title: Clinical staging and survival in refractory celiac disease: a single center experience.
abstract: OBJECTIVE
  Refractory celiac disease (RCD) occurs when both symptoms and intestinal damage persist or recur despite strict adherence to a gluten-free diet. In RCD, the immunophenotype of intraepithelial lymphocytes may be normal and polyclonal (RCD I) or abnormal and monoclonal (RCD II). The aim is to describe the clinical characteristics, treatment, and long-term outcome in a large single-center cohort of patients with RCD.
  
  
  METHODS
  We compared the clinical characteristics and outcome in 57 patients with RCD: 42 with RCD I and 15 with RCD II.
  
  
  RESULTS
  Fifteen of 57 patients died during follow-up (n=8 with RCD I and n=7 with RCD II), each within the first 2 years after RCD diagnosis. The overall 5-year cumulative survival is 70%, 80%, and 45% for the entire cohort, RCD I, and RCD II, respectively. The refractory state itself and enteropathy-associated T-cell lymphoma (EATL) were the most common causes of death, respectively. A new staging system is proposed based on the cumulative effect of 5 prognostic factors investigated at the time of the refractory state diagnosis: for patients in stages I, II, and III, the 5-year cumulative survival rate was 96%, 71%, and 19%, respectively (P< .0001).
  
  
  CONCLUSIONS
  RCD is associated with high mortality with RCD II having an especially poor prognosis because of the development of EATL. A new staging model is proposed that may improve the precision of prognosis in patients with RCD.
authors.affiliation: Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA.
authors.forename: Alberto
authors.initials: A
authors.lastname: Rubio-Tapia
authors.forename: Darlene G
authors.initials: DG
authors.lastname: Kelly
authors.forename: Brian D
authors.initials: BD
authors.lastname: Lahr
authors.forename: Ahmet
authors.initials: A
authors.lastname: Dogan
authors.forename: Tsung-Teh
authors.initials: TT
authors.lastname: Wu
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Murray
mesh_terms: D000328:Adult; D000368:Aged; D002446:Celiac Disease / Q000145:classification / Q000188:drug therapy / Q000401:mortality* / Q000473:pathology; D018450:Disease Progression; D016099:Endoscopy, Gastrointestinal; D005260:Female; D006801:Humans; D016399:Lymphoma, T-Cell / Q000209:etiology; D008297:Male; D008875:Middle Aged