Andrea Dirmeier

Association of the novel serologic anti-glycan antibodies anti-laminarin and anti-chitin with complicated Crohn's disease behavior.

Background: We tested a panel of novel serological anti‐glycan antibodies including the previously unpublished anti‐laminarin IgA (Anti‐L) and anti‐chitin IgA (Anti‐C) carbohydrate antibodies for the presence in Crohns disease (CD) patients, diagnosis and differentiation of CD, association with complicated disease behavior, and marker stability over time. Methods: The presence of Anti‐L, Anti‐C, anti‐chitobioside IgA (ACCA), anti‐laminaribioside IgG (ALCA), anti‐mannobioside IgG (AMCA), and anti‐Saccaromyces cervisiae IgG (gASCA) carbohydrate antibodies were tested in serum samples from 824 participants (363 CD, 130 ulcerative colitis [UC], 74 other gastrointestinal diseases, and 257 noninflammatory bowel/gastrointestinal disease controls) of the German IBD‐network by enzyme‐linked immunosorbent assay (ELISA; Glycominds, Lod, Israel) and for perinuclear antineutrophil cytoplasmic antibody (pANCA) by immunofluorescence. Results: In all, 77.4% of the CD patients were positive for at least 1 of the anti‐glycan antibodies. gASCA or the combination of gASCA/pANCA remained most accurate for the diagnosis of CD, but the combined use of the antibodies improved differentiation of CD from UC. Several single markers as well as an increasing antibody response were independently linked to a severe disease phenotype, as shown for the occurrence of complications, CD‐related surgery, early disease onset, and ileal disease location. This was observed for both quantitative and qualitative antibody responses. The antibody status remained stable over time in most IBD patients. Conclusions: A panel of anti‐glycan antibodies including the novel Anti‐L and Anti‐C may aid in differentiation of CD from UC, is associated with complicated CD behavior and IBD‐related surgery, and is stable over time in a large patient cohort. Inflamm Bowel Dis 2009

Serum anti-glycan antibodies predict complicated Crohn's disease behavior: A cohort study†

Background: A high proportion of patients with Crohns disease (CD) over time develop complications like fistulae and strictures, requiring surgery. We tested a panel of antiglycan antibodies for predicting the occurrence of complications and CD‐related surgery in an adult patient cohort. Methods: Serum samples of 149 CD patients of the German inflammatory bowel disease (IBD) network were tested for the presence of anti‐laminarin IgA (Anti‐L), anti‐chitin IgA (Anti‐C), anti‐chitobioside IgA (ACCA), anti‐laminaribioside IgG (ALCA), anti‐mannobioside IgG (AMCA), and anti‐Saccaromyces cerevisiae IgG (gASCA) carbohydrate antibodies by enzyme‐linked immunosorbent assay (ELISA) (IBDX® panel, Glycominds, Lod, Israel) in a blinded fashion. Clinical data were available on occurrence of complicated disease or CD‐related surgery as well as disease activity, onset, and location. Results: The median follow‐up of the patients without any previous complication or surgery at time of sample procurement was 53.7 months. Overall, 26.3% developed a complication and 17.1% underwent CD‐related surgery, respectively. Positivity for gASCA, AMCA, ACCA, and Anti‐L alone or an increasing frequency of positive serum antibodies independently predicted a faster progression toward a more severe disease course. Once a complication or surgery had occurred only positivity for Anti‐L or more than 3 markers out of the whole panel indicated progression to an additional surgery or complication. The antibody status of most patients remained stable over time. Conclusions: This is the first study showing the clinical value of serum antiglycan antibodies for prediction of a more complicated disease course in adult patients with CD. (Inflamm Bowel Dis 2010)

Serum soluble TNF receptor I and II levels correlate with disease activity in IBD patients

Background Tumor necrosis factor alpha (TNF&agr;) is a proinflammatory cytokine and an important mediator in the pathophysiology of inflammatory bowel disease (IBD). The effects of TNF&agr; are mediated by 2 specific receptors, a 55‐kDa protein (TNF‐RI) and a 75‐kDa receptor (TNF‐RII), which are usually bound to the cell surface. Soluble TNF receptors I and II (sTNF‐RI + II) are released by proteolytic cleavage of the extracellular domains of these receptors. Soluble TNF‐Rs act as TNF antagonists and can inhibit TNF&agr;‐mediated proinflammatory effects. Methods Levels of sTNF‐RI + II were measured using commercially available enzyme‐linked immunosorbent assays (ELISAs). Serum levels of sTNF‐RI + II of 76 healthy volunteers were compared to serum levels of 373 clinically well‐characterized patients with Crohns disease (CD) and 118 patients with ulcerative colitis (UC) with different disease activity from the German IBD competence network serum bank. CD patient subgroups were defined according to the Vienna Classification. Results The serum levels of sTNF‐RI were significantly increased in all groups (active, chronic active, and remission) of CD and UC patients compared to healthy controls. sTNF‐RII levels were significantly higher in active CD patients compared to UC patients with no overlap of the 95% confidence interval. Significantly higher values of sTNF‐RII compared to controls were also observed in CD patients and UC patients in remission. There was no statistically significant difference in sTNF‐RI or sTNF‐RII levels when patient subgroups were analyzed according to disease behavior or disease localization. Conclusion sTNF‐RI is upregulated in the serum of IBD patients compared to healthy controls and could be used as a marker for disease activity. sTNF‐RII levels are significantly more elevated in serum of active CD patients as compared to UC and could be used as an additional parameter to discriminate both diseases. (Inflamm Bowel Dis 2007)

Characterization of Changes in Serum Anti-Glycan Antibodies in Crohn's Disease – a Longitudinal Analysis

Introduction Anti-glycan antibodies are a promising tool for differential diagnosis and disease stratification of patients with Crohns disease (CD). We longitudinally assessed level and status changes of anti-glycan antibodies over time in individual CD patients as well as determinants of this phenomenon. Methods 859 serum samples derived from a cohort of 253 inflammatory bowel disease (IBD) patients (207 CD, 46 ulcerative colitis (UC)) were tested for the presence of anti-laminarin (Anti-L), anti-chitin (Anti-C), anti-chitobioside (ACCA), anti-laminaribioside (ALCA), anti-mannobioside (AMCA) and anti-Saccharomyces cerevisiae (gASCA) antibodies by ELISA. All patients had at least two and up to eleven serum samples taken during the disease course. Results Median follow-up time for CD was 17.4 months (Interquartile range (IQR) 8.0, 31.6 months) and for UC 10.9 months (IQR 4.9, 21.0 months). In a subgroup of CD subjects marked changes in the overall immune response (quartile sum score) and levels of individual markers were observed over time. The marker status (positive versus negative) remained widely stable. Neither clinical phenotype nor NOD2 genotype was associated with the observed fluctuations. In a longitudinal analysis neither changes in disease activity nor CD behavior led to alterations in the levels of the glycan markers. The ability of the panel to discriminate CD from UC or its association with CD phenotypes remained stable during follow-up. In the serum of UC patients neither significant level nor status changes were observed. Conclusions While the levels of anti-glycan antibodies fluctuate in a subgroup of CD patients the antibody status is widely stable over time.

Clinical utility of anti‐glycan antibodies in pediatric crohn's disease in comparison with an adult cohort

Background: We tested a panel of serological anti‐glycan antibodies including the novel anti‐laminarin (Anti‐L) and anti‐chitin (Anti‐C) antibodies in pediatric Crohns disease (CD) patients for diagnosis of CD and association with complicated CD behavior. In addition, we compared this panel in pediatric CD with adult CD patients for possible changes in accuracy over time. Methods: Anti‐L, Anti‐C, anti‐chitobioside (ACCA), anti‐laminaribioside (ALCA), anti‐mannobioside (AMCA), and anti‐Saccaromyces cervisiae (gASCA) antibodies were tested in serum samples of 131 pediatric participants (59 CD, 27 ulcerative colitis [UC], and 45 noninflammatory bowel disease [IBD] controls) with enzyme‐linked immunosorbent assay (ELISA). The results were compared to an adult cohort of 728 participants (355 CD, 129 UC, and 244 non‐IBD controls). Results: In all, 78% of the pediatric CD patients were positive for at least one of the anti‐glycan antibodies. gASCA was most accurate for the diagnosis of CD, but combined use of the antibodies improved differentiation of CD from UC. gASCA, AMCA, ALCA, or Anti‐L and an increasing antibody level were independently linked to complicated CD behavior, CD‐related surgery, and ileal disease location (odds ratio 3.9–8.7). Considering the age at sample procurement the accuracy of the markers compared to an adult cohort remained stable for the differentiation of CD versus UC as well as for the association with complications, CD‐related surgery, and ileal disease involvement. Conclusions: A panel of anti‐glycan antibodies including the novel Anti‐L and Anti‐C may aid in the differentiation of pediatric CD from UC and is associated with complicated CD behavior. The marker accuracy remained constant over time. (Inflamm Bowel Dis 2011;)

Hemoglobin and hematocrit levels in the prediction of complicated Crohn's disease behavior--a cohort study.

Background Markers that predict the occurrence of a complicated disease behavior in patients with Crohns disease (CD) can permit a more aggressive therapeutic regimen for patients at risk. The aim of this cohort study was to test the blood levels of hemoglobin (Hgb) and hematocrit (Hct) for the prediction of complicated CD behavior and CD related surgery in an adult patient population. Methods Blood samples of 62 CD patients of the German Inflammatory Bowel Disease-network “Kompetenznetz CED” were tested for the levels of Hgb and Hct prior to the occurrence of complicated disease behavior or CD related surgery. The relation of these markers and clinical events was studied using Kaplan-Meier survival analysis and adjusted COX-proportional hazard regression models. Results The median follow-up time was 55.8 months. Of the 62 CD patients without any previous complication or surgery 34% developed a complication and/or underwent CD related surgery. Low Hgb or Hct levels were independent predictors of a shorter time to occurrence of the first complication or CD related surgery. This was true for early as well as late occurring complications. Stable low Hgb or Hct during serial follow-up measurements had a higher frequency of complications compared to patients with a stable normal Hgb or Hct, respectively. Conclusions Determination of Hgb or Hct in complication and surgery naïve CD patients might serve as an additional tool for the prediction of complicated disease behavior.

Serologic Anti-GP2 Antibodies Are Associated with Genetic Polymorphisms, Fibrostenosis, and Need for Surgical Resection in Crohn's Disease.

Background:The presentation of Crohns disease (CD) is heterogeneous and often leads to serious complications and need for surgery. We tested serum anti-zymogen granule glycoprotein 2 (GP2) antibodies, including its novel isoform alpha, for association with genetic variants, diagnosis, disease stratification, and prediction of CD courses in a combined cross-sectional and cohort study. Methods:Serum samples of 303 CD, 108 ulcerative colitis, 72 other inflammatory gastrointestinal diseases, and 206 controls without predominant gastrointestinal diseases controls (HC) were tested for the presence of Anti-GP2 and Anti-Saccharomyces cervisiae (ASCA) by enzyme-linked immunosorbent assay. Genetic analysis was performed using the Illumina Immunochip. Results:GP2 IgA and IgG had the highest discriminatory capability for CD versus ulcerative colitis and CD versus inflammatory gastrointestinal diseases. We identified an association of GP2 IgA and IgG each with 5 distinct single-nucleotide polymorphisms. Levels of anti-GP2 IgG were moderately associated with ileal disease location. Interestingly, both, anti-GP2 IgA and IgG were exclusively associated with the occurrence of stenosis and need for surgery, independently of disease location, but not with fistulizing CD, early disease onset or disease activity. ASCA IgG and IgA were qualitatively and quantitatively linked to CD, CD complications, and need for surgery. Increased levels of ASCA IgG and IgA and positivity for ASCA IgG, but neither levels nor positivity for GP2 IgG or IgA were predictive of the earlier occurrence of complications or surgery. Conclusions:Anti-GP2 antibodies may aid as a tool for diagnosis and differentiation of CD and could indicate a more complicated CD course.

Mo1247 Serologic Anti-GP2 Antibodies Are Associated With Strictures and Need for Surgical Resection in Crohn's Disease

Background: Crohǹs disease (CD) often leads to serious complications, such as fistulae and strictures as well as need for surgery. Early and prolonged immunosuppressive therapy has the potential to alter the natural history of CD. Several serum markers have been tested for the stratification of CD, but their use in clinical practice is still limited. Recently zymogen granule glycoprotein 2 (GP2)was identified as themajor autoantigen of CD-specific pancreatic autoantibodies. Aims: We tested serologic anti-GP2 antibodies for their association with complications and surgery, disease location, disease activity and age at disease onset in patients with CD in a cross-sectional analysis. Methods: Serum samples from 303 CD patients of a tertiary university hospital (mean age 36.1 years, 52.8% female) were tested for the presence of Anti-GP2 IgA and Anti-GP2 IgG by ELISA. Clinical data on disease location, age at disease onset, clinical disease activity, serum CRP, complications (strictures and fistulae) and surgery were available in a prospectively maintained database. Analysis was performed using Wilcoxon rank sum test and logistic regression analysis. Reported odds ratios (ORs) correspond to 10 unit (U) increase in marker levels. Results: After a median follow-up time from diagnosis of 104.6 [interquartile range (IQR) 58.1,168.1] months 77.6% of the CD patients had a complication (49.2% fistulae, 58.4% stenosis), 72.3% underwent surgery and 85.5% had ileal disease involvement. At time of sample procurement 36.5% had clinically active disease and 51.6% had elevated CRP. Levels of anti-GP2 IgG were linked to complicated CD (p=0.002, area under the curve (AUC) 0.62) and ileal disease location (p=0.004, AUC 0.64). Interestingly, both, anti-GP2 IgA and IgG were associated with the occurrence of stenosis and need for surgery (p ,0.001 p=0.003, AUC 0.62 0.64), but not with fistulizing CD, early disease onset, clinically active disease or elevated CRP. After correction for early disease onset and ileal involvement anti-GP2 IgG levels remained significantly linked to stenosis (OR for 10 U increase in GP2 IgG: 1.07 (95% confidence interval (CI): 1.01, 1.1)) and need for surgery (OR for 10 U increase in GP2 IgG: 1.1 (95% CI: 1.01, 1.2)). If patients had both, strictures and fistulae, the association of anti-GP2 IgG with stricturing CD remained significant after correction for the presence of fistulas (OR for 10 U increase in GP2 IgG: 1.07 (95% CI 1.02, 1.1)). Conclusions: Specific levels of anti-GP2 antibodies are independently associated with stricturing CD and need for surgical intervention. Ongoing studies evaluate anti-GP2 levels for their predictive capabilities, the stability of these markers over time and the combination with genetic markers to assess their use in clinical practice.

390 The Novel Anti-Glycan Antibodies Anti-L and Anti-C in Conjunction with ALCA, ACCA, gASCA and AMCA Predict Early Development of Fistulae, Stenoses and Surgery in Patients with Crohn's Disease: A Prospective Analysis

The Novel Anti-Glycan Antibodies Anti-L and Anti-C in Conjunction with ALCA, ACCA, gASCA and AMCA Predict Early Development of Fistulae, Stenoses and Surgery in Patients with Crohns Disease: A Prospective Analysis Florian Rieder, Alexandra Wolf, Stephan Schleder, Andrea Dirmeier, Ulrike Strauch, Florian Obermeier, Larissa Spector, Ella Fire, Jennifer Yarden, Gerhard Rogler, Nir Dotan, Frank Klebl

Activin in acute pancreatitis: Potential risk-stratifying marker and novel therapeutic target

Acute Pancreatitis is a substantial health care challenge with increasing incidence. Patients who develop severe disease have considerable mortality. Currently, no reliable predictive marker to identify patients at risk for severe disease exists. Treatment is limited to rehydration and supporting care suggesting an urgent need to develop novel approaches to improve standard care. Activin is a critical modulator of inflammatory responses, but has not been assessed in pancreatitis. Here, we demonstrate that serum activin is elevated and strongly correlates with disease severity in two established murine models of acute pancreatitis induced by either cerulein or IL-12 + IL-18. Furthermore, in mice, inhibition of activin conveys survival benefits in pancreatitis. In addition, serum activin levels were measured from a retrospective clinical cohort of pancreatitis patients and high activin levels in patients at admission are predictive of worse outcomes, indicated by longer overall hospital and intensive care unit stays. Taken together, activin is a novel candidate as a clinical marker to identify those acute pancreatitis patients with severe disease who would benefit from aggressive treatment and activin may be a therapeutic target in severe acute pancreatitis.