title: Persistent mucosal damage and risk of fracture in celiac disease.
abstract: BACKGROUND
  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.
  
  
  METHODS
  This was a cohort study.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
authors.affiliation: Celiac Disease Center (B.L., P.H.R.G.), Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York 10027; Clinical Epidemiology Unit (B.L., J.F.L.), Department of Medicine, Karolinska University Hospital and Karolinska Institutet, SE-171 77 Stockholm, Sweden; Department of Surgical Sciences (K.M.), Section of Orthopaedics, Uppsala University, SE-751 05 Uppsala, Sweden; and Department of Pediatrics (J.F.L.), Örebro University Hospital, SE-70185; Örebro, Sweden.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Lebwohl
authors.forename: Karl
authors.initials: K
authors.lastname: Michaëlsson
authors.forename: Peter H R
authors.initials: PH
authors.lastname: Green
authors.forename: Jonas F
authors.initials: JF
authors.lastname: Ludvigsson
mesh_terms: D000293:Adolescent; D000328:Adult; D001284:Atrophy / Q000150:complications / Q000473:pathology; D002446:Celiac Disease / Q000150:complications* / Q000473:pathology; D002648:Child; D002675:Child, Preschool; D005260:Female; D050723:Fractures, Bone / Q000209:etiology* / Q000473:pathology; D006620:Hip Fractures / Q000209:etiology / Q000473:pathology; D006801:Humans; D007413:Intestinal Mucosa / Q000473:pathology*; D008297:Male; D008875:Middle Aged; D058866:Osteoporotic Fractures / Q000209:etiology* / Q000473:pathology; D012306:Risk