In their recent paper, Lebwohl and colleagues report an interesting finding: persistent villous atrophy (VA) does not seem to be associated with increased mortality in coeliac disease (CD).
This conclusive statement is quite surprising. As already stated by the authors, CD patients are at risk of earlier death,[2, 3] and failure in mucosal healing has been thought to be the main factor.[4, 5] This study seems to call into question this consolidate hypothesis, and it deserves some comments from a clinical practice's point of view.
We know that histological recovery takes different times, according to the age when gluten-free diet (GFD) has started. In our experience, subdividing the patients according to age, only the younger patients (5–30 years) showed significant improvement of histology within 12 months (P < 0.034); older patients (>30 years) showed histological improvement, but this was not statistically significant, even after 24 months on a GFD.
Gluten-free diet is generally advised to CD patients for three main reasons: treating symptoms related to the disease; preventing immunological gluten-related disorders; and preventing neoplastic complications. GFD and adherence to diet are considered the key factors in obtaining mucosal healing and in preventing occurrence of complications.[7, 8] In our experience, the time to the occurrence of complications with GFD seems to be related to type of disease rather than to the severity of the histological lesion at the time of the diagnosis.
In fact, considering the time of appearance of complications after GFD had started, complications occurred after a mean/median time with GFD of 6.5/5 years [standard deviation (s.d.) ± 5.08] in classical CD, and after a mean/median time of 3.5/4 years (s.d. ± 1) in subclinical CD. However, looking at the compliance to GFD in patients developing complications, we found that 6/14 (42.9%) patients with classical CD were not fully compliant with GFD, whilst 2/4 (50%) of subclinical CD were not fully compliant (P = n.s.).
In light of our and Lebwohl's experience, should a GFD still be advised to prevent complications? Despite the retrospective design, Lebwohl's study calls into question whether and why an increased complication rate (increased mortality rate included) occurs in CD. Furthermore, confirmative and prospective studies are, therefore, welcomed.