Mucosal recovery and mortality in adults with celiac disease after treatment with a gluten-free diet

Abstract

Objectives: Clinical response is typically observed in most adults with celiac disease (CD) after treatment with a gluten-free diet (GFD). The rate of mucosal recovery is less certain. The aims of this study were (1) to estimate the rate of mucosal recovery after GFD in a cohort of adults with CD, and (2) to assess the clinical implications of persistent mucosal damage after GFD.

Methods: The study group included adults with biopsy-proven CD evaluated at the Mayo Clinic who had duodenal biopsies at diagnosis and at least one follow-up intestinal biopsy to assess mucosal recovery after starting a GFD. The primary outcomes of interest were mucosal recovery and all-cause mortality.

Results: Of 381 adults with biopsy-proven CD, 241 (73% women) had both a diagnostic and follow-up biopsy available for re-review. Among these 241, the Kaplan-Meier rate of confirmed mucosal recovery at 2 years following diagnosis was 34% (95% confidence interval (CI): 27-40%), and at 5 years was 66% (95% CI: 58-74%). Most patients (82%) had some clinical response to GFD, but it was not a reliable marker of mucosal recovery (P=0.7). Serological response was associated with confirmed mucosal recovery (P=0.01). Poor compliance to GFD (P<0.01), severe CD defined by diarrhea and weight loss (P<0.001), and total villous atrophy at diagnosis (P<0.001) were strongly associated with persistent mucosal damage. There was a trend toward an association between achievement of mucosal recovery and a reduced rate of all-cause mortality (hazard ratio=0.13, 95% CI: 0.02-1.06, P=0.06), adjusted for gender and age.

Conclusions: Mucosal recovery was absent in a substantial portion of adults with CD after treatment with a GFD. There was a borderline significant association between confirmed mucosal recovery (vs. persistent damage) and reduced mortality independent of age and gender. Systematic follow-up with intestinal biopsies may be advisable in patients diagnosed with CD as adults.

Figure

Villous to crypt ratio and number of intraepithelial lymphocytes in adult patients with untreated and treated celiac disease: Note the significant improvement on villous to crypt ratio (Panel A) and significant decrease in the number of intraepithelial lymphocytes (Panel B) after treatment with a gluten-free diet (both p<.001). Red line is the reference for change from diagnosis to follow-up data.

Figure

Villous to crypt ratio and number of intraepithelial lymphocytes in adult patients with untreated and treated celiac disease: Note the significant improvement on villous to crypt ratio (Panel A) and significant decrease in the number of intraepithelial lymphocytes (Panel B) after treatment with a gluten-free diet (both p<.001). Red line is the reference for change from diagnosis to follow-up data.