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Anti-tissue Transglutaminase Antibody Levels Indicate Severity of Villous Abnormalities in Celiac Disease
Jefferson Adams posted an article in Celiac Disease & Gluten Intolerance ResearchCeliac.com 06/06/2014 - Celiac disease guidelines suggest that some patients with high anti-tTG ab levels might be diagnosed without biopsy. A team of Indian researchers recently reviewed their celiac disease database to determine if anti-tissue transglutaminase (tTG) antibody (ab) titers correlate with severity of villous abnormalities in Indian patients, and to find out a cutoff value of anti-tTG ab fold-rise that might best predict celiac disease. The researchers included P. Singh, L. Kurray, A. Agnihotri, P. Das, A.K. Verma, V. Sreenivas, S. Datta Gupta, and G.K. Makharia. The are affiliated with the Departments of Gastroenterology and Human Nutrition, Pathology, and Biostatistics at the All India Institute of Medical Sciences in New Delhi, India. The team reviewed data on 366 anti-tTG ab-positive individuals who received duodenal biopsies. The team conducted anti-tTG ab screens before patients began a gluten-free diet, and they expressed anti-tTG ab results in terms of fold-rise by calculating ratio of observed values with cutoff value. Celiac disease was diagnosed only in patients with positive serology, villous atrophy greater than Marsh grade 2, and clear response to gluten-free diet. Average anti-tTG fold-rise in groups with Marsh grade ≤2 was 2.6 (±2.5), grade 3a was 4.0 (±3.9), 3b was 5.7 (±5.1), and 3c was 11.8 (±8.0). Overall positive likelihood ratio for diagnosing celiac disease was 15.4 and 27.4 at 12- and 14-fold-rise of anti-tTG ab titer, respectively. The positive predictive value of diagnosis of celiac disease was 100% when anti-tTG ab titer was 14-fold higher over the cutoff value. Fifty-seven (43.9%) patients with anti-tTG titer rise less than 2-fold also had celiac disease. Levels of anti-tTG rise directly with severity of villous abnormality. High anti-tTG ab titers indicate likely villous atrophy. Contrary to emerging wisdom, even patients with anti-tTG ab levels less than 2-times baseline should receive mucosal biopsies, because many patients with celiac disease have such low levels. Source: J Clin Gastroenterol. 2014 Feb 27.
Hemolysis Interferes with the Detection of Anti-Tissue Transglutaminase Antibodies in Celiac Disease
Jefferson Adams posted an article in Celiac Disease & Gluten Intolerance ResearchCeliac.com 06/17/2010 - In a recent letter to the editors of Clinical Chemistry, Carolina Arguelles-Grande, Gary L. Norman, Govind Bhagat, and Peter H. R. Green describe how hemolysis interferes with the detection of anti–tissue transglutaminase antibodies in celiac disease. They are variously affiliated with the Departments of Medicine and Pathology at Columbia University's College of Physicians and Surgeons in New York, and with INOVA Diagnostics, Inc., in San Diego, CA. Using human recombinant or erythrocyte tTG-IgA–based ELISA assays to measure anti–tissue transglutaminase (tTG) antibodies is one of the favored methods for diagnosing celiac disease. However, assessments of various tTG kits have shown variations in sensitivity, which has raised some alarms among clinicians. Many clinicians suspect that hemolysis plays a role in these variations. To assess the effect of hemolysis on tTG-IgA titers, the team looked at blood samples from 9 patients with biopsy-confirmed, active celiac disease who chose to participate in the study. They split the samples into 3 groups, with three samples in each group. They divided the samples according to tTG-IgA concentration after thawing. They categorized the samples as high titer (>185 U), intermediate titer (100–140 U), and borderline titer (20–50 U). The team hemolyzed a whole-blood sample taken from 1 tTG/DGP-seronegative patient. They measured hemoglobin in the sample at 149 g/L of hemoglobin. They repeatedly froze and thawed the sample until 90% of cells hemolyzed. They then serially diluted in ratios of 1:2, 1:5, 1:10, 1:50, 1:100, 1:500 in PBS to obtain hemoglobin concentrations of 67.1, 26.8, 13.4, 2.7, 1.3, and 0.27 g/L, respectively. They then added to each sample at a 1:1 ratio. For the tTG sequestration assessment, the team added human recombinant tTG from Diarect AG for final concentrations of 0.04, 0.02, 0.01, and 0.002 g/L. The team used undiluted serum as the baseline titer reference, and serum diluted 1:2 in PBS as a control. To measure antibody titers, they used 2 ELISA test kits: QUANTA LiteTM h-tTG IgA (human erythrocyte tTG-IgA based) and Gliadin II (DGP-IgA based) from INOVA Diagnostics, Inc. The team conducted blinded screens per manufacturer instructions, and compared the results for each group using the Mann–Whitney U-test, with P values <0.05 considered significant. They discovered that adding hemolyzed blood (HB) to sera of patients with active celiac disease lowered levels of anti-tTG, with intermediate- and borderline-titer groups seeing the largest reduction. Anti-DGP antibodies remained unchanged. Total average titer loss of anti-tTG vs anti-DGP antibodies was 36% vs 13% in the high-titer groups (P 0.026), 45% vs 3% (P = 0.026) in the intermediate titer groups, and 51% vs 2% in the borderline-titer groups (P = 0.0022) The team also found that adding ever higher concentrations of hemoglobin lowered the titers of anti-tTG, but not of anti-DGP, causing negative anti-tTG results in samples with low tTG antibody concentrations. The anti-tTG titer decreased 2%–65% in the high-titer groups, 1%–81% in the intermediate-titer groups, and 16%–74% in the borderline-titer group at hemoglobin concentrations of 0.3– 67.1 g/L. This compares with a decrease in anti-DGP titers of 10%–16% for high-titer groups, 4%–8% for intermediate-titer groups, and 7%–3% for the borderline-titer groups at hemoglobin concentrations of 0.3– 67.1 g/L. In all groups, tTG titer reduction was greater at higher concentrations of HB/HGB and gradually recovered as the red tint started to vanish at about 13 g/L of HGB, until complete visual disappearance at about 0.3g/L HGB). In the intermediate- and borderline-titer groups, titer reduction induced false-negative results at 20 U, with the anti-tTG, but not anti-DGP assays for HGB concentrations â‰¥13 or â‰¥0.3 g/L, respectively. They also found that raising concentrations of exogenous tTG (recombinant human tTG) to intermediate-titer blood samples triggered a significant reduction in anti-tTG assay titers similar to that seen with hemoglobin (range, 32%–82%; mean, 69%), as compared with that of anti-DGP titers (mean, 18%; range, 1%–38%; P = 0.0159). Hemolysis is clearly indicated by a red tint in serum plasma, and is one of the most common reasons for labs to reject specimens. Visible hemolysis starts at about 0.5 g/L of hemoglobin and is obvious above 1.3 g/L of hemoglobin. The results show that that hemolysis does interfere with the detection of anti-tTG antibodies, and that visibly hemolyzed blood samples generate false-negative anti–tTG-IgA results. These findings may explain false-negative tests for celiac disease that arise when clinicians use tTG-IgA assays. They encourage clinicians and laboratories to take measures to avoid hemolysis. If they notice hemolyzed blood samples, they should alert physicians so new blood samples can be taken. If redrawing samples is not possible, hemolyzed samples should be measured for anti-DGP antibodies. Clinicians who suspect hemolysis should consider using anti-DGP serological tests, which are not influenced by hemolysis. Source: Clinical Chemistry. 2010;56:1034-1036. DOI: 10.1373/clinchem.2010.143263
Jefferson Adams posted an article in Celiac Disease Diagnosis, Testing & TreatmentCeliac.com 08/11/2009 - While the use of anti-tTG antibodies is common practice in the diagnosis of celiac disease, their value in long-term follow-up remains controversial. A team of researchers recently set out to assess the value of anti-tTG antibodies in long-term follow-up. The research team was made up of C.R. Dipper, S. Maitra, R. Thomas, C.A. Lamb, A.P.C. McLean-Tooke, R. Ward, D. Smith, G. Spickett, and J.C. Mansfield. Their goal was to see if they could use serial anti-tTG antibody levels to gauge adherence to a gluten-free diet (GFD) and to spot patients facing complications from celiac disease. Researchers conducted a cohort follow-up study of 182 adult subjects over 54-months. The team charted patient self-assessment of gluten-free diet adherence; anti-tTG antibody concentration and serum ferritin, vitamin B12 and folate. When possible, they measured bone mineral density (BMD) and duodenal histology. The team found that patients with persistently high anti-tTG antibody levels commonly showed abnormal duodenal histology (P < 0.001), low ferritin (P < 0.01) and poor adherence to the GFD (P < 0.001). Anti-tTG antibody specificity was > 85% while the sensitivity was 39–60%. Anti-tTG antibody concentrations fell rapidly following successful implementation of a gluten-free diet, and remained normal in those who faithfully followed the gluten-free diet. From these results, the team advocates the use of anti-tTG antibody concentrations to monitor newly diagnosed and established patients with celiac disease, and to target dietary intervention accordingly to reduce the risk of long-term problems. Alimentary Pharmacology & Therapeutics. 2009;30(3):236-244.
Scott Adams posted an article in Celiac Disease Diagnosis, Testing & TreatmentClin Chem Lab Med. 2004;42(10):1092-7 Celiac.com 01/22/2005 - A study by Italian researchers has found that anti-tissue transglutaminase (tTG) antibodies, once considered to be identical to anti-endomysial antibodies (EMA) in celiac disease, can also be found in patients with inflammatory bowel disease. The researchers looked at serum and intestinal tTG levels in 49 patients with Crohns disease, 29 patients with ulcerative colitis, 45 patients with celiac disease, 85 autoimmune patients as disease controls, and 58 volunteers as healthy controls. Additionally, Immunoglobulin A (IgA) anti-recombinant human tissue transglutaminase and anti-endomysial antibody detection in sera and fecal supernatants, along with adsorption of positive sera with recombinant human tissue transglutaminase, were performed on all patients. The researchers detected an increase in tTG concentration in all patients with celiac disease, and also low positive values in those with Crohns disease and ulcerative colitis, however the EMA were only detected in those with celiac disease. According to the researchers, the "Data highlight that both circulating and intestinal anti-tissue transglutaminases are detectable in inflammatory bowel disease, and that they are related to disease activity. These features underline that, in addition to anti-tissue transglutaminase, an anti-endomysial antibody test is necessary in the diagnostic work-up of celiac sprue, especially in patients with known inflammatory bowel disease." This study supports others that have found that the sole use of tTG to diagnose celiac disease may lead to misdiagnoses, and EMA testing must be performed to make an accurate celiac disease diagnosis.
J Autoimmun. 2004 Feb;22(1):65-72 Celiac.com 01/29/2004 - A new cloning technique developed by Italian researchers may lead to more accurate diagnoses of celiac disease in borderline patients, including those who are asymptomatic. The technique screens for anti-tTG antibodies in the intestinal mucosa by utilizing a cloning process to amplify the antibodies, thus allowing for their detection even in cases where only minute amounts are present. The new technique is similar to that developed and long utilized by Dr. Kenneth Fine of Enterolab, in that both techniques look for the presence of antibodies in the intestinal mucosa rather than in the blood. The new technique also has the potential to easily screen large numbers of people, which, if the researchers are correct, will lead to a celiac disease diagnostic explosion, as those who are missed by current screening methods will be properly diagnosed. The number of celiacs who are missed using current screening techniques is a topic of debate, and Dr. Fines methods have demonstrated that "in normal people without specific symptoms or syndromes , the stool test is just under three times more likely to be positive than blood tests," as reported in the Winter 2004 edition of Scott-Free newsletter. It would be very interesting to see how many people test positive in a healthy population using this new technique. Below is the abstract of the article: One-step cloning of anti tissue transglutaminase scFv from subjects with celiac disease. Celiac disease is characterized by intestinal mucosal injury and malabsorption precipitated by dietary exposure to gluten of some cereals with a prominent role being played by gliadins, specific antigenic determinants found in wheat gluten. Patients suffering from celiac disease have serum antibodies recognizing gliadin, as well as the Endomysial autoantigen tissue transglutaminase. Phage display antibody libraries have revealed ectopic production of anti-transglutaminase antibodies by intestinal lymphocytes with a biased use of the VH5 antibody gene family. Here we report a study on the pairing of VH and VL families in the antibodies to transglutaminase. Our results led to the construction of small phage display antibody libraries based on the amplification of the two genes in the VH5 family from intestinal lymphocytes. This method can be used for the rapid characterization of the anti-transglutaminase response in a potentially large number of subjects including asymptomatic patients whose serum antibodies may be undetectable.