et al. Gastrointestinal and non-gastrointestinal presentation in patients with celiac disease. Arch Iran Med 2013; 16:78–82.
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Sapone A, Bai JC, Ciacci C, Dolinsek J, Green PH, Hadjivassiliou M, et al. Spectrum of gluten related disorders: consensus on new nomenclature and classification. BMC Med 2012; 10:13. Green PHR, Cellier C. Celiac disease. N Engl J Med 2007; 357: 1731–1734. Fasano A, Catassi C. Current approaches to diagnosis and treatment of celiac disease: an evolving spectrum. Gastroenterology 2001; 120:636–651. Sharaiha RZ, Lebwohl B, Reimers L, Bhagat G, Green PH, Neugut Al, et al. Increasing incidence of enteropathy-associated T-cell lymphoma in the United States, 1973-2008. Cancer 2012; 118:3786–3792. Silano M, Volta U, Mecchia AM, Dessı´ M, Di Benedetto R, De Vincenzi M. Collaborating centers if the Italian registry of the complications of coeliac disease. Delayed diagnosis of coeliac disease increases cancer risk. BMC Gastroenterol 2007; 7:8. Wierdsma NJ, van Bokhorst-de van der Schueren MA, Berkenpas M, Mulder CJ, van Bodegraven AA. Vitamin and mineral deficiencies are highly prevalent in newly diagnosed celiac disease patients. Nutrients 2013; 5:3975–3992. Cable RG, Glynn SA, Kiss JE, Mast AE, Steele WR, Murphy EL, et al. Iron deficiency in blood donors: the REDS-II Donor Iron Status Evaluation (RISE) study. Transfusion 2012; 52:702–711. Baart AM, van Noord PA, Vergouwe Y, Moons KG, Swinkels DW, Wiegerinck ET, et al. High prevalence of subclinical iron deficiency in whole blood donors not deferred for low hemoglobin. Transfusion 2013; 53: 1670–1677. Oberhuber G, Granditsch G, Vogelsang H. The histopathology of celiac disease: time for a standardized report scheme for pathologists. Eur J Gastroenterol Hepatol 1999; 11:1185–1194. Godard AF, James MW, McIntyre AS, Scott BB. Guidelines for the management of iron deficiency anaemia. Gut 2011; 60:1309–1316. Rubio-Tapia A, Hill ID, Kelly CP, Calderwood AH, Murray JA. ACG Clinical Guidelines: diagnosis and management of celiac disease. Am J Gastroenterol 2013; 108:656–676.
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Improving detection of celiac disease patients: a prospective study in iron-deficient blood donors without anemia in north Italy Renato Cannizzaroa, Alessandro Da Ponteb, Maria Tabusoa, Mario Mazzucatob, Valli De Rec, Laura Caggiaric, Mara Fornasariga, Stefania Maieroa, Enrico Orzesa and Vincenzo Canzonierid Objective To evaluate the prevalence of celiac disease in asymptomatic iron-deficient blood donors without anemia. Material and methods Between the period February 2004 and January 2006, iron-deficient male donors with serum ferritin less than 30 ng/ml and female donors with serum ferritin less than 10 ng/ml were screened for immunoglobulin A (IgA) and IgG antitissue transglutaminase antibodies and donors with positive antibody titers were referred for endoscopy with multiple biopsies of the second/third part of duodenum. The frequency of celiac disease in iron-deficient blood donors without anemia and the predictive value of ferritin levels were analyzed. Results Of the 1679 blood donors, 579 (34.4%) were identified as iron deficient and screened for celiac disease. 290 (50%) were men (mean age: 39 years; range: 19–65) and 289 (50%) were women (mean age: 37 years; range: 19–63). Thirteen donors (2.2%) were positive for serum IgA antitissue transglutaminase antibodies, of whom six were men (2.0%) and seven were women (2.4%). 10 donors of 13 (1.7%) at histology presented alterations in the mucosal architecture according to the modified Marsh classification (Marsh I–III). Low ferritin level was not predictive for celiac disease (median serum ferritin level in celiac donors
Introduction Celiac disease (CD) is an immune-mediated enteropathy triggered by the ingestion of gluten in genetically susceptible individuals, causing injury to the small intestine. Mustalahti et al. [1] found a large variability in the prevalence of CD between European nations, ranging from 0.4 to 2.3%. The prevalence of CD is increasing not only among European populations but also in Eastern populations [2–5], but still many patients remain undiagnosed. Many studies have used blood donors as a population to study the prevalence of CD among healthy individuals, with a prevalence ranging from 0.1 to 1% [4–9]. Clinical presentations of CD include gastrointestinal symptoms such as abdominal pain, diarrhea, weight loss, vomiting, constipation, and nongastrointestinal signs and symptoms such as iron deficiency with or without anemia, osteoporosis, neurological disorders, abnormal liver tests, and skin disorders [10,11]. Gluten-related disorders have been classified as symptomatic, silent, and potential [12]. c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 0954-691X
14.7 ng/ml and in nonceliac donors 15.8 ng/ml, Wilcoxon test: P not significant). The prevalence of celiac disease among iron-deficient blood donors without anemia was 1.7%. Conclusion The prevalence of celiac disease in our population of asymptomatic iron-deficient blood donors without anemia was 1.7%. We suggest screening for celiac disease in iron-deficient individuals without anemia to increase diagnosis of asymptomatic celiac disease. Eur J c 2014 Wolters Kluwer Gastroenterol Hepatol 26:721–724 Health | Lippincott Williams & Wilkins. European Journal of Gastroenterology & Hepatology 2014, 26:721–724 Keywords: blood donors, celiac disease, iron deficiency, prevalence, screening a Department of Gastroenterology, bTranslational Research Department, Stem Cell Unit, cDepartment of Translational Research, Faculty of Bioproteomic and d Department of Pathology, Centro di Riferimento Oncologico, National Cancer Institute, IRCCS, Aviano (PN), Italy
Correspondence to Renato Cannizzaro, MD, Department of Gastroenterology, Centro di Riferimento Oncologico, National Cancer Institute, Via Franco Gallini, 2 33081 Aviano (PN) Italy Tel: + 39 0434 659281; fax: + 39 0434659515; e-mail: [email protected] Received 20 December 2013 Accepted 14 March 2014
Untreated CD may lead to complications such as impaired splenic function, infertility or recurrent abortion, ulcerative jejunoileitis, enteropathy-associated T-cell lymphoma, and adenocarcinoma of the jejunum [13–15]. Moreover, Silano et al. [16] have reported that delayed diagnosis of CD increases the risk of cancer. Iron-deficient anemia is now the most common clinical presentation of CD [10]. A recent study by Wierdsma et al. [17] has shown that 46% of early-diagnosed CD patients have decreased iron storage. Nevertheless, the prevalence of CD in an iron-deficient but not anemic population is not known. Recent guidelines recommend testing for CD in patients with unexplained iron-deficiency anemia, but there is no consensus on weather patients with iron deficiency without anemia should be investigated, and further research is needed. Subclinical iron deficiency is a common feature in periodic blood donors not deferred for low hemoglobin levels [18,19]. Therefore, we focused on evaluating the prevalence of CD in asymptomatic iron-deficient blood donors without anemia. DOI: 10.1097/MEG.0000000000000100
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
722 European Journal of Gastroenterology & Hepatology 2014, Vol 26 No 7
Patients and methods
Results
During the period February 2004–January 2006, all periodic blood donors of the National Cancer Institute Transfusion Department of Aviano were annually tested for serum ferritin concentration, a test recommended for a long time by the Italian Transfusional Scientific Community and mandatory since March 2005. A ferritin value lower than 30 ng/ml for men and 10 ng/ml for women is considered an index of iron deficiency. Serum samples were kept refrigerated at – 301C and checked within a month for tissue transglutaminase antibodies (tTG Ab), both immunoglobulin A (IgA) and IgG (Eurospital Eu-tTG IgG and IgA; Eurospital, Trieste, Italy), considering positive all results above 7 and 26 U/l for IgA and IgG anti-tTG Ab, respectively. All donors positive for anti-tTG Ab were recalled and advised for counseling with a gastroenterologist for further investigation. All tTG-positive donors were seen in outpatient gastroenterology clinics. Signs and symptoms specific for CD, such as diarrhea, abdominal pain, bloating, weight loss, recurrent aphtosis, and skin lesions, were evaluated by a gastroenterologist. All tTG-positive donors were also evaluated for rectal bleeding and were tested for occult blood in the stool. All tTG-positive patients underwent human leukocyte antigen typing. Gastric and duodenal endoscopic examinations with four biopsies of the second/third part of the duodenum were performed in all donors with positive IgA tTG Ab titers using a videogastroscope Olympus GIF-Q165 (Olympus, Tokyo, Japan). Histological analysis of the biopsies was carried out by an expert pathologist (V.C.). The severity of intestinal mucosal damage was scored according to the modified Marsh classification [20] as follows: increase in intraepithelial lymphocytes (IEL) (type I), increase in IEL with crypt hyperplasia (type II), mild villous flattening (type IIIA), marked villous flattening (grade IIIB), and total villous flattening (grade IIIC). Patients with Marsh I–III changes and positive serology were considered positive for CD. All 10 CD patients underwent re-examination. The first follow-up assessment was scheduled at 3–6 months after diagnosis, at 12 months from diagnosis, and then every 12–24 months. At each follow-up assessment, IgA and IgG tTG antibody levels and ferritin levels were rechecked. All patients underwent esophagogastroduodenoscopy with biopsies of the second/third part of the duodenum after 2–3 years from diagnosis. None of the enrolled donors reported typical gastrointestinal symptoms or extragastrointestinal signs or symptoms of CD. All enrolled healthy blood donors were on a normal diet with no restrictions.
1679 consecutive periodic donors between February 2004 and January 2006 were screened for iron deficiency, considered as a serum ferritin level below 30 ng/ml for men and 10 ng/ml for women. There were 1092 men and 587 women, mean age 41 years (range: 19–65). 579 (34.4%) blood donors were iron deficient and were screened for CD. Two hundred and ninety (50%) were men, with a mean age of 39 years (range: 19–65), and 289 (50%) were women, with a mean age of 37 years (range: 19–63). Thirteen (2.2%) donors, seven men and six women, tested positive for IgA tTG Ab. Two women tested positive for both IgA and IgG tTG Ab. The mean value of IgA tTG Ab in the 13 donors was 16.2 AU/ml (range: 7–24). The mean value of IgG Ab in the two donors was 31.7 AU/ml (range: 26.2–37.2). All tTG positive individuals were positive for DQ2 and DQ8 at human leukocyte antigen typing. All donors tested negative for occult blood in the stool. Ten donors (1.7%), six men and four women, had histological changes on duodenal biopsies according to the modified Marsh classification. Four donors had Marsh I changes, three had Marsh III A changes, two had Marsh III B changes, and one had Marsh III C changes. Three patients were classified as Marsh 0 type. In the three patients with Marsh 0, the mean level of IgA tTG Ab was 10 AU/ml (range: 7–16). In the four patients with Marsh I, the mean level of IgA tTG Ab was 14.8 AU/ml (range: 7.5–21.4). In the six patients with Marsh III lesions, the mean level of IgA tTG Ab was 21.1 AU/ml (range: 16.1–24). No statistically significant association was observed between tTG Ab levels and duodenal lesions (P = 0.84). Patients with positive serology and Marsh I–III changes were considered positive for CD. Between the male and the female groups, there were no statistically significant differences with respect to the mean age, prevalence of positivity for IgA tTG Ab (2.0 vs. 2.4% for men and women, respectively, P = 0.84), and prevalence of CD (2.1 vs. 1.4% for men and women, respectively, P = 0.64). Two of the four women were also positive for IgG tTG Ab. Low ferritin level was not predictive for CD (median serum ferritin level in celiac donors 14.7 ng/ml, range: 3–37, in nonceliac donors 15.8 ng/ml, range: 1–40, Wilcoxon test: P not significant). The prevalence of CD was 1.7%. All celiac patients started a gluten-free diet. All patients with Marsh I–III lesions responded to a gluten-free diet, with normalization of ferritin values and a normalization of the mucosal architecture at follow-up (Figs 1 and 2).
Statistical analysis
Data are presented as absolute numbers and percentages. Differences between groups were tested for significance using the Wilcoxon test. Statistical significance was considered at P less than 0.05.
Discussion In the present study, the prevalence of iron deficiency without anemia was 34.4%, with a prevalence of 50% for male and female populations. The prevalence of CD in asymptomatic iron-deficient blood donors without anemia was 1.7%, two-fold higher than the general Italian population, which is 0.7%, as reported by Mustalahti et al. [1]. The prevalence of CD was 2.1% in men and 1.4% in women, indicating a higher prevalence in male donors, in
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Celiac disease in iron-deficient blood donors Cannizzaro et al. 723
Fig. 1
A duodenal biopsy specimen showing intraepithelial lymphocytes, crypt hyperplasia, and villous flattening (Marsh III).
Fig. 2
not evaluated as we incorporated IgG tTG into the serology testing. The diagnosis was made on the basis of positivity of serum IgA tTG Ab combined with a positive histology of biopsies from the second/third part of the duodenum with characteristic histological changes according to the modified Marsh classification (IEL, crypt hyperplasia, and villous atrophy). All patients with Marsh I–III lesions were considered positive for CD. A limitation of our study is that biopsies of the bulb were not taken; therefore, the actual prevalence of CD may have been underestimated. All patients with Marsh I–III lesions responded to a gluten-free diet, with normalization of ferritin values and a normalization of the mucosal architecture. The three patients with positive IgA tTG Ab levels and no histological changes according to the Marsh–Oberhuber classification showed normalized IgA tTG Ab levels during follow-up. Early recognition and treatment of CD is important to prevent severe complications and neoplasia. Recent guidelines for the diagnosis and management for CD recommend celiac serology in all patients with unexplained iron-deficiency anemia [21,22]. Despite the lack of firm evidence, celiac serology has also been recommended in patients with iron deficiency without anemia [22]. In our study, the prevalence of CD in iron deficiency without anemia was almost two-fold higher than that in the general Italian population [1]. Therefore, the findings of our study strongly support such a recommendation. Iron deficiency without anemia should not be underestimated because it could be the only initial sign of CD. Greater clinical awareness could lead to early recognition and treatment of CD, with prevention of related complications. In conclusion, all asymptomatic individuals with iron deficiency without anemia should be investigated for CD for improved detection of nonclassical forms of CD and prevention of severe complications.
Acknowledgements Special thanks are due to Eurospital, Trieste, for providing tissue transglutaminase antibodies. A duodenal biopsy specimen after 3 years of a gluten-free diet showing tall villi and sparse intraepithelial lymphocytes (Marsh 0).
agreement with previous studies [4–9], although the difference is not statistically significant (P = 0.64). As hypothesized previously by Shahbazkhani et al. [4], undiagnosed CD women may be excluded from blood donor volunteers because of anemia caused by menstrual blood loss. Most of the affected individuals were younger than 40 years of age. The most sensitive antibody tests for the diagnosis of CD are the IgA class. It is known that selective IgA deficiency is more common in patients with CD than in the general population – one case in 40 as compared with one in 400 [13]. Therefore, both IgA and IgG tTG Ab were used for screening in the present study. Total IgA serum levels were
Renato Cannizzaro was responsible for planning and conducting the study, collecting and interpreting data, and drafting the manuscript. Alessandro Da Ponte was responsible for collecting data, statistical analysis, interpretation of data, and drafting the manuscript. Maria Tabuso, Mara Fornasarig and Stefania Maiero were responsible for interpreting data and drafting the manuscript. Valli De Re was responsible for drafting the manuscript. Laura Caggiari was responsible for drafting the manuscript. Mario Mazzucato was responsible for collecting and interpreting data. Enrico Orzes was responsible for interpretation of data. Vincenzo Canzonieri was responsible for histological examination of biopsies.
Conflicts of interest
There are no conflicts of interest.
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724 European Journal of Gastroenterology & Hepatology 2014, Vol 26 No 7
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