Persistent villous atrophy predicts development of complications and mortality in adult patients with coeliac disease: a multicentre longitudinal cohort study and development of a score to identify high-risk patients

Over a median follow-up of 110 months, patients with persistent villous atrophy had significantly increased risk of complications (HR 9.53, 95% CI 4.77 to 19.04) and mortality (HR 2.93, 95% CI 1.43 to 6.02). Complications included type 1 and type 2 refractory coeliac disease, enteropathy-associated T-cell lymphoma, and other malignancies. A 5-point clinical score incorporating age at diagnosis ≥45 years, classical disease pattern, lack of clinical response to gluten-free diet, and poor gluten-free diet adherence was developed in cohort 1 and externally validated in cohort 2, achieving an AUC of 0.78 (95% CI 0.68 to 0.89). The study is limited by retrospective ascertainment, variable diagnostic methods across centres, selection bias as follow-up biopsies were not routine, and inability to measure minimal gluten exposure.