Persistent Villous Atrophy Heightens Risk for Complications in Celiac Disease

villous-atrophyResearchers have developed and validated a scoring system to identify patients with celiac disease at risk for persistent villous atrophy (pVa).

  1. Age at diagnosis
  2. Disease pattern
  3. Clinical response to gluten-free diet
  4. Gluten-free diet adherence

pVa is associated with complications and mortality and warrants follow-up evaluation.

High-risk patients may require follow-up biopsy and other interventions.

• 1

“Villous atrophy (VA) can persist in some patients despite a [gluten-free diet (GFD)], usually due to poor dietary adherence or slow responsiveness to a GFD or hypersensitivity to gluten and, less commonly, premalignant/malignant complications of [celiac disease (CD)],”

  • Annalisa Schiepatti, PhD, of the University of Pavia in Italy et al wrote in Gut.

“Furthermore, few studies have evaluated which factors may be associated with pVA in CD, so the clinical phenotype of patients at higher risk of pVA is still poorly defined.”

In a multicenter longitudinal study, Schiepatti and colleagues evaluated the relationship between pVA (defined as Marsh ≥ 3a) and long-term CD outcomes and developed a score to identify patients at risk for pVA.

Of 2,182 adults diagnosed with CD between 2000 and 2021, 694 underwent follow-up duodenal biopsy after a median 32 months on GFD and were included in the study cohort.

At follow-up, 34.1% had ongoing symptoms and 23% had pVA.

Patients with pVA had an increased risk for complications (HR = 9.53; 95% CI, 4.77-19.04) and mortality (HR = 2.93; 95% CI, 1.43-6.02).

Researchers developed a scoring system that categorized patient risk for pVa as low (0-1 points, 5% pVA), intermediate (2 points, 16% pVA) or high (≥ 3 points, 73% pVA), based on predictors that included:

  1. age at diagnosis (≥ 45 years; OR = 2.01; 95% CI, 1.21-3.34)
  2. classical pattern of CD (OR = 2.14; 95% CI, 1.28-3.58)
  3. lack of clinical response to GFD (OR = 2.4; 95% CI, 1.43-4.01)
  4. poor GFD adherence (OR = 48.9; 95% CI, 26.1-91.8)

In receiver operating characteristic analysis, researchers noted the score had “very good predictive ability” for pVA (ROC-AUC = 0.86; 95% CI, 0.82-0.89).

Schiepatti and colleagues validated the score with a cohort of 144 patients with CD who underwent duodenal biopsy after a median of 40 months from diagnosis, of whom 26 had pVA.

In the validation cohort, the predictive score “performed well” in identifying patients with and without pVA (ROC-AUC = 0.78; 95% CI, 0.68-0.89).

“We have shown that patients with pVA have an increased risk of complications and mortality,”

  • Schiepatti and colleagues concluded.

“Our score allows early identification of patients with CD at high risk of pVA who may require targeted interventions and personalized follow-up modalities to contrast poor long-term outcomes.”