Diagnostic Value of Persistently Low Positive TGA‐IgA Titers in Symptomatic Children With Suspected Celiac Disease

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Abstract
Objectives: While the algorithm to diagnose celiac disease (CD) in children with elevated anti‐transglutaminase IgA (TGA‐IgA) titers (>10 times upper limit of normal, ULN) is well defined, the management of children with low TGA‐IgA values represents a clinical challenge. We aimed to identify the diagnostic value of persistently low positive TGA‐IgA titers in predicting CD in children.Methods: We retrospectively analyzed children with symptoms or signs of CD, not eligible for a no‐biopsy approach. We included children with at least 2 TGA‐IgA measurements, endomysial antibody (EMA) assessment and esophagogastroduodenoscopy with biopsies. TGA‐IgA values were provided as multiples of ULN. Patients were classified in groups according to median TGA‐IgA values: A (TGA‐IgA>1 ⩽ 5 × ULN; defined as “low‐positive”), B (TGA‐IgA > 5 < 10 × ULN; “moderate‐positive”), and C (controls).Results: Data of 281 children were analyzed. Of 162 children in group A, CD was diagnosed in 142 (87.7%), whereas normal duodenal mucosa was found in 20. In group B, all 62 children (100%) received a CD diagnosis. Group C included 57 controls. EMA were undetectable in 31 (15%) of mucosal atrophy cases. On the receiver‐operating characteristic curve (area under the curve = 0.910), a mean value of 1.7 ULN showed a sensitivity of 81.4% and specificity of 81.8% to predict mucosal damage.Conclusions: Repeated low or moderate TGA‐IgA values (<5 ULN or <10 ULN) are good predictors of a CD diagnosis. Symptomatic children with persistently low positive TGA‐IgA titers should undergo esophagogastroduodenoscopy regardless of their EMA status.

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