Current and future role of biomarkers in Crohn’s disease risk assessment and treatment

Figures & data

Figure 1 Crohn’s disease phenotypic behavior over time, according to Montreal classification at diagnosis and follow-up in 404 pediatric patients. Dramatic changes occurred in the proportion of disease behavior subgroups – from inflammatory nonpenetrating, nonstricturing disease (B1) to stricturing (B2) or penetrating disease (B3) (P < 0.01).

Copyright © 2004, Elsevier. Reproduced with permission from Vernier-Massouille et al.³¹

Table 1 Seroprevalence of ASCA positivity, IgA and IgG in non-IBD disease

Disease	ELISA assay	ASCA IgA	ASCA IgG	ASCA IgA or IgG	Study
Systemic candidiasis	Lille assay, inhouse	–	–	100%	Standaert-Vitse et al^Citation57
Various acute bacterial infections	Aesku Diagnostics, Germany	–	–	22%	Berlin et al^Citation58
Cystic fibrosis, pediatric	Quanta-Lite, Inova Diagnostics, USA	13%	11%	21%	Condino et al^Citation59
Cystic fibrosis, adult	Quanta-Lite, Inova Diagnostics, USA	44%	–	–	Lachenal et al^Citation60
Intestinal tuberculosis	Aesku Diagnostics, Germany	43%	47%	67%	Makharia et al^Citation61
Celiac disease (pre-treatment)	Quanta-Lite, Inova Diagnostics, USA	20%	54%	59%	Granito et al^Citation62
Type 1 diabetes mellitus	Orgentec, Germany	10%	21%	25%	Sakly et al^Citation63
Primary biliary cirrhosis	Quanta-Lite, Inova Diagnostics, USA	19%	11%	23%	Muratori et al^Citation64
Primary sclerosing cholangitis	Quanta-Lite, Inova Diagnostics, USA	32%	28%	44%	Muratori et al^Citation64
Autoimmune hepatitis	Quanta-Lite, Inova Diagnostics, USA	12%	16%	18%	Muratori et al^Citation64
Ankylosing spondylitis	Quanta-Lite, Inova Diagnostics, USA	23%	12%	–	Riente et al^Citation65
Rheumatoid arthritis	Quanta-Lite, Inova Diagnostics, USA	18%	10%	–	Riente et al^Citation65

Abbreviations: ASCA, antibodies to Saccharomyces cerevisiae; ELISA, enzyme-linked immunosorbent assay; IBD, inflammatory bowel disease; IgA, immunoglobulin A; IgG, immunoglobulin G.

Table 2 Summary of seromarker characteristics in IBD

Seromarker	Antigenic determinant	Disease indication	Sensitivity, specificity, PPV, NPV
ASCA	Mannose residue forms the phosphopeptidomannan of the cell wall of Saccharomyces cerevisiae; also expressed by Candida albicans	CD • Sensitivity for CD improved when used in combination with pANCA	Sensitivity: 53%^Citation80 Specificity: 89%^Citation80 PPV: 73%a,^Citation81 PPV: 84% with (−) pANCA^Citation81 NPV: 68%^Citation78
pANCA	Unidentified protein of the nuclear envelope of neutrophils	UC • May be (+) in CD with UC-like phenotype • May predict chronic pouchitis following IPAA	Sensitivity: 55%^Citation80 Specificity: 89%^Citation80 PPV: 82%a,^Citation81 NPV: 89%^Citation78
Anti-OmpC	Outer membrane porin, originally isolated from Escherichia coli^Citation87	CD • May identify CD in up to 15% of ASCA (−) patients	Sensitivity: 20%–55%^Citation44 Specificity: 89%^Citation44 PPV: 83.4%b,^Citation82 NPV: 25.3b,^Citation82
Anti-I2	Bacterial sequence derived from Pseudomonas fluorescens	CD	Sensitivity: 42%^Citation44 Specificity: 76%^Citation44 PPV: 96%c,^Citation83 NPV: 26%^‡c,^Citation83
Anti-CBir1	Flagellin, CBir (Clostridium subphylum)	CD • May help to differentiate CD from UC in pANCA (+) patients	Sensitivity: 50%c,^Citation84 Specificity: 53%c,^Citation84 PPV: 45%c,^Citation85 NPV: not reported
Combination seromarker panel (Prometheus IBD Serology – 7)	ASCA (IgA, IgG), anti-OmpC, anti-CBir1, NSNA with IFA perinuclear pattern and DNAse sensitivity	Differentiating IBD from non-IBD, and CD from UC	Sensitivity: 80%^Citation86 Specificity: 61.5%^Citation86 PPV: 68%^Citation86 NPV: 75%^Citation86

Notes:

a Value reported for distinguishing CD from UC;

b Using expanded-spectrum IgA antibody to multiple outer membrane porins (Omp);

c Exclusive pediatric cohort.

Abbreviations: ASCA, antibodies to Saccharomyces cerevisiae; CD, Crohn’s disease; IBD, inflammatory bowel disease; IFA, indirect fluorescent-antibody assay; IgA, immunoglobulin A; IPAA, ileal pouch-anal anastomosis; NPV, negative predictive value; NSNA, neutrophil-specific nuclear auto-antibodies; OmpC, outer membrane porin C; pANCA, perinuclear ANCA; PPV, positive predictive value; UC, ulcerative colitis.

Table 3 Studies of serologic panels in predicting disease phenotype in Crohn’s disease

Study	Year	Design	Population	N	Serologic markersa	Key findings
Mow et al^Citation71	2004	Retrospective	Adult	303	ASCA, anti-OmpC, anti-I2	Anti-I2, anti-OmpC, and ASCA were each individually associated with IP/S disease or small bowel surgery Patients seropositive for anti-I2, anti-OmpC, and ASCA were more likely to develop complicated disease behavior than those with reactivity to 2, 1, or 0 markers (P ≤ 0.001) Percentage of patients with complicated disease increased with increasing magnitude of antibody response
Arnott et al^Citation72	2004	Retrospective	Adult	142	ASCA, anti-OmpC, anti-I2	Presence and magnitude of responses associated with small bowel disease (P = 0.02), disease progression (P < 0.001), perforating disease (P = 0.008), and surgery (P < 0.001)
Papadakis et al^Citation73	2007	Retrospective	Adult	731	ASCA, anti-OmpC, anti-I2, anti-CBir1	Confirmed that anti-CBir1 is independently associated with complicated CD phenotype (P = 0.0004) Proportion of patients with IP/S disease increased with increasing reactivity to all 4 antigens Addition of anti-CBir1 reactivity enhanced discrimination of CD phenotypes, particularly complicated disease (IP/S), small bowel involvement, and UC-like disease
Dubinsky et al^Citation74	2006	Prospective	Pediatric	196	ASCA, anti-OmpC, anti-I2, anti-CBir1	Anti-OmpC (P = 0.0006) and anti-I2 (P = 0.0034) were associated with IP/S disease Frequency of IP/S disease increased with increasing number of immune responses (P = 0.002) OR of developing IP/S disease was highest among children with all 4 immune markers (OR 11.0; 95% CI 1.5–80.4; P = 0.03)
Dubinsky et al^Citation75	2008	Prospective, longitudinal	Pediatric	796	ASCA, anti-OmpC, anti-CBir1	Frequency of IP/S disease and surgery increased significantly with both the number of immune responses (P < 0.0001) and magnitude of responses (P < 0.0001) Immune reactivity to OmpC and CBir1 and presence of ASCA were associated with faster progression to complicated disease and surgery, significantly faster than reactivity to 1 or 2 antigens (P < 0.0001) The magnitude of immune response also influences faster progression to complicated disease and surgery (P < 0.0001)
Ippoliti et alb,^Citation76	2009	Retrospective	Adolescent and adult	731	ASCA, CBir1, OmpC, 12, NOD2	NOD2 was associated with small bowel disease involvement (P < 0.001), fibrostenosing phenotype (P < 0.0001), history of small bowel surgery (P < 0.05), and inversely with UC-like phenotype (P < 0.01) The prevalence of fibrostenosis was significantly associated with the number of positive antibodies as well as QSS With combined serologic reactivity and NOD2 status, ORs for developing fibrostenotic disease were greater with presence of NOD2 variants and also increased with higher QSS

Notes:

a pANCA was measured in some studies but not calculated with the antibodies to determine cumulative association with aggressive disease;

b Ippoliti et al studied CD patients’ seroreactivity and their NOD2 status.

Abbreviations: ASCA, antibodies to Saccharomyces cerevisiae; CD, Crohn’s disease; CI, confidence interval; IP/S, internal-penetrating/stricturing disease; NOD2, nucleotide oligomerization domain 2; OmpC, outer membrane porin C; OR, odds ratio; QSS, quartile sum score; UC, ulcerative colitis.

Figure 2 Frequency of complicated small bowel disease, as represented by antibody quartile sum score. A summation score of 3–12 for antibody titers toward I2, OmpC, and ASCA was calculated and categorized into quartiles (QSS). Patients with higher sum scores had greater frequency of complicated course (fibrostenosing, penetrating, or small bowel disease, or need for surgery).

Copyright © 2008, Elsevier. Reproduced with permission from Mow et al.⁷¹

Note: *Denotes negative P trend.
Abbreviations: ASCA, antibodies to Saccharomyces cerevisiae; OmpC, outer membrane porin C; QSS, quartile sum score; UC, ulcerative colitis.

Figure 3 Kaplan–Meier plot estimates for internal-penetrating/stricturing disease and need for bowel surgery by QSS of antibody titers toward I2, OmpC, and ASCA among CD patients. The figure depicts a higher probability of maintaining a simple, noncomplicated disease course during prospective follow-up, among those patients who fall into the lower QSS groups (QSS groups 1 and 2) (A). Conversely, half of the patients in QSS group 3 required surgery within 100 months of follow-up (B).

Copyright © 2008, Elsevier. Reproduced with permission from Dubinsky et al.⁷⁵

Abbreviations: ASCA, antibodies to Saccharomyces cerevisiae; CD, Crohn’s disease; OmpC, outer membrane porin C; QSS, quartile sum score.

Table 4 Significant individual associations of antibody responses and NOD2/CARD15 genotype with Crohn’s disease phenotypes^71,89,97

Marker	Significant individual associations
	Small bowel involvement	Complicated CD phenotype^a	Small bowel surgery	UC-like behavior
ASCA	Yes	Yes	Yes	Yes (negative)
pANCA	Yes (negative)	Yes (negative)	Yes (negative)	Yes
Anti-I2	No	Yes	Yes	No
Anti-OmpC	No	Yes	Yes	No
Anti-CBir1	Yes	Yes	No	No
NOD2^b	Yes	Yes	No	Yes (negative)

Notes:

a Complicated CD phenotypes include fibrostenosing or internal-perforating disease;

b NOD2 is a CD susceptibility gene.

Abbreviations: ASCA, antibodies to Saccharomyces cerevisiae; CARD15, Caspase-activating recruitment domain 15; CD, Crohn’s disease; NOD2, nucleotide oligomerization domain 2; OmpC, outer membrane porin C; pANCA, perinuclear ANCA; UC, ulcerative colitis.

Figure 4 Frequency of carriage of NOD2/CARD15 variant relative to semiquantitative antibody reactivity, as represented by quartile sum (range 4–16). The dotted line represents the mean 31.8% frequency of carriage of at least one NOD2/CARD15 variant, across the entire cohort.

Copyright © 2007, Elsevier. Reproduced with permission from Devlin et al.¹¹¹

Abbreviations: NOD2, nucleotide oligomerization domain 2; CARD15, caspase-activating recruitment domain 15.

Table 5 Demonstration of synergism between NOD2 variants and antibody levels in fibrostenosis

Quartile	Presence of NOD2 variant?	Odds ratio (confidence limits)	Pvalue
4–6	No	Reference	Reference
	Yes	0.2 (0–1.2)
7–9	No	1.2 (0.6–2.2)	0.004
	Yes	2.7 (1.3–5.5)
10–13	No	3.3 (1.8–6.0)	0.003
	Yes	7.3 (3.7–14.4)
14–16	No	4.8 (2.3–10.1)	0.01
	Yes	9.6 (4.2–21.8)

Copyright © 2010, John Wiley & Sons, Inc. Reproduced with permission from Ippoliti et al.⁷⁶

Abbreviation: NOD2, nucleotide oligomerization domain 2.

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