Persistent Mucosal Damage and Risk of Fracture in Celiac Disease

• Published in: The journal of clinical endocrinology and metabolism Vol. 99; no. 2; pp. 609 - 616
• Main Authors: Lebwohl, Benjamin, Michaëlsson, Karl, Green, Peter H. R, Ludvigsson, Jonas F
• Format: Journal Article
• Language: English
• Published: Bethesda, MD Endocrine Society 01.02.2014; Copyright by The Endocrine Society
• Subjects: Adolescent; Adult; Atrophy - complications; Atrophy - pathology; Biological and medical sciences; Celiac Disease - complications; Celiac Disease - pathology; Child; Child, Preschool; Endocrine Research; Endocrinopathies; Feeding. Feeding behavior; Female; Fractures, Bone - etiology; Fractures, Bone - pathology; Fundamental and applied biological sciences. Psychology; Hip Fractures - etiology; Hip Fractures - pathology; Humans; Intestinal Mucosa - pathology; Male; Medical sciences; Medicin och hälsovetenskap; Middle Aged; Osteoporotic Fractures - etiology; Osteoporotic Fractures - pathology; Risk; Vertebrates: anatomy and physiology, studies on body, several organs or systems; Vertebrates: endocrinology; Immunopathology; Obesity; Nutrition; Mucosa; Diseases of the osteoarticular system; Nutrition disorder; Metabolic diseases; Risk; Fracture; Coeliac disease; Trauma; Intestinal malabsorption; Risk factor; Digestive diseases; Intestinal disease; Endocrinology; Nutritional status
• ISSN: 0021-972X; 1945-7197; 1945-7197
• DOI: 10.1210/jc.2013-3164

Context: Celiac disease (CD) is associated with an increased fracture risk, an increase that persists after diagnosis. A significant proportion of patients with CD have persistent villous atrophy (VA) on follow-up biopsy. Objective: The objective of the study was to determine whether persistent VA impacts long-term fracture risk. Design: This was a cohort study. Setting and Patients: We identified all patients in Sweden with histological evidence of CD who underwent a follow-up biopsy and compared patients with persistent VA with those with mucosal healing. Main Outcome Measures: The following were measured: 1) any fracture; 2) likely osteoporotic fracture (defined as fractures of the hip, distal forearm, thoracic and lumbar spine, or proximal humerus); and 3) hip fracture. Results: Of 7146 patients, VA was present on follow-up biopsy in 43%. There was no significant association between persistent VA and overall fractures [hazard ratio (HR) of persistent VA compared with those with healing 0.93, 95% confidence interval (CI) 0.82–1.06] or with likely osteoporotic fractures (HR 1.11, 95% CI 0.84–1.46). Persistent VA was associated with an increased risk of hip fracture (HR 1.67, 95% CI 1.05–2.66). Hip fracture risk increased, depending on the degree of VA (HR for partial VA compared with those with healing 1.70, 95% CI 0.82–3.49, HR for subtotal/total VA compared with those with healing 2.16, 95% CI 1.06–4.41). Conclusions: Persistent VA on follow-up biopsy is predictive of hip fracture risk. The association between persistent VA and hip fractures, but not fractures overall, implies that thinner sc tissue and fall or trauma may be mechanisms by which persistent VA confers an increased fracture risk.