Diabetologia: Early and late histological confirmation of celiac disease in children with new-onset type 1 diabetes

Background: Celiac disease is a common complication of type 1 diabetes in children and adolescents
.
Many people are asymptomatic at diagnosis, identified by screening for IgA antibodies against tissue transglutaminase (anti-tTGA)
.
There is currently no clear evidence whether asymptomatic patients with type 1 diabetes benefit from a gluten-free diet (GFD)]
.
However, some studies have shown that asymptomatic celiac disease negatively affects growth and weight gain in children, although no effect on blood sugar control has been shown
.
It has also been shown that in a substantial proportion of children with type 1 diabetes, mildly elevated serum anti-TGA levels at the onset of diabetes decrease or even become negative over time despite continued gluten intake
.

OBJECTIVE: The aim of this study was to analyze whether children and adolescents with new-onset type 1 diabetes and a positive screening result could delay the diagnosis of celiac disease
.
We compared metabolic outcomes, cardiovascular risk factors, acute complication rates, GFD adherence, weight gain and growth in children and adolescents with new-onset type 1 diabetes and elevated anti-tTGA levels at the onset of diabetes who received Histological confirmation of early or advanced celiac disease
.

METHODS: This was a multicenter population cohort study
.
Participants ≤18 years of age who were diagnosed with type 1 diabetes between 1995 and June 2021 and had elevated IgA tissue transglutaminase antibodies (anti-tTGA) on celiac disease screening at diabetes onset were included
.
We compared the outcomes of participants with diabetes lasting more than 1 year who had histologically confirmed celiac disease within the first 6 months and celiac disease diagnosed within 6 to 36 months after diabetes diagnosis
.

RESULTS: Among 92,278 children and adolescents diagnosed with type 1 diabetes, 26,952 (29.
2%) had anti-tTGA data records at the time of diabetes onset
.
Of these, 2340 (8.
7%) had elevated anti-tTGA levels
.
Screen-positive individuals were younger (median age 9.
0 vs 9.
8 years, p<0.
001) and more common in women (53.
1% vs 44.
4%, p<0.
001)
.
A total of 533 participants (22.
8% of those who screened positive) had documented biopsies, of which 444 had documented histological confirmation of celiac disease
.
Of the 411 participants with biopsy-proven celiac disease and follow-up data in the 36 months prior to diabetes, 264 (64.
2%) were in the first 6 months after diabetes onset and 147 (35.
8%) were Histological confirmation was performed 6 to 36 months later
.
At follow-up (median diabetes duration 5.
3 and 5.
1 years, respectively), estimated median HbA1c levels (62.
8 mmol/mol vs 62.
2 mmol/mol [7.
9% vs 7.
8%]), cardiovascular risk markers (blood lipids , microalbuminuria, blood pressure), the incidence of acute diabetic complications (diabetic ketoacidosis, severe hypoglycemia), and the proportion of participants achieving anti-tTGA levels within the normal range did not differ between groups
.
During the observation period, participants with delayed histological diagnosis of celiac disease showed no negative effects on growth or weight gain
.

Figure 1 (a) Proportion of children and adolescents with new-onset type 1 diabetes who received tTGA antibody screening at the onset of type 1 diabetes and (b) histology for celiac disease following a positive screening result since 2001
.
Error bars indicate 95% agreement

Table 1 Adjusted outcome variables for participants with early versus delayed histological diagnosis of celiac disease (n = 411) at the last follow-up visit

Figure 2 SDS values ​​of (a) height and (b) body mass index in patients with early versus delayed biopsy-proven celiac disease
.
Error bars represent 95% agreement
.
SDS values ​​were shown at diagnosis of type 1 diabetes (409 for both), at biopsy (279 and 277, respectively), 2 years after biopsy (365 for both) and at last follow-up (409 for both; Median diabetes duration in the early and delayed biopsy groups was 5.
3 and 5.
1 years, respectively)

Table 2 assesses acute complications of diabetes in patients with early versus delayed histologically diagnosed celiac disease (n = 411)

Conclusions: Our study suggests that in asymptomatic patients with new-onset type 1 diabetes, the histological diagnosis of celiac disease may be delayed
.

Original source: Kamrath C, Tittel SR, Dunstheimer D, et al.
Early vs late histological confirmation of coeliac disease in children with new-onset type 1 diabetes.
Diabetologia 2022 Apr 30