Prevalence of celiac disease among blood donors in Sistan and Balouchestan Province, Southeastern Iran.
ABSTRACT The prevalence of celiac disease is common in Iran. The aim of the present study was to determine the prevalence of celiac disease in apparently healthy blood donors of Sistan and Balouchestan Province, southeastern Iran.
Serum samples of 1600 consecutive apparently healthy blood donors at Zahedan Blood Donation Center were assayed for anti-tissue transglutaminase (tTG) antibody. The levels of IgG antibodies against tTG were screened for all subjects with IgA deficiency. All subjects with positive anti-tTG IgA or IgG were offered upper gastrointestinal endoscopy and duodenal mucosal biopsies.
IgA deficiency was found in 28:1600 (1.8%) of the subjects, among whom 4 cases were positive for IgG-class tTG antibody. Meanwhile, 10 blood donors were positive for anti-tTG IgA antibody. With the exception of 2 subjects who had normal small bowel biopsies, the remainder of the subjects' biopsy findings were compatible with celiac disease. The prevalence of celiac disease was found to be 0.88% (1/114) based on tTGA positivity.
The prevalence of celiac disease among the southeastern Iranian population is high and comparable with other parts of Iran as well as many other countries.
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ABSTRACT: There may be a positive association between coeliac disease and serum hypertransaminasaemia but evidence is conflicting. To conduct a systematic review and meta-analysis to determine the prevalence of coeliac disease in adults presenting with cryptogenic serum hypertransaminasaemia and the prevalence of hypertransaminasaemia in patients with newly diagnosed coeliac disease. MEDLINE and EMBASE were searched up to August 2010. Case series and case-control studies recruiting adults with either cryptogenic hypertransaminasaemia that applied serological tests for coeliac disease and/or distal duodenal biopsy to participants or newly diagnosed biopsy-proven coeliac disease that assessed serum transaminases were eligible. The pooled prevalence of coeliac disease in individuals presenting with abnormal serum transaminases and the pooled prevalence of hypertransaminasaemia in newly diagnosed coeliac disease were calculated with 95% confidence intervals (CI). Eleven eligible studies were identified. Pooled prevalences of positive coeliac serology and biopsy-proven coeliac disease in cryptogenic hypertransaminasaemia were 6% (95% CI 3% to 10%) and 4% (95% CI 1% to 7%) respectively. Pooled prevalence of abnormal serum transaminases in newly diagnosed coeliac disease was 27% (95% CI 13% to 44%). Exclusion of gluten led to normalisation of serum transaminase levels in 63% to 90% of patients within 1 year. Undetected coeliac disease is a potential cause for cryptogenic hypertransaminasaemia in 3% to 4% of cases. More than 20% of individuals with newly diagnosed coeliac disease may have abnormal serum transaminases and these normalise on a gluten-free diet in the majority of cases.Alimentary Pharmacology & Therapeutics 07/2011; 34(1):33-40. · 4.55 Impact Factor
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ABSTRACT: Iron deficiency anemia (IDA) is one of the well recognized presentations of celiac disease (CD). According to the lack of data from our population in this regard, we determined the prevalence of CD in patients presenting with IDA to see if it is worthwhile to do a precise screening for CD in such patients. This cross-sectional study was conducted on patients referred with IDA to Poursina Hakim Gastroenterology Clinic, Isfahan (IRAN). All included patients underwent upper gastrointestinal endoscopy and duodenal biopsy. Histopathological changes were assessed according to the Marsh classification. Also, patients were evaluated for IgA anti-tissue transglutaminase (t-TG) antibody with enzyme-linked immunosorbent assay (ELISA) technique. CD was defined as having Marsh II or above histopathology or being seropositive with Marsh I histopathology and having a good response to gluten free diet (GFD). During the study, 130 patients with the mean age of 35.5±13.7 (67.7% female [20.4% post-menopausal]) were undergone seropathological studies. According to histopathological study and a clinical response to GFD, 13 patients (10%) were ultimately diagnosed with CD. Nine patients (6.9%) were seropositive, from which, five patients (3.8%) were ultimately diagnosed as CD cases. IgA anti-tTG became negative in all of these patients after six months of GFD. CD should be considered in any adult patient presenting with unexplained IDA, even if not accompanied with gastrointestinal symptoms. Routine duodenal biopsy performed during diagnostic upper gastrointestinal endoscopy is worthwhile in order to investigate for CD as an underlying cause of IDA in adult patients.International journal of preventive medicine 04/2012; 3(4):273-7.
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ABSTRACT: BACKGROUND: Coeliac disease (CD), originally thought to be largely confined to Northern Europe and Australasia and uncommon in North America and the Middle East, is now recognised to be equally common in all these countries. It is still thought to be rare in the Orient and Sub-Saharan Africa. AIM: To assess geographical differences and time trends in the frequency of CD. METHODS: Medline and Embase searches were conducted on 10 November 2012, from 1946 and 1980 respectively, using the key words: coeliac disease or celiac disease + prevalence or incidence or frequency. RESULTS: There were significant intra- and inter-country differences in the prevalence and incidence of CD. Only 24 ethnic Chinese and Japanese patients have been reported in the English literature. Of CD-associated HLA DQ antigens, DQ2 occurs in 5-10% of Chinese and sub-Saharan Africans, compared to 5-20% in Western Europe. DQ8 occurs in 5-10% of English, Tunisians and Iranians, but in <5% of Eastern Europeans, Americans and Asians. The prevalence and incidence of both clinically and serologically diagnosed CD increased in recent years. These geographical and temporal differences seem genuine, although variable indices of suspicion and availability of diagnostic facilities are confounding factors. CONCLUSIONS: Coeliac disease is increasing in frequency, with significant geographical differences. Although few cases have been described to date in the Orient and Sub-Saharan Africa, there is a significant prevalence of HLA DQ2 and wheat consumption is of the same order as that in Western Europe. CD may therefore become more common in the future in these countries.Alimentary Pharmacology & Therapeutics 06/2013; · 4.55 Impact Factor
Archives of Iranian Medicine, Volume 13, Number 4, July 2010301
Celiac disease (CD) re?ects intolerance to glia-
din (a component of gluten) from wheat and related
proteins from rye and barley. CD is characterized
by abnormal small intestinal mucosa, signs of im-
munological activation in the lamina propria of
the small bowel, and full recovery from signs and
symptoms when placed on a gluten-free diet.1 CD
patients produce antibodies that recognize gliadin,
endomysium (an intermyo?bril substance found
in primate smooth-muscle connective tissue) and
transglutaminase (the major autoantigenic compo-
nent of endomysium).2 Serological methods of de-
tecting antibodies to gliadin (AGA), endomysium
(EMA) and tissue transglutaminase (tTG antibody)
have become the preferred methods of diagnosing
and screening both symptomatic and asymptomatic
patients for CD.3 However, biopsy of the small in-
testine remains the “gold standard” for the diagnosis
Authors’ af?liations: 1Department of Gastroenterology, School of
Medicine, Zahedan University of Medical Sciences, Zahedan, 2De-
partment of Pathology, School of Medicine, Zahedan University of
Medical Sciences, Zahedan, 3Zahedan Blood Bank Center, Zahedan,
4Research Center for Gastroenterology and Liver Diseases, Shahid Be-
heshti University of Medical Sciences, Tehran, 5Department of Clini-
cal Biochemistry, School of Medicine, Zahedan University of Medical
Sciences, Zahedan, Iran.
Corresponding author and reprints: Mohammad Hashemi PhD, De-
partment of Clinical Biochemistry, School of Medicine, Zahedan Uni-
versity of Medical Sciences, Zahedan, Iran. Tel: +98-541-244-2881,
E-mail: firstname.lastname@example.org; email@example.com
Accepted for publication: 20 January 2010
Prevalence of Celiac Disease among Blood Donors in
Sistan and Balouchestan Province, Southeastern Iran
Ali Bahari MD1, Mehrbod Karimi MD2, Ismail Sanei-Moghaddam MD3, Farzad Firouzi MD4,
Mohammad Hashemi PhD•5
Background: The prevalence of celiac disease is common in Iran. The aim of the present study was to determine the
prevalence of celiac disease in apparently healthy blood donors of Sistan and Balouchestan Province, southeastern Iran.
Methods: Serum samples of 1600 consecutive apparently healthy blood donors at Zahedan Blood Donation Center were
assayed for anti-tissue transglutaminase (tTG) antibody. The levels of IgG antibodies against tTG were screened for all
subjects with IgA de?ciency. All subjects with positive anti-tTG IgA or IgG were offered upper gastrointestinal endoscopy
and duodenal mucosal biopsies.
Results: IgA de?ciency was found in 28:1600 (1.8%) of the subjects, among whom 4 cases were positive for IgG-class
tTG antibody. Meanwhile, 10 blood donors were positive for anti-tTG IgA antibody. With the exception of 2 subjects who
had normal small bowel biopsies, the remainder of the subjects’ biopsy ?ndings were compatible with celiac disease. The
prevalence of celiac disease was found to be 0.88% (1/114) based on tTGA positivity.
Conclusion: The prevalence of celiac disease among the southeastern Iranian population is high and comparable with
other parts of Iran as well as many other countries.
Keywords: Celiac disease, Iran, prevalence, tissue transglutaminase antibody
A. Bahari, M. Karimi, I. Sanei-Moghaddam MD, et al.
Archives of Iranian Medicine, Volume 13, Number 4, July 2010
The majority of CD cases are either asymptom-
atic or have minor/minimal symptoms, suggesting
that a considerable number of cases remain undiag-
nosed and that the true prevalence of the disease is
unknown.3 CD is a worldwide health problem and
its prevalence varies among different races and na-
There are few reports regarding the prevalence
of CD in some parts of Iran.10,12,13 We screened the
blood donors in Sistan and Baluchestan Province,
one of the largest provinces in Iran, for presence of
CD by serological tests and histological evaluation
of the small intestine.
Materials and Methods
This study was performed on 1600 apparently
healthy blood donors at Zahedan Blood Donation
Center during a four month period (October 2006
to February 2007). The project was approved by the
local Ethics Committee of Zahedan University of
Medical Sciences and written informed consent was
obtained from each individual participating in this
All eligible volunteers were consecutively includ-
ed in the study, in accordance with the following
criteria established at baseline: good health, aged
between 17 and 65 years and weight greater than 50
kg. The study also included volunteers who would
have been excluded by reason of anemia (a hemato-
crit level lower than 36% for women and lower than
38% for men). The exclusion of these volunteers
could well reduce the CD prevalence in the sample
of blood donors when compared with the general
population, as anemia is one of the clinical symp-
toms of CD. Among 1600 blood donor volunteers, 7
anemic individuals were included.
Sera of the donors were kept at -80°C until analy-
sis. Sera were screened for tissue transglutaminase
(tTG) immunoglobulin A (IgA) and total IgA anti-
bodies. The level of IgG antibodies against tTG was
screened for all subjects with IgA de?ciency. Do-
nors with positive tTG antibodies (IgA or IgG) were
contacted and questioned about symptoms and signs
of CD with the use of a semi-structured question-
naire and were offered upper endoscopy and small
intestinal biopsy to con?rm the diagnosis.
Antibodies against tTG IgG and IgA were tested
with an enzyme-linked immunosorbent assay (ELI-
SA) kit (Genesis Diagnostics Ltd., Cambridgeshire,
UK) based on recombinant human tTG as an anti-
gen. Quantitative determination of IgA was done
using a commercial kit (Dade Behring Marburg
Gmbh, Germany). The reference value for IgA was
0.7 – 4 g/L.
Upper gastrointestinal endoscopy was performed
with an Olympus endoscope (GIF-V 70, Olympus,
Japan) at the Department of Gastroenterology. Dur-
ing the procedure, three duodenal biopsy samples
were obtained for routine histological analysis.
Formalin-?xed biopsy specimens stained with he-
matoxylin and eosin were studied with the use of
light microscopy and morphometric techniques. A
single expert pathologist, unaware of clinical in-
formation, assessed the biopsy specimen according
to the scoring system described by Marsh. Marsh
0: normal mucosa, Marsh I: increased number of
intra-epithelial lymphocytes, usually exceeding 20
per 100 enterocytes, Marsh II: proliferation of the
crypts, Marsh III: partial or complete villous atro-
phy, and Marsh IV: hypoplasia of the small bowel
Serum samples collected from 1600 apparently
healthy blood donors (1418 males and 182 females)
with the mean age of 33.2 years (range: 17 – 65
years) were investigated. More men than women
were enrolled (8:1) because the blood donors were
mostly males in our blood donation center.
There were 28 cases (1.8%) revealed to have IgA
de?ciency, among which 25 were males and 3 were
females. Thus, the prevalence of IgA de?ciency was
1.8% (25:1418) among males and 1.6% (3:182)
Of the 28 IgA-de?cient subjects, 4 cases were
positive for IgG-class tTG antibody. On the other
hand, 10 healthy blood donors were positive for tTG
IgA antibody. Therefore, a total of 14 subjects were
positive for tTG antibodies (IgA- or IgG-class). All
14 positive cases for tTG antibodies were male. The
results showed that the prevalence of CD was 0.88%
(1/114) based on tTG antibodies’ positivity. These
subjects were offered upper endoscopy and biopsy
for de?nitive diagnosis of CD, of which 2 donors
refused the procedure. Among those biopsied, path-
Celiac Disease among Blood Donors in
Archives of Iranian Medicine, Volume 13, Number 4, July 2010303
ological examination revealed changes compatible
with Marsh 0 in two, Marsh I in three, Marsh II in
two, Marsh III in four and Marsh IV in one (Table
In this study we found that the prevalence of CD
is 0.88% (1:114) among the southeastern Iranian
population. Although blood donors cannot be con-
sidered to be representative of the general popula-
tion, we selected them because these are apparently
healthy individuals, especially regarding nutrition
and the absence of serious diseases. In addition,
they are easily accessible and the possibility of us-
ing blood collected at the blood center makes the
study not only less aggressive for the participants,
but also more acceptable and feasible.
For screening of CD, we measured IgA and IgG an-
tibodies to human tissue transglutaminase (tTG) as
it offers equal or even superior performance to anti-
endomysial antibodies (EMA-IgA) using a monkey
substrate.15–18 Meanwhile, total IgA was assessed
nephelometrically. Among 14 cases diagnosed as
having CD, only 2 had intact intestinal morphology.
The remaining subjects had biopsy changes compat-
ible with CD. There are two reasons for this ?nding:
1) false positive tTG result that is rare but do occur
2) CD enteropathy can be patchy and missed due to
All of the 14 cases with positive serological an-
tibodies for CD were males due to the preponder-
ance of male subjects among blood donors at our
center (1418 vs. 182). It has been reported that CD
occurs in up to 10% of individuals with selective
IgA de?ciency.19 On the other hand, selective IgA
de?ciency occurs in 1 to 2% of patients with CD.20
In this study, IgA de?ciency was found in 1.8% of
patients with CD.
There are few reports regarding the prevalence of
CD in Iran. Akbari et al.12 reported a prevalence of
0.96% (1:104) in an apparently healthy population
in two cities of northern (Sari) and southern (Ker-
man) Iran. Shahbazkhani et al.10 reported the preva-
lence of 0.6% (1/166) of CD in apparently healthy
Iranian blood donors at the Tehran Blood Donation
Center. In a study performed on 1440 subjects in the
city of Shiraz (southern Iran), Saberi-Firouzi et al.13
have found a prevalence of 0.56% (1:180) of which
they concluded that CD in that region was not as
prevalent as other parts of Iran.
The 0.88% (1:114) estimated prevalence for CD
found in our study is in agreement with a previous
report of the northern and southern parts of Iran,12
however, it is higher than previously reported on
blood donors from Tehran (capital of Iran)10 and
Patient No. Age (year) SexSymptoms
138Male Abdominal pain, diarrhea IgARefused
3 26MaleConstipation, abdominal pain IgAMarsh III
4 32MaleAbdominal pain, diarrheaIgA Marsh I
5 23Male Abdominal pain, diarrheaIgAMarsh III
6 29MaleConstipationIgA Marsh II
7 62Male Anemia, abdominal pain IgA Marsh IV
8 20Male AsymptomaticIgAMarsh I
923MaleAsymptomatic IgAMarsh I
10 32MaleAbdominal pain, diarrhea IgAMarsh III
11 24MaleRecurrent aphtous stomatitis IgGMarsh 0
1321MaleShort stature IgGMarsh III
1432Male Asymptomatic IgGMarsh II
Table 1. Characteristics of blood donors with positive serological antibodies
for celiac disease in Sistan and Baluchestan Province, southeastern Iran
A. Bahari, M. Karimi, I. Sanei-Moghaddam MD, et al.
Archives of Iranian Medicine, Volume 13, Number 4, July 2010
Shiraz (southern Iran).13 This discrepancy in the
prevalence of CD in Iran might be associated with
ethnic differences between these regions.
Some investigators determined the frequency of
CD in diseases such as diabetes mellitus, chronic
non-bloody diarrhea and Behcet’s Disease in Iran.
Shahbazkhani et al. reported a high prevalence of
CD (2.4%) in Iranian patients with type I diabetes
mellitus21 and 19% (19/100) of patients with chron-
ic non-bloody diarrhea.22 In another study Zamani
et al.23 found that the frequency of CD was 1.3%
(4/288) among patients with Behcet’s Disease.
The prevalence of CD among blood donors shows
geographical variation and is approximately 0.74%
in Iceland,24 1.5% in Brazil,25 2.6% in Mexico,26
0.14% in Tunisia,9 1.3% in Turkey, and 0.45% in the
In the present study histopathological evaluation
was performed using the Marsh criteria. The nor-
mal upper limit of intraepithelial lymphocytes (IEL)
in the distal duodenum may vary in different areas
due to ethnic and environmental factors. Nasseri-
Moghaddam et al. have reported that IEL levels less
than 35/100 epithelial cells in immunohistochemi-
cal and 34/100 epithelial cells in hematoxylin-eosin
staining are normal.28
In conclusion, the present study detected a 0.88
(1:114) prevalence of CD in apparently healthy
blood donors from southeast Iran. Unfortunately,
there are only few studies on the prevalence of CD
in Iran.10,12,13 This is mainly due to lack of a national
registry system as well as the idea of rarity of CD in
Iran. Furthermore, since Iran is a wide geographic
country of different ethnicities, studying the epi-
demiological aspects of an uncommon disease re-
quires great ?nancial support, which most research
This study was supported by a research grant from
Zahedan University of Medical Sciences. The au-
thors would like to thank all subjects who willingly
participated in the study.
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