Objective Initiation of a gluten-free diet without proper diagnostic work-up of coeliac disease is a frequent and demanding problem. Recent diagnostic guidelines suggest a gluten challenge of at least 14 days followed by duodenal biopsy in such patients. The rate of false-negative outcome of this approach remains unclear. We studied responses to 14-day gluten challenge in subjects with treated coeliac disease.
Design We challenged 20 subjects with biopsy-verified coeliac disease, all in confirmed mucosal remission, for 14 days with 5.7 grams per oral gluten daily. Duodenal biopsies were collected. Blood was analysed by multiplex assay for cytokine detection, and by flow cytometry using HLA-DQ:gluten tetramers.
Results Nineteen participants completed the challenge. Villous blunting appeared at end of challenge in 5 of 19 subjects. Villous height to crypt depth ratio reduced with at least 0.4 concomitantly with an increase in intraepithelial lymphocyte count of at least 50% in 9 of 19 subjects. Interleukin-8 plasma concentration increased by more than 100% after 4 hours in 7 of 19 subjects. Frequency of blood CD4+ effector-memory gut-homing HLA-DQ:gluten tetramer-binding T cells increased by more than 100% on day 6 in 12 of 15 evaluated participants.
Conclusion A 14-day gluten challenge was not enough to establish significant mucosal architectural changes in majority of patients with coeliac disease (sensitivity ≈25%–50%). Increase in CD4+ effector-memory gut-homing HLA-DQ:gluten tetramer-binding T cells in blood 6 days after gluten challenge is a more sensitive and less invasive biomarker that should be validated in a larger study.
Trial registration number NCT02464150
- Coeliac Disease
- Gluten Free Diet
- T-cell Receptor
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Contributors Study concept and design (KEAL, VKS, GIS, LMS), acquisition of data (VKS, HMR, LFR, SDK), analysis and interpretation of data (all authors), drafting of the manuscript (VKS, LMS), critical revision of the manuscript for important intellectual content (KEAL, LFR, GIS, HMR, SDK), statistical analysis (VKS, LFR, GIS), obtained funding (KEAL, LMS), administrative (VKS, GIS, KEAL), technical and material support (VKS, GIS), study supervision (KEAL, LMS).
Funding VKS was funded by grants from South-Eastern Norway Regional Health Authority and from Regeneron (Tarrytown, NY). The work was otherwise supported by grants from the South-Eastern Norway Regional Health Authority, from the Research Council of Norway through its Centre of Excellence funding scheme (project number 179573/V40) and from Stiftelsen Kristian Gerhard Jebsen.
Competing interests Knut EA Lundin and Ludvig M Sollid are holders of a patent application on the detection of gluten-specific T cell by HLA-DQ:tetramers (EP20140789602). KEAL is an advisor to ImmusanT. LMS is an advisor to ImmusanT and is consultant to Celgene and Intrexon. Regeneron and ImmusanT have provided research grants to the research group of LMS.
Patient consent All data are de-identified. All patients have signed a separate consent form approved by the regional ethical committee of South-East Norway and have consented to publication in medical journal.
Ethics approval The regional ethical committee of South-East Norway (ref 2013/1237)
Provenance and peer review Not commissioned; externally peer reviewed.
Correction notice This article has been corrected since it published Online First. The competing interests statement has been updated.