WebMD Medical News
Louise Chang, MD
Sept. 15, 2009 -- Patients with celiac disease -- a genetic, inherited
disorder marked by intestinal damage -- are at a modestly increased risk of
death, as suspected, according to a new study.
But in a surprise finding, the researchers discovered that those with less
severe degrees of celiac disease are at higher risk of death than the
"There is an increased risk of death from celiac disease," says Jonas
Ludvigsson, MD, PhD, the study's lead author and an associate professor of
pediatrics at Orebro University Hospital, Sweden. Depending on the severity of
the disease, he found the increased risk to range from 35% to 72%.
"But the risk of dying is still very uncommon," he tells WebMD. "Most
researchers would have expected the increase [in risk to be higher]," he says.
The study is published in this week's issue of TheJournal of
the American Medical Association.
About one of every 133 people has celiac disease, according to the Celiac
Sprue Association, but only about 3% have been diagnosed. In people with the
disease, eating certain types of protein known as gluten -- found in many
breads and crackers -- triggers an autoimmune response that results in small
intestine damage. That damage, in turn, decreases the ability of the small
intestine to absorb nutrients. Malnutrition and other complications follow.
Treatment focuses on eating a gluten-free diet.
Although the risk of death for celiac disease patients has been known, less
is known about those with a less severe form of the disease. "We studied the
early stage of celiac disease as well, inflammation and latent celiac disease,"
Ludvigsson and his colleagues looked at data reports on intestinal tissue
studied at the microscopic level, collected from biopsies that had been taken
from Swedish patients from the years 1969 to 2008.
They divided the biopsy data from more than 46,000 patients into three
groups: those with celiac disease, defined by the presence of villous atrophy
(intestinal damage); those with a less severe form, in which there is
inflammation without villous atrophy of the intestinal lining; and those with
latent disease. Patients with latent disease have positive blood tests but no
physical findings of intestinal damage or inflammation, and doctors typically
take a wait-and-see approach with them before treating.
The researchers compared all patients with a comparison group from the
general population and followed them for a median of about seven to nine years
(half were followed longer, half less). Among those with celiac disease, there
were 3,049 deaths; among those with inflammation, 2,967 died and among the
latent group, 183 died.
The increased risk of death, the researchers found, differed by group:
But Ludvigsson puts the finding in perspective. The most important finding,
he says, is the relatively low overall risk of death, even though it is
increased. It translates, he says, "into very few actual deaths."
The researchers also found that those diagnosed before age 20 had nearly
twice the risk of death, overall, but Ludvigsson says that, too, needs to be
put into perspective. "Kids are at increased risk of mortality," he says. Even
though the risk is increased, he says, it is still very low.
The higher risk in those with less severe disease, Ludvigsson says, may be
because of the untreated inflammation, as those patients may not be told
to follow a gluten-free diet.
The risk of death was found to be highest in the first year of follow-up,
Deaths were often from malignancy or cardiovascular disease, the researchers
found. Exactly why isn't known, but Ludvigsson says that the longtime
inflammation associated with celiac disease may boost the risk of other
disorders, such as heart disease and cancer.
The findings that those in the less severe group have risk of death, and
sometimes higher than others, are concerning, says Daniel Leffler, MD, director
of clinical research at The Celiac Center, Beth Israel Deaconess Medical
Center, Boston, and an assistant professor of medicine at Harvard Medical
School, who reviewed the study for WebMD.
The other surprise to him was that the risk of death, although it declined
after the first year of diagnosis, did not normalize. "Other studies have shown
that once you treat, the risk of death goes back to that of the normal
population. This study didn't show that. It went down but didn't go down to
In an accompanying editorial, Peter Green, MD, a doctor at the Celiac
Disease Center, Columbia University College of Physicians and Surgeons, New
York, concludes that: "more attention should be given to the lesser degrees of
intestinal inflammation and gluten sensitivity."
Even though the study didn't go into the effects of treatment, Ludvigsson
says he thinks the advice is clear. "I believe the take-home message is: adhere
to a gluten-free diet. Although this study did not show that gluten-free diet
protects against death, there are strong indications that a gluten-free diet
diminishes the risk of complications in celiac disease.''
Leffler agrees, noting that there is no way to know from the data whether or
not the patients studied were adhering to a gluten-free diet. Treatment, he
says, would be expected to have an important effect on death risk.
SOURCES:Jonas F. Ludvigsson, MD, PhD, researcher, Orebro University Hospital,
Orebro, Sweden.Ludvigsson, J. TheJournal of the American Medical
Association, Sept. 16, 2009; vol 302: pp 1171-1178.Green P. TheJournal of the American Medical Association,
Sept. 16, 2009; vol 302: pp 1225-1226.Daniel Leffler, MD, director of clinical research, Celiac Center, Beth
Israel Deaconess Medical Center, Boston.
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