Celiac disease : how complicated can it get? Tjon, J.M.L.

Celiac disease : how complicated can it get?

Tjon, J.M.L.

Citation

Tjon, J. M. L. (2011, November 30). Celiac disease : how complicated can it get?. Retrieved from https://hdl.handle.net/1887/18156

Version: Corrected Publisher’s Version

License: Licence agreement concerning inclusion of doctoral thesis in the Institutional Repository of the University of Leiden

Downloaded from: https://hdl.handle.net/1887/18156

Note: To cite this publication please use the final published version (if

applicable).

C ^HAPTER 1

G ENERAL I NTRODUCTION

C ELIAC D ISEASE : H OW C OMPLICATED C AN I T G ET ?

Jennifer M-L. Tjon

, Jeroen van Bergen

and Frits Koning

1

Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands.

Immunogenetics. 2010 Oct; 62(10): 641-651

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͘ dŚĞƐĞ ĮŶĚŝŶŐƐ ĐĂŵĞ ƚŽŐĞƚŚĞƌ ǁŝƚŚ

ƚŚĞŽďƐĞƌǀĂƟŽŶƚŚĂƚϰ

dĐĞůůůŝŶĞƐĨƌŽŵĚƵŽĚĞŶĂůďŝŽƉƐŝĞƐŽĨƉĂƟĞŶƚƐƐƉĞĐŝĮĐĂůůLJ

ƌĞƐƉŽŶĚƚŽŐůƵƚĞŶƉĞƉƟĚĞƐƉƌĞƐĞŶƚĞĚďLJ,>ͲYϮĂŶĚͬŽƌ,>ͲYϴ

͘dŚĞĞƟŽůŽŐLJŽĨ

ZŝƐŵƵĐŚůĞƐƐĐůĞĂƌ͕ďƵƚƐĞĞŵƐƚŽďĞĂƐƐŽĐŝĂƚĞĚǁŝƚŚ,>ͲYϮ

͘

/Ŷ ƐŚŽƌƚ͕ ƚŚĞ ĐŽŵƉůĞdž ŝŶƚĞƌƉůĂLJ ŽĨ ŵƵůƟƉůĞ ŐĞŶĞƟĐ ĂŶĚ ĞŶǀŝƌŽŶŵĞŶƚĂů ĨĂĐƚŽƌƐ ǁŝůů

ĚĞƚĞƌŵŝŶĞƚŚĞĚĞǀĞůŽƉŵĞŶƚŽĨĂŶĚŝƚƐĐŽŵƉůŝĐĂƟŽŶƐ͘dŚŝƐƌĞǀŝĞǁĚĞƐĐƌŝďĞƐĐƵƌƌĞŶƚ

ŬŶŽǁůĞĚŐĞŽŶŐůƵƚĞŶ͕,>ͲYĂŶĚƚŚĞŝŵŵƵŶŽƉĂƚŚŽŐĞŶĞƐŝƐŽĨĂŶĚŝƚƐĐŽŵƉůŝĐĂƟŽŶƐ͘

/ŶĂĚĚŝƟŽŶ͕ǁĞƉƌĞƐĞŶƚĂůŝŬĞůLJƐĞƋƵĞŶĐĞŽĨĞǀĞŶƚƐŝŶƚŚĞĚĞǀĞůŽƉŵĞŶƚŽĨĂŶĚĚŝƐĐƵƐƐ

ƚŚĞĨĂĐƚŽƌƐƚŚĂƚŵĂLJŝŶŇƵĞŶĐĞƚŚĞƌŝƐŬŽĨĚĞǀĞůŽƉŵĞŶƚ͘

'½çã›Ä͗㫛—®Ý›ƒÝ›®Ä—瑮Ħ›Äò®ÙÊÄÛÄヽãÙ®¦¦›Ù

dŚĞǀŝƐĐŽͲĞůĂƐƟĐƉƌŽƉĞƌƟĞƐŽĨŐůƵƚĞŶĂƌĞĞƐƐĞŶƟĂůĨŽƌĚŽƵŐŚĨŽƌŵĂƟŽŶŽĨǁŚĞĂƚŇŽƵƌ

ĂŶĚŐŝǀĞďƌĞĂĚŝƚƐƵŶŝƋƵĞƚĞdžƚƵƌĞĂŶĚƚĂƐƚĞ͘ĞĐĂƵƐĞŽĨŝƚƐƵŶŝƋƵĞƉƌŽƉĞƌƟĞƐŐůƵƚĞŶŝƐ

ǁŝĚĞůLJƵƐĞĚŝŶƚŚĞĨŽŽĚŝŶĚƵƐƚƌLJ͗ŶŽƚŽŶůLJŝŶƉƌŽĚƵĐƚƐƚŚĂƚĂƌĞƌĞĂĚŝůLJĂƐƐŽĐŝĂƚĞĚǁŝƚŚ

ǁŚĞĂƚ͕ůŝŬĞďƌĞĂĚ͕ĐŽŽŬŝĞƐĂŶĚƉĂƐƚĂ͕ďƵƚĂůƐŽĂƐĂŚŝĚĚĞŶŝŶŐƌĞĚŝĞŶƚŝŶƐĂƵĐĞƐ͕ŝŶƐƚĂŶƚ

ƐŽƵƉƐĂŶĚĞǀĞŶŵĞĚŝĐĂƟŽŶ͘ŽŶƐĞƋƵĞŶƚůLJ͕ƚŚĞĚĂŝůLJŐůƵƚĞŶŝŶƚĂŬĞŽŶĂŐůƵƚĞŶͲĐŽŶƚĂŝŶŝŶŐ

ĚŝĞƚŝŶtĞƐƚĞƌŶͲƵƌŽƉĞĂŶĚƚŚĞhŶŝƚĞĚ^ƚĂƚĞƐŝƐŚŝŐŚ͕ďĞƚǁĞĞŶϭϱĂŶĚϮϬŐƌĂŵƉĞƌĚĂLJ͘

dŚĞŽŵŶŝƉƌĞƐĞŶĐĞŽĨŐůƵƚĞŶŵĂŬĞƐĂĚŚĞƌĞŶĐĞƚŽĂŐůƵƚĞŶͲĨƌĞĞĚŝĞƚĐŚĂůůĞŶŐŝŶŐĨŽƌ

ƉĂƟĞŶƚƐ͘

'ůƵƚĞŶŝƐĂŚĞƚĞƌŽŐĞŶĞŽƵƐŵŝdžƚƵƌĞŽĨŐůŝĂĚŝŶƐĂŶĚŐůƵƚĞŶŝŶƐŝŶǁŚĞĂƚŽƌƐŝŵŝůĂƌƉƌŽƚĞŝŶƐ

ŝŶďĂƌůĞLJĂŶĚƌLJĞ͘ĂĐŚǁŚĞĂƚǀĂƌŝĞƚLJĞdžƉƌĞƐƐĞƐŵƵůƟƉůĞɲͲ͕ɶͲĂŶĚʘͲŐůŝĂĚŝŶƐŝŶĂĚĚŝƟŽŶ

ƚŽůŽǁĂŶĚŚŝŐŚŵŽůĞĐƵůĂƌǁĞŝŐŚƚŐůƵƚĞŶŝŶƐ͘'ůƵƚĞŶŚĂƐĂǀĞƌLJŚŝŐŚĐŽŶƚĞŶƚŽĨƚŚĞĂŵŝŶŽͲ ĂĐŝĚƐŐůƵƚĂŵŝŶĞ;ϯϬйͿĂŶĚƉƌŽůŝŶĞ;ϭϱйͿ͘LJǀŝƌƚƵĞŽĨŝƚƐŚŝŐŚŐůƵƚĂŵŝŶĞĐŽŶƚĞŶƚŐůƵƚĞŶŝƐ

ƌŝĐŚŝŶŶŝƚƌŽŐĞŶ͕ĂŶĞƐƐĞŶƟĂůĨĂĐƚŽƌĨŽƌƐĞĞĚŐĞƌŵŝŶĂƟŽŶ͘dŚĞŚŝŐŚƉƌŽůŝŶĞĐŽŶƚĞŶƚƌĞŶĚĞƌƐ

ŐůƵƚĞŶŚŝŐŚůLJƌĞƐŝƐƚĂŶƚƚŽĚĞŐƌĂĚĂƟŽŶďLJŐĂƐƚƌŽŝŶƚĞƐƟŶĂůĞŶnjLJŵĞƐ͕ŵĂŬŝŶŐŝƚƉŽƐƐŝďůĞĨŽƌ

ůĂƌŐĞŝŵŵƵŶŽŐĞŶŝĐŐůƵƚĞŶƉĞƉƟĚĞƐƚŽƌĞĂĐŚƚŚĞŵƵĐŽƐĂůƐƵƌĨĂĐĞ

͘ƐŵŽĚĞƌŶǁŚĞĂƚ

ǀĂƌŝĞƟĞƐĐŽŶƚĂŝŶƚŚƌĞĞĐŽŵƉůĞƚĞŐĞŶŽŵĞƐĞŶĐŽĚŝŶŐŐůŝĂĚŝŶƐĂŶĚŐůƵƚĞŶŝŶƐ͕ƵƉƚŽϭϬϬ

ĚŝīĞƌĞŶƚŐůƵƚĞŶƉƌŽƚĞŝŶƐŵĂLJďĞƉƌĞƐĞŶƚŝŶĂƐŝŶŐůĞǁŚĞĂƚǀĂƌŝĞƚLJĂŶĚŵĂŶLJŽĨƚŚĞƐĞĂƌĞ

ŝŵƉůŝĐĂƚĞĚŝŶƚŚĞƉĂƚŚŽŐĞŶĞƐŝƐŽĨ͘

,>ͲY͗㫛ÝãÙÊĦ›Ý㗮ݛƒÝ›ͲƒÝÝʑ®ƒã›—¦›Ä›½Ê‘çݐù¥ƒÙ

dŚĞƐƚƌŽŶŐŐĞŶĞƟĐŝŶŇƵĞŶĐĞŝŶŝƐĂƉƉĂƌĞŶƚĂƐƚŚĞĐŽŶĐŽƌĚĂŶĐĞďĞƚǁĞĞŶŵŽŶŽnjLJŐŽƟĐ

ƚǁŝŶƐŝƐϴϬй͕ǁŚĞƌĞĂƐŝŶĚŝnjLJŐŽƟĐƚǁŝŶƐƚŚŝƐŝƐŽŶůLJϭϭй

͕ǁŚŝĐŚŝƐĂƉƉƌŽdžŝŵĂƚĞůLJƚŚĞ

ƐĂŵĞĂƐƚŚĞƌŝƐŬĨŽƌĮƌƐƚͲĚĞŐƌĞĞƌĞůĂƟǀĞƐ

͘dŚĞŵĂŝŶŐĞŶĞƟĐŝŶŇƵĞŶĐĞŝŶŝƐ,>͕

ǁŚŝĐŚǁĂƐĮƌƐƚŝŶĚŝĐĂƚĞĚďLJƐƚƵĚŝĞƐĚĞƐĐƌŝďŝŶŐƚŚĞƉƌĞĚŽŵŝŶĂŶĐĞŽĨ,>ͲϴĂŶĚ,>ͲZϯ

ƐĞƌŽƚLJƉĞƐŝŶƉĂƟĞŶƚƐ

͘>ĂƚĞƌƐƚƵĚŝĞƐĞƐƚĂďůŝƐŚĞĚƚŚĂƚƚŚĞƐƚƌŽŶŐĞƐƚĂƐƐŽĐŝĂƟŽŶŝƐ

ǁŝƚŚ,>ͲYϮ;YΎϬϱϬϭ͕YΎϬϮϬϭ͕ƚĞƌŵĞĚ,>ͲYϮ͘ϱŚĞƌĞĂŌĞƌͿ

͕ǁŚŝĐŚŝƐĞŶĐŽĚĞĚ

ƚŽŐĞƚŚĞƌǁŝƚŚ,>ͲϴĂŶĚ,>ͲZϯŽŶƚŚĞŚŝŐŚůLJĐŽŶƐĞƌǀĞĚĂŶĐĞƐƚƌĂůŚĂƉůŽƚLJƉĞϴ͘ϭ

͘

ŝƐĂƐƐŽĐŝĂƚĞĚƚŽĂůĞƐƐĞƌĞdžƚĞŶƚǁŝƚŚ,>ͲYϴ;YΎϬϯ͕YΎϬϯϬϮͿ

͘dŚĞƐƚƌŽŶŐ

ĂƐƐŽĐŝĂƟŽŶďĞƚǁĞĞŶ,>ͲYϮ͘ϱĂŶĚŝƐĨƵƌƚŚĞƌŝůůƵƐƚƌĂƚĞĚďLJƚŚĞŽďƐĞƌǀĂƟŽŶƚŚĂƚ

ϭϳ

«ƒÖã›Ù

=

ŝŶĚŝǀŝĚƵĂůƐŚŽŵŽnjLJŐŽƵƐĨŽƌ,>ͲYϮ͘ϱŚĂǀĞĂĮǀĞͲĨŽůĚŝŶĐƌĞĂƐĞĚƌŝƐŬĨŽƌĚĞǀĞůŽƉŵĞŶƚ

ŽĨ  ĐŽŵƉĂƌĞĚ ƚŽ ŝŶĚŝǀŝĚƵĂůƐ ŚĞƚĞƌŽnjLJŐŽƵƐ ĨŽƌ ,>ͲYϮ͘ϱ

͘ ^ŝŵŝůĂƌůLJ͕ ,>ͲY Ϯ͘ϱ

ŚŽŵŽnjLJŐŽƐŝƚLJ ŝƐ ĂƐƐŽĐŝĂƚĞĚ ǁŝƚŚ ƚŚĞ ĚĞǀĞůŽƉŵĞŶƚ ŽĨ Z // ĂŶĚ ZͲĂƐƐŽĐŝĂƚĞĚ

ůLJŵƉŚŽŵĂ͕ǁŚĞƌĞĂƐƚŚŝƐĂƐƐŽĐŝĂƟŽŶŝƐůĞƐƐĐůĞĂƌĨŽƌ,>ͲYϮ͘ϱŚĞƚĞƌŽnjLJŐŽƐŝƚLJĂŶĚ,>Ͳ

Yϴ

͘ŶŽƚŚĞƌ,>ͲYϮǀĂƌŝĂŶƚĞdžŝƐƚƐ͗,>ͲYϮ͘Ϯ;YΎϬϮϬϭ͕YΎϬϮϬϮͿǁŚŝĐŚŚĂƐ

ĂƉĞƉƟĚĞͲďŝŶĚŝŶŐŵŽƟĨƚŚĂƚŝƐĂůŵŽƐƚŝĚĞŶƟĐĂůƚŽƚŚĂƚŽĨ,>ͲYϮ͘ϱ

͘tŚĞƌĞĂƐ,>Ͳ

YϮ͘ϱƉƌĞĚŝƐƉŽƐĞƐƚŽ͕,>ͲYϮ͘ϮĚŽĞƐŶŽƚ͘dŚŝƐĚŝīĞƌĞŶĐĞŝƐƌĞůĂƚĞĚƚŽƚŚĞƉĞƉƟĚĞͲ ďŝŶĚŝŶŐƉƌŽƉĞƌƟĞƐŽĨƚŚĞƐĞ,>ͲYϮǀĂƌŝĂŶƚƐ͘dŚĞĞƐƟŵĂƚĞĚƌŝƐŬĞīĞĐƚŽĨ,>ͲYϮĂŶĚ

,>ͲYϴŽŶĚĞǀĞůŽƉŵĞŶƚŝƐĞƐƟŵĂƚĞĚƚŽďĞΕϯϱй

͘

EŽƚ Ăůů ,>ͲYϮ͘ϱ

 ĂŶĚ ,>ͲYϴ

 ŝŶĚŝǀŝĚƵĂůƐ ĚĞǀĞůŽƉ ͕ ŝŶĚŝĐĂƟŶŐ ƚŚĂƚ ƚŚĞƐĞ ,>Ͳ ŐĞŶŽƚLJƉĞƐ ĂƌĞ ŶĞĐĞƐƐĂƌLJ ďƵƚ ŶŽƚ ƐƵĸĐŝĞŶƚ ĨŽƌ  ĚĞǀĞůŽƉŵĞŶƚ͘ ZĞĐĞŶƚ ůĂƌŐĞͲƐĐĂůĞ

ŐĞŶĞƟĐĂƐƐŽĐŝĂƟŽŶƐƚƵĚŝĞƐŝĚĞŶƟĮĞĚŵĂŶLJĂĚĚŝƟŽŶĂůŐĞŶĞƟĐůŽĐŝƚŚĂƚĂůůŵĂŬĞĂƐŵĂůů

ĐŽŶƚƌŝďƵƟŽŶƚŽƚŚĞƌŝƐŬƚŽĚĞǀĞůŽƉ;ŽdžϭĂŶĚdĂďůĞϭͿ͘/ŵƉŽƌƚĂŶƚůLJ͕ŵŽƐƚŽĨƚŚĞƐĞ

ŐĞŶĞƐĞŶĐŽĚĞƉƌŽƚĞŝŶƐŝŶǀŽůǀĞĚŝŶŝŵŵƵŶŝƚLJǁŚŝĐŚƐƵƉƉŽƌƚƐƚŚĞŶŽƟŽŶƚŚĂƚŝƐĂŶ

ŝŵŵƵŶĞƌĞůĂƚĞĚĚŝƐŽƌĚĞƌĂŶĚƉŽƐƐŝďůLJƉƌŽǀŝĚĞƐĐůƵĞƐŽŶƚŚĞŝŵŵƵŶŽƉĂƚŚŽŐĞŶĞƐŝƐŽĨ͘

dƒ½›ϭ͘>ʑ®ƒÝÝʑ®ƒã›—ó®ã«—›ò›½ÊÖÛÄã͘ΎKĚĚƐƌĂƟŽƐĨƌŽŵƵďŽŝƐĞƚĂů͘^ϲϬ

ϭϴ

«ƒÖã›Ù

=

d«›ƒ—ƒÖã®ò›®ÃÃçěٛÝÖÊÄݛ͗¦½çã›Ä͕,>ͲYƒÄ—ϰ

d‘›½½Ý

ƐŶŽƚĞĚĂďŽǀĞ͕ĚĞǀĞůŽƉƐĂůŵŽƐƚĞdžĐůƵƐŝǀĞůLJŝŶ,>ͲYϮ͘ϱ

Žƌ,>ͲYϴ

ŝŶĚŝǀŝĚƵĂůƐ͘

/ƚŝƐĂůƐŽǁĞůůĞƐƚĂďůŝƐŚĞĚƚŚĂƚŝŶƉĂƟĞŶƚƐ͕ŐůƵƚĞŶͲĚĞƌŝǀĞĚƉĞƉƟĚĞƐƉƌĞƐĞŶƚĞĚďLJĞŝƚŚĞƌ

,>ͲYϮ͘ϱŽƌ,>ͲYϴŝŶĚƵĐĞĂϰ

dĐĞůůƌĞƐƉŽŶƐĞ͘ŽƚŚ,>ͲYϮ͘ϱĂŶĚ,>ͲYϴ

ƉƌĞĨĞƌƚŽďŝŶĚƉĞƉƟĚĞƐǁŝƚŚŶĞŐĂƟǀĞůLJĐŚĂƌŐĞĚĂŵŝŶŽĂĐŝĚƐĂƚĂŶĐŚŽƌƌĞƐŝĚƵĞƐ͘'ůƵƚĞŶ

ƉĞƉƟĚĞƐ͕ŚŽǁĞǀĞƌ͕ĂƌĞǀŝƌƚƵĂůůLJĚĞǀŽŝĚŽĨŶĞŐĂƟǀĞĐŚĂƌŐĞƐĂŶĚŶĂƟǀĞŐůƵƚĞŶƉĞƉƟĚĞƐ

ƚŚƵƐďŝŶĚƉŽŽƌůLJƚŽ,>ͲYϮ͘ϱŽƌ,>ͲYϴ͘ŽŶƐĞƋƵĞŶƚůLJ͕ϰ

dĐĞůůƐƐƉĞĐŝĮĐĨŽƌŶĂƟǀĞ

ŐůƵƚĞŶƉĞƉƟĚĞƐĂƌĞƌĂƌĞ͘/ƚŚĂƐďĞĐŽŵĞĐůĞĂƌƚŚĂƚƚŚĞĞŶnjLJŵĞƟƐƐƵĞƚƌĂŶƐŐůƵƚĂŵŝŶĂƐĞ

Ϯ ;d'ϮͿ ĐĂŶ ŵŽĚŝĨLJ ŐůƵƚĞŶ ƉĞƉƟĚĞƐ ƚŽ Įƚ ƚŚĞ ƌĞƋƵŝƌĞŵĞŶƚƐ ĨŽƌ ŚŝŐŚ ĂĸŶŝƚLJ ďŝŶĚŝŶŐ

ƚŽ ,>ͲYϮ ĂŶ ,>ͲYϴ

͘ d'Ϯ ĐĂŶ ĐŽŶǀĞƌƚ ŶŽŶͲĐŚĂƌŐĞĚ ŐůƵƚĂŵŝŶĞ ŝŶƚŽ ŶĞŐĂƟǀĞůLJ

ĐŚĂƌŐĞĚŐůƵƚĂŵŝĐĂĐŝĚ͕ĂƉƌŽĐĞƐƐĐĂůůĞĚĚĞĂŵŝĚĂƟŽŶ͘ĞĐĂƵƐĞŐůƵƚĞŶŚĂƐĂŚŝŐŚĐŽŶƚĞŶƚ

ŽĨ ŐůƵƚĂŵŝŶĞ ;YͿ ĂŶĚ ƉƌŽůŝŶĞ ;WͿ͕ ƚŚĞ ƐĞƋƵĞŶĐĞƐ YW͕ YyW ĂŶĚ YyyW ;ŝŶ ǁŚŝĐŚ y ĐĂŶ

ƌĞƉƌĞƐĞŶƚĂŶLJĂŵŝŶŽĂĐŝĚͿĂƌĞĨƌĞƋƵĞŶƚůLJĨŽƵŶĚŝŶŐůƵƚĞŶƉĞƉƟĚĞƐ͘^ƚƌŝŬŝŶŐůLJ͕ŽŶůLJŝŶƚŚĞ

ƐĞƋƵĞŶĐĞYyWƚŚĞŐůƵƚĂŵŝŶĞŝƐĐŽŶǀĞƌƚĞĚ͕ǁŚŝĐŚƌĞƐƵůƚƐŝŶŚŝŐŚůLJƐĞůĞĐƟǀĞŝŶƚƌŽĚƵĐƟŽŶ

ŽĨŶĞŐĂƟǀĞĐŚĂƌŐĞƐŝŶŐůƵƚĞŶƉĞƉƟĚĞƐ

͘dŚŝƐƐƉĞĐŝĮĐĚĞĂŵŝĚĂƟŽŶƉƌŽĐĞƐƐŝŶƚƌŽĚƵĐĞƐƚŚĞ

ŶĞŐĂƟǀĞĐŚĂƌŐĞƐĂƚƚŚĞƉŽƐŝƟŽŶƐĨĂǀŽƌĞĚďLJ,>ͲYϮĂŶĚ,>ͲYϴ͕ƚŚĞƌĞďLJĞdžƉĂŶĚŝŶŐ

ƚŚĞƉƌĞƐĞŶƚĂďůĞŐůƵƚĞŶƉĞƉƟĚĞƌĞƉĞƌƚŽŝƌĞ;&ŝŐƵƌĞϮͿ͘ƐĂƌĞƐƵůƚ͕ƚŚĞŐůƵƚĞŶͲƐƉĞĐŝĮĐϰ

$ dĐĞůůƌĞƉĞƌƚŽŝƌĞŝƐƐƵďƐƚĂŶƟĂůůLJĞdžƉĂŶĚĞĚǁŚŝĐŚĞŶŚĂŶĐĞƐƚŚĞŝŶŇĂŵŵĂƟŽŶĂŶĚĚŝƐĞĂƐĞ

ĚĞǀĞůŽƉŵĞŶƚ;&ŝŐƵƌĞϮͿ͘

d'ϮŝƐŵŽƐƚůLJƌĞƚĂŝŶĞĚŝŶƚƌĂĐĞůůƵůĂƌůLJŝŶĂŶŝŶĂĐƟǀĞĨŽƌŵĂŶĚŝƐĂĐƟǀĂƚĞĚƵƉŽŶŝƚƐƌĞůĞĂƐĞ

ĚƵƌŝŶŐ ƟƐƐƵĞ ĚĂŵĂŐĞ

͘ dŚĞƌĞĨŽƌĞ͕ ƐŽŵĞƚŚŝŶŐ ƐŚŽƵůĚ ƚƌŝŐŐĞƌ ƟƐƐƵĞ ĚĂŵĂŐĞ ǁŚŝĐŚ

ŝŶŝƟĂƚĞƐd'ϮƌĞůĞĂƐĞ͕ĂůůŽǁŝŶŐƚŚĞŵŽĚŝĮĐĂƟŽŶŽĨŐůƵƚĞŶƉĞƉƟĚĞƐ͘tŚĞƌĞĂƐϰ

$5$/"66$

ƌĞƐƉŽŶƐĞƐĂŐĂŝŶƐƚŶĂƟǀĞŐůƵƚĞŶƉĞƉƟĚĞƐĂƌĞƌĞůĂƟǀĞůLJƌĂƌĞ͕ƚŚĞLJĐŽƵůĚƌĞƉƌĞƐĞŶƚƚŚĞ

ĮƌƐƚďƌĞĂĐŚŝŶŽƌĂůƚŽůĞƌĂŶĐĞƚŽŐůƵƚĞŶ͘dŚĞƉƌĞƐĞŶƚĂƟŽŶŽĨŶĂƟǀĞŐůƵƚĞŶƉĞƉƟĚĞƐďLJ

,>ͲYϮŽƌ,>ͲYϴƚŽϰ

dĐĞůůƐǁŝůůůĞĂĚƚŽƚŚĞƉƌŽĚƵĐƟŽŶŽĨ/&EͲɶ;&ŝŐƵƌĞϮͿ͘/&EͲɶ

ǁŝůůŝŶƚƵƌŶůĞĂĚƚŽŚŝŐŚĞƌĞdžƉƌĞƐƐŝŽŶŽĨƚŚĞ,>ͲYŵŽůĞĐƵůĞƐĂŶĚƚŚĞƌĞďLJƚŽŝŶĐƌĞĂƐĞĚ

ŐůƵƚĞŶƉĞƉƟĚĞƉƌĞƐĞŶƚĂƟŽŶ;&ŝŐƵƌĞϮͿ͘/ŶƚŚĞƉƌĞƐĞŶĐĞŽĨŐůƵƚĞŶ͕ƚŚŝƐĐŽƵůĚďĞĐŽŵĞĂ

ƐĞůĨͲĂŵƉůŝĨLJŝŶŐůŽŽƉƚŚĂƚĐŽƵůĚĐĂƵƐĞůŝŵŝƚĞĚƟƐƐƵĞĚĂŵĂŐĞůŽĐĂůůLJ͘dŚŝƐƟƐƐƵĞĚĂŵĂŐĞ

ǁŽƵůĚůĞĂĚƚŽƚŚĞƌĞůĞĂƐĞŽĨd'ϮƚŚĂƚǁŝůůŵŽĚŝĨLJŶĂƟǀĞŐůƵƚĞŶƉĞƉƟĚĞƐŝŶƚŽŚŝŐŚĂĸŶŝƚLJ

ůŝŐĂŶĚƐ ĨŽƌ ,>ͲYϮ ĂŶĚͬŽƌ ,>ͲYϴ͕ ƚŚĞƌĞďLJ ĞdžƉĂŶĚŝŶŐ ƚŚĞ ŐůƵƚĞŶͲƐƉĞĐŝĮĐ ϰ

$ 5$

Box 1. Non-HLA genes associated with CD

Candidate gene association study: Candidate genes, selected on the basis of current understanding of CD immunopathology, were tested for association with CD. Genes studied with this approach include, among others, IFN-γ, FAS, TCR, and TG2

. No convincing association with CD was found.

Genetic linkage study: This approach is aimed at the identification of chromosomal regions that likely contain disease-causing genes in families with a high prevalence of CD. The genomic region 2q33 showed linkage to CD in multiple populations. This region contains the genes CD28, CTLA4 and ICOS which all control different aspects of the T cell response

. Linkage was also found for chromosome 5q31-33

and chromosome 19p13.1

. Linkage to these regions, however, could not always be replicated in other populations.

Genome-wide association study (GWAS): In recent years it has become possible to perform large-scale case

control-based association studies using single nucleotide polymorphisms (SNPs). With this approach it is possible

to identify common variants in the genome that predispose to disease. Until now, 10 non-HLA loci associated

with CD have been identified and linkage to 2q33 has been confirmed (Table 1)

. Recently, 13 additional

true risk variants and 13 suggestive risk variants were identified

. Although causality has only been proven for

the risk allele SH2B3

, it is clear that nearly all associated regions contain genes involved in immune response.

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ĚĞĂŵŝĚĂƟŽŶďLJd'Ϯ͘

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E<ƌĞĐĞƉƚŽƌƐĂŶĚƚŚĞĂďŝůŝƚLJƚŽůLJƐĞƐƚƌĞƐƐĞĚĞƉŝƚŚĞůŝĂůĐĞůůƐŝŶĚĞƉĞŶĚĞŶƚŽĨdĐĞůůƌĞĐĞƉƚŽƌ

ƐŝŐŶĂůŝŶŐ͕ǁŚŝĐŚůŝŬĞůLJĐŽŶƚƌŝďƵƚĞƐƚŽƚŚĞƚLJƉŝĐĂůƟƐƐƵĞĚĂŵĂŐĞŝŶ͘

/ŶZ͕ƚŚĞƐƵƌǀŝǀĂů͕ĞdžƉĂŶƐŝŽŶĂŶĚĂĐƋƵŝƐŝƟŽŶŽĨĂŶE<ĐĞůůͲůŝŬĞƉŚĞŶŽƚLJƉĞďLJ/>ƐŝƐ

ĞǀĞŶŵŽƌĞƉƌŽŶŽƵŶĐĞĚƚŚĂŶŝŶ͕ƉŽƐƐŝďůLJĂƐĂƌĞƐƵůƚŽĨƚŚĞƉƌĞƐĞŶĐĞŽĨůĂƌŐĞƌĂŵŽƵŶƚƐ

ŽĨ/>Ͳϭϱ͘Z//ƉĂƟĞŶƚƐŚĂǀĞĂŶĂďĞƌƌĂŶƚĐůŽŶĂů/>ƉŽƉƵůĂƟŽŶƚŚĂƚůĂĐŬƐƐƵƌĨĂĐĞdZͲ

ϯĞdžƉƌĞƐƐŝŽŶ͘^ƚƵĚŝĞƐŽŶĂďĞƌƌĂŶƚdZͲϯ

/>ůŝŶĞƐĨƌŽŵZ//ƉĂƟĞŶƚƐƐŚŽǁĞĚƚŚĂƚ͕

ƵƉŽŶƐƟŵƵůĂƟŽŶǁŝƚŚ/>Ͳϭϱ͕ƚŚĞƐĞĐĞůůůŝŶĞƐĞdžƉƌĞƐƐŐƌĂŶnjLJŵĞĂŶĚůLJƐĞƚŚĞŝŶƚĞƐƟŶĂů

ĞƉŝƚŚĞůŝĂůĐĞůůůŝŶĞ,dϮϵ͕ƐƵŐŐĞƐƟŶŐĂƌŽůĞĨŽƌĂďĞƌƌĂŶƚ/>ƐŝŶƉĞƌƉĞƚƵĂƟŶŐĞƉŝƚŚĞůŝĂů

ĚĂŵĂŐĞŝŶZ//

͘dŚĞƌĞĨŽƌĞ͕/>ͲϭϱĚĞƉĞŶĚĞŶƚE<ĐĞůůͲůŝŬĞƚƌĂŶƐĨŽƌŵĂƟŽŶŽĨ/>ƐŵĂLJ

ďĞĂŶĞƐƐĞŶƟĂůƐƚĞƉŝŶƚŚĞŝŵŵƵŶŽƉĂƚŚŽůŽŐLJŽĨZ͘

&®¦çٛ ϯ͘ ÙÊÝÝヽ» ›ãó››Ä 㫛 ϰ¹ d ‘›½½ ٛÝÖÊÄݛ ƒÄ— /> ‘ùãÊãÊø®‘®ãù͘ dŚĞ ϰ⁴

$ 5$ /"66$

ƌĞƐƉŽŶƐĞ ƚŽ ŐůƵƚĞŶ ŵĂLJ ůĞĂĚ ƚŽ /&EͲɶ ƉƌŽĚƵĐƟŽŶ ĂŶĚ ƉŽƚĞŶƟĂůůLJ ƚŽ ƵƉƌĞŐƵůĂƟŽŶ ŽĨ />Ͳϭϱ͕ ǁŚŝĐŚ ŝŶ

ƚƵƌŶ ƐƚƐ />ͲŵĞĚŝĂƚĞĚ ĐLJƚŽƚŽdžŝĐŝƚLJ͘ ĐƟǀĂƚĞĚ />Ɛ ůLJƐĞ ƚŚĞ ĞƉŝƚŚĞůŝƵŵ͕ ǁŚŝĐŚ ůĞĂĚƐ ƚŽ d'Ϯ ƌĞůĞĂƐĞ

ĂŶĚ ƐƵďƐĞƋƵĞŶƚ ĚĞĂŵŝĚĂƟŽŶ ŽĨ ŐůƵƚĞŶ ƉĞƉƟĚĞƐ͘ dŚŝƐ ŵĂLJ ĐŽŶƐƟƚƵƚĞ LJĞƚ ĂŶŽƚŚĞƌ ƐĞůĨͲĂŵƉůŝĨLJŝŶŐ

ĨĞĞĚďĂĐŬ ůŽŽƉ͕ ĂƐ ĚĞĂŵŝĚĂƟŽŶ ŽĨ ŐůƵƚĞŶ ƉĞƉƟĚĞƐ ǁŝůů ĞŶŚĂŶĐĞ ƚŚĞ ϰ

 d ĐĞůů ƌĞƐƉŽŶƐĞ ;ƐĞĞ &ŝŐƵƌĞ ϮͿ͘

Ϯϭ

«ƒÖã›Ù

=

Box 2. IL-15

IL-15 is a cytokine that, just as IL-2, is able to induce T cell proliferation, IFN-γ production and cytotoxicity. Furthermore, IL- 15 is known to play an important role in NK cell development and activation

. Under normal circumstances, IL-15 expression is strictly regulated at the level of transcription, translation and secretion

. In CD this regulation is disrupted, which results in massive upregulation of IL-15 in the epithelium and lamina propria. The abnormal availability of IL-15 results in chronic inflammation by survival, proliferation and activation of IELs

. Furthermore, IL-15 can exert an inhibitory effect on TGF-β, a negative regulator of the immune response

. Recently it has been shown that IL-15 can synergize with IL-21, a cytokine expressed on CD4+ T cells and a stimulator of IFN-γ production and cytolytic activity of CD8+ T cells and NK cells

.

ã«Ù›Ý«Ê½—Ãʗ›½¥ÊÙ㫛ٮݻÊ¥—›ò›½ÊÖÛÄã

dŚĞ ĞdžƉĂŶƐŝŽŶ ŽĨ ƚŚĞ ƉƌĞƐĞŶƚĂďůĞ ŐůƵƚĞŶ ƉĞƉƟĚĞ ƌĞƉĞƌƚŽŝƌĞ ĚƵĞ ƚŽ ƚŚĞ ƌĞůĞĂƐĞ ĂŶĚ

ĂĐƟǀŝƚLJŽĨd'ϮŝƐĂĐƌŝƟĐĂůƐƚĞƉŝŶƚŚĞƉĂƚŚŽŐĞŶĞƐŝƐŽĨĨƵůůͲďůŽǁŶ͘^ĞǀĞƌĂůůŝŶĞƐŽĨ

ĞǀŝĚĞŶĐĞ ƐƵƉƉŽƌƚ ƚŚĞ ŶŽƟŽŶ ƚŚĂƚ ƚŚĞ ůĞǀĞů ŽĨ ŐůƵƚĞŶ ƉƌĞƐĞŶƚĂƟŽŶ ƚŽ d ĐĞůůƐ ĐƌŝƟĐĂůůLJ

ŝŶŇƵĞŶĐĞƐƚŚĞƌŝƐŬŽĨĚŝƐĞĂƐĞĚĞǀĞůŽƉŵĞŶƚ͘

&ŝƌƐƚ͕,>ͲYϮ͘ϱŚŽŵŽnjLJŐŽƵƐŝŶĚŝǀŝĚƵĂůƐŚĂǀĞĂĮǀĞͲĨŽůĚŚŝŐŚĞƌƌŝƐŬŽĨĚĞǀĞůŽƉŵĞŶƚ

ƚŚĂŶ ,>ͲYϮ͘ϱ ŚĞƚĞƌŽnjLJŐŽƵƐ ŝŶĚŝǀŝĚƵĂůƐ

͘ dŚŝƐ ŐĞŶĞ ĚŽƐĞ ĞīĞĐƚ ĚŝƌĞĐƚůLJ ĐŽƌƌĞůĂƚĞƐ

ǁŝƚŚ ƚŚĞ ŵĂŐŶŝƚƵĚĞ ŽĨ ƚŚĞ ϰ

 d ĐĞůů ƌĞƐƉŽŶƐĞ͗ ĂŶƟŐĞŶ ƉƌĞƐĞŶƟŶŐ ĐĞůůƐ ;WͿ ĨƌŽŵ

,>ͲYϮ͘ϱ ŚŽŵŽnjLJŐŽƵƐ ŝŶĚŝǀŝĚƵĂůƐ ŝŶĚƵĐĞ ǀĞƌLJ ƐƚƌŽŶŐ ƉƌŽůŝĨĞƌĂƟǀĞ d ĐĞůů ƌĞƐƉŽŶƐĞƐ

ĂŶĚ/&EɶƉƌŽĚƵĐƟŽŶ͕ǁŚŝůĞWĨƌŽŵ,>ͲYϮ͘ϱͬYyŚĞƚĞƌŽnjLJŐŽƵƐŝŶĚŝǀŝĚƵĂůƐŝŶĚƵĐĞ

ŵƵĐŚǁĞĂŬĞƌƌĞƐƉŽŶƐĞƐ

͘dŚĞƐĞĚĂƚĂŝŶĚŝĐĂƚĞƚŚĂƚƚŚĞŶƵŵďĞƌŽĨ,>ͲYϮ͘ϱŵŽůĞĐƵůĞƐ

ĐĂƉĂďůĞŽĨƉƌĞƐĞŶƟŶŐŐůƵƚĞŶƉĞƉƟĚĞƐŽŶƚŚĞƐƵƌĨĂĐĞŽĨWǁŝůůĚĞĮŶĞƚŚĞŵĂŐŶŝƚƵĚĞ

ŽĨƚŚĞϰ

dĐĞůůƌĞƐƉŽŶƐĞ͘

^ĞĐŽŶĚ͕ǁŚĞƌĞĂƐ,>ͲYϮ͘ϱŝƐĂƐƐŽĐŝĂƚĞĚǁŝƚŚĚĞǀĞůŽƉŵĞŶƚ͕ƚŚĞŚŽŵŽůŽŐŽƵƐ,>Ͳ

YϮ͘ϮŝƐŶŽƚ͘ůƚŚŽƵŐŚƚŚĞƐĞƚǁŽǀĂƌŝĂŶƚƐŚĂǀĞĂůŵŽƐƚŝĚĞŶƟĐĂůƉĞƉƟĚĞďŝŶĚŝŶŐŵŽƟĨƐ͕

,>ͲYϮ͘ϮĐĂŶŽŶůLJďŝŶĚĂƐƵďƐĞƚŽĨƚŚĞŐůƵƚĞŶƉĞƉƟĚĞƐƚŚĂƚĐĂŶďŝŶĚƚŽ,>ͲYϮ͘ϱ͘

dŚŝƐĚŝīĞƌĞŶĐĞŝƐĞdžƉůĂŝŶĞĚďLJƚŚĞĨĂĐƚƚŚĂƚĂƉƌŽůŝŶĞĂƚƉŽƐŝƟŽŶϯŝŶƉĞƉƟĚĞƐŚĂǀĞĂŶ

ĂĚǀĞƌƐĞĞīĞĐƚŽŶƉĞƉƟĚĞďŝŶĚŝŶŐƚŽ,>ͲYϮ͘Ϯ

͘ƐŐůƵƚĞŶĞƉŝƚŽƉĞƐĐůƵƐƚĞƌŝŶƉƌŽůŝŶĞͲ ƌŝĐŚ ƌĞŐŝŽŶƐ

͕ ŵĂŶLJ ŐůƵƚĞŶ ƉĞƉƟĚĞƐ ŚĂǀĞ Ă ƉƌŽůŝŶĞ Ăƚ ƉŽƐŝƟŽŶ ϯ ĂŶĚ ĚŽ ŶŽƚ ďŝŶĚ ƚŽ

,>ͲYϮ͘Ϯ

͘ ŽŶƐĞƋƵĞŶƚůLJ͕ ,>ͲYϮ͘ϱ ŝƐ ĂďůĞ ƚŽ ƉƌĞƐĞŶƚ Ă ŵƵĐŚ ďƌŽĂĚĞƌ ƌĞƉĞƌƚŽŝƌĞ

ŽĨŐůƵƚĞŶƉĞƉƟĚĞƐƚŚĂŶ,>ͲYϮ͘Ϯ͘/ŶĂĚĚŝƟŽŶ͕,>ͲYϮ͘ϱŝƐďĞƩĞƌĂƚƌĞƚĂŝŶŝŶŐŐůƵƚĞŶ

ƉĞƉƟĚĞƐ ŝŶ ŝƚƐ ďŝŶĚŝŶŐ ŐƌŽŽǀĞ ĐŽŵƉĂƌĞĚ ƚŽ ,>ͲYϮ͘Ϯ

͘ Ɛ Ă ƌĞƐƵůƚ͕ ŐůƵƚĞŶ ƉĞƉƟĚĞ

ƉƌĞƐĞŶƚĂƟŽŶďLJ,>ͲYϮ͘ϱŝƐƉƌŽƚƌĂĐƚĞĚĐŽŵƉĂƌĞĚƚŽƉƌĞƐĞŶƚĂƟŽŶďLJ,>ͲYϮ͘ϮǁŚŝĐŚ

ǁŝůůŝŶĐƌĞĂƐĞƚŚĞĐŚĂŶĐĞĨŽƌƉƌŽĚƵĐƟǀĞϰ

dĐĞůůƐƟŵƵůĂƟŽŶ͘

dŚŝƌĚ͕ŝƐĂƐƐŽĐŝĂƚĞĚŵĂŝŶůLJǁŝƚŚ,>ͲYϮ͘ϱĂŶĚƚŽĂůĞƐƐĞƌĞdžƚĞŶƚǁŝƚŚ,>ͲYϴ͘

ůƚŚŽƵŐŚĂǀĂƌŝĞƚLJŽĨŐůƵƚĞŶƉĞƉƟĚĞƐŚĂƐďĞĞŶŝĚĞŶƟĮĞĚƚŚĂƚĐĂŶƐƟŵƵůĂƚĞ,>ͲYϴ

ƌĞƐƚƌŝĐƚĞĚ d ĐĞůůƐ ĨƌŽŵ  ƉĂƟĞŶƚƐ͕ ŽŶĞ ɲͲŐůŝĂĚŝŶ ƉĞƉƟĚĞ ŝŶ ƉĂƌƟĐƵůĂƌ ĂƉƉĞĂƌƐ ƚŽ ďĞ

ŝŵŵƵŶŽĚŽŵŝŶĂŶƚ ĂƐ ƚŚŝƐ ƉĞƉƟĚĞ ŝŶǀĂƌŝĂďůLJ ŝŶĚƵĐĞƐ ƐƉĞĐŝĮĐ d ĐĞůů ƌĞƐƉŽŶƐĞƐ ŝŶ ,>Ͳ

Yϴ

  ƉĂƟĞŶƚƐ

;<ŽŽLJ Ğƚ Ăů͘ ƵŶƉƵďůŝƐŚĞĚ ĚĂƚĂͿ͘ /Ŷ ĐŽŶƚƌĂƐƚ ƚŽ ƚŚĞ ,>ͲYϮ͘ϱ

ƌĞƐƚƌŝĐƚĞĚɲͲŐůŝĂĚŝŶƉĞƉƟĚĞƐ͕ƚŚĞ,>ͲYϴƉĞƉƟĚĞŝƐŶŽƚĚĞƌŝǀĞĚĨƌŽŵĂƉƌŽůŝŶĞͲƌŝĐŚ

ƌĞŐŝŽŶ ŽĨ ƚŚĞ ɲͲŐůŝĂĚŝŶ ƉƌŽƚĞŝŶ ĂŶĚ ƚŚĞƌĞĨŽƌĞ ůŝŬĞůLJ ƐƵƐĐĞƉƟďůĞ ƚŽ ĚĞŐƌĂĚĂƟŽŶ ŝŶ ƚŚĞ

ŐĂƐƚƌŽŝŶƚĞƐƟŶĂů ƚƌĂĐƚ͘ &ƵƌƚŚĞƌŵŽƌĞ͕ ǁŚĞƌĞĂƐ ĨŽƌ ,>ͲYϮ Ă ƐŝŶŐůĞ ĚĞĂŵŝĚĂƟŽŶ ŝŶ Ă

ŐůƵƚĞŶƉĞƉƟĚĞŝƐƐƵĸĐŝĞŶƚƚŽĞǀŽŬĞĂϰ

dĐĞůůƌĞƐƉŽŶƐĞ͕ĨŽƌ,>ͲYϴĚĞĂŵŝĚĂƟŽŶĂƚ

ƚǁŽƉŽƐŝƟŽŶƐŝƐƉƌĞĨĞƌƌĞĚ

͕ǁŚŝĐŚŵĂLJůŝŵŝƚƚŚĞŐĞŶĞƌĂƟŽŶŽĨƐƚƌŽŶŐĂŶƟŐĞŶŝĐŐůƵƚĞŶ

ƉĞƉƟĚĞƐ͘dŚĞĨĂĐƚƚŚĂƚƚŚĞŝŵŵƵŶŽĚŽŵŝŶĂŶƚ,>ͲYϴƉĞƉƟĚĞŝƐŵŽƌĞƌĞĂĚŝůLJĚĞŐƌĂĚĞĚ

ϮϮ

«ƒÖã›Ù

=

ĂŶĚƌĞƋƵŝƌĞƐŵŽƌĞĚĞĂŵŝĚĂƟŽŶƐƚĞƉƐ͕ůŝŵŝƚƐƚŚĞĂǀĂŝůĂďŝůŝƚLJĨŽƌĂŶƟŐĞŶƉƌĞƐĞŶƚĂƟŽŶĂŶĚ

ŵĂLJƚŚĞƌĞĨŽƌĞůŝŵŝƚƚŚĞƌŝƐŬƚŽĚĞǀĞůŽƉ͘

&ŽƵƌƚŚ͕ ĨƵƌƚŚĞƌ ĞǀŝĚĞŶĐĞ ƚŚĂƚ ƚŚĞ ůĞǀĞů ŽĨ ŐůƵƚĞŶ ƉƌĞƐĞŶƚĂƟŽŶ ŝƐ Ă ĐƌŝƟĐĂů ƉĂƌĂŵĞƚĞƌ

ĐŽŵĞƐĨƌŽŵĂƚŽƚĂůůLJĚŝīĞƌĞŶƚĂŶŐůĞ͗ŵŽƐƚƉĂƟĞŶƚƐƚŽůĞƌĂƚĞŽĂƚĞǀĞŶƚŚŽƵŐŚŝƚŚĂƐ

ďĞĞŶƐŚŽǁŶƚŚĂƚƚŚĞŐůƵƚĞŶͲůŝŬĞŵŽůĞĐƵůĞƐŝŶŽĂƚĐĂŶĞůŝĐŝƚϰ

dĐĞůůƌĞƐƉŽŶƐĞƐŝŶ

ƉĂƟĞŶƚƐ

dŚĞƌĞĂƌĞƚǁŽƐƚƌŝŬŝŶŐĚŝīĞƌĞŶĐĞƐďĞƚǁĞĞŶƚŚĞƌĞůĂƟǀĞůLJƐĂĨĞŽĂƚĂŶĚƚŚĞ

ĚŝƐĞĂƐĞŝŶĚƵĐŝŶŐĐĞƌĞĂůƐǁŚĞĂƚ͕ďĂƌůĞLJĂŶĚƌLJĞ͗;ϭͿǁŚŝůĞƚŚĞŐůƵƚĞŶͲůŝŬĞŵŽůĞĐƵůĞƐŝŶ

ŽĂƚĐŽŶƚĂŝŶŽŶůLJƚǁŽĂŶƟŐĞŶŝĐƐĞƋƵĞŶĐĞƐ͕ĚŽnjĞŶƐĂƌĞĨŽƵŶĚŝŶŐůƵƚĞŶĂŶĚƚŚĞŐůƵƚĞŶͲůŝŬĞ

ŵŽůĞĐƵůĞƐŽĨďĂƌůĞLJĂŶĚƌLJĞ͕;ϮͿƚŚĞ͞ŐůƵƚĞŶ͟ĐŽŶƚĞŶƚŽĨŽĂƚŝƐŵƵĐŚůŽǁĞƌĐŽŵƉĂƌĞĚƚŽ

ƚŚĞŽƚŚĞƌĐĞƌĞĂůƐ͘ŽŶƐƵŵƉƟŽŶŽĨŽĂƚƚŚƵƐƌĞƐƵůƚƐŝŶĂŵƵĐŚůŽǁĞƌĞdžƉŽƐƵƌĞƚŽĂŶƟŐĞŶŝĐ

ƉĞƉƟĚĞƐŝŶĐŽŵƉĂƌŝƐŽŶǁŝƚŚƚŚĞŽƚŚĞƌĐĞƌĞĂůƐĂŶĚƚŚŝƐŝƐĂƉƉĂƌĞŶƚůLJƚŽůĞƌĂƚĞĚĂƐŝƚĚŽĞƐ

ŶŽƚůĞĂĚƚŽĚŝƐĞĂƐĞŝŶƚŚĞŵĂũŽƌŝƚLJŽĨƉĂƟĞŶƚƐ͘

ŽůůĞĐƟǀĞůLJ͕ƚŚĞƐĞĚĂƚĂŝŶĚŝĐĂƚĞƚŚĞƉƌĞƐĞŶĐĞŽĨĂƚŚƌĞƐŚŽůĚƚŽĚĞǀĞůŽƉ͘/ŶŝƟĂƟŽŶŽĨ

ďĞĐŽŵĞƐŵŽƌĞůŝŬĞůLJǁŝƚŚŝŶĐƌĞĂƐĞĚdĐĞůůĞdžƉŽƐƵƌĞƚŽŐůƵƚĞŶĂŶƟŐĞŶƐ͘dŚŝƐĞdžƉŽƐƵƌĞ

ŝƐŝŶŇƵĞŶĐĞĚďLJƚŚĞƚLJƉĞĂŶĚĂŵŽƵŶƚŽĨ,>ͲYĂƐƚŚŝƐĚĞƚĞƌŵŝŶĞƐƚŚĞĞĸĐŝĞŶĐLJŽĨ

ŐůƵƚĞŶƉĞƉƟĚĞƉƌĞƐĞŶƚĂƟŽŶƚŽϰ

dĐĞůůƐ͘&Žƌ,>ͲYϮ͘ϱŚŽŵŽnjLJŐŽƵƐŝŶĚŝǀŝĚƵĂůƐ͕ƚŚĞ

ƚŚƌĞƐŚŽůĚƚŽĚĞǀĞůŽƉŝƐŵŽƐƚĞĂƐŝůLJĞdžĐĞĞĚĞĚ͕ǁŚĞƌĞĂƐĨŽƌ,>ͲYϮ͘Ϯ

ĂŶĚ,>ͲYϴ

ŝŶĚŝǀŝĚƵĂůƐƚŚĞƚŚƌĞƐŚŽůĚŝƐŵƵĐŚŚŝŐŚĞƌ͘

—›ò›½ÊÖÛÄã͗ƒݛٮ›ÝÊ¥çÄ¥ÊÙãçăã››ò›ÄãÝ

dŚĞƉĂƐƚƚǁŽĚĞĐĂĚĞƐŚĂǀĞǁŝƚŶĞƐƐĞĚƚŚĞŝĚĞŶƟĮĐĂƟŽŶŽĨƐĞǀĞƌĂůĐƌŝƟĐĂůŝŵŵƵŶŽůŽŐŝĐĂů

ĨĂĐƚŽƌƐŝŶ͕ĨƌŽŵǁŚŝĐŚĂůŝŬĞůLJƐĞƋƵĞŶĐĞŽĨĞǀĞŶƚƐŝŶƚŚĞĚĞǀĞůŽƉŵĞŶƚŽĨƚŚŝƐĚŝƐĞĂƐĞ

ĐĂŶďĞĚĞĚƵĐĞĚ͘/ƚŝƐǁĞůůŬŶŽǁŶƚŚĂƚŚĞĂůƚŚLJŝŶĚŝǀŝĚƵĂůƐĐĂŶŚĂǀĞĂŶƟďŽĚŝĞƐĂŐĂŝŶƐƚ

ŶĂƟǀĞŐůƵƚĞŶƉĞƉƟĚĞƐ͘ƐĂŶĂŶƟďŽĚLJƌĞƐƉŽŶƐĞŝƐĐŽŶƚƌŽůůĞĚďLJϰ

dĐĞůůŚĞůƉ͕ƐƵĐŚ

ŝŶĚŝǀŝĚƵĂůƐŵŽƐƚůŝŬĞůLJŚĂǀĞϰ

dĐĞůůƐƐƉĞĐŝĮĐĨŽƌŶĂƟǀĞŐůƵƚĞŶƉĞƉƟĚĞƐ͕ŝŶĚŝĐĂƟŶŐƚŚĂƚ

ƚŚĞŵĞƌĞƉƌĞƐĞŶĐĞŽĨƐƵĐŚdĐĞůůƐŝƐ͕ŝŶŐĞŶĞƌĂů͕ŶŽƚƐƵĸĐŝĞŶƚƚŽĞdžĐĞĞĚƚŚĞƚŚƌĞƐŚŽůĚƚŽ

ĚĞǀĞůŽƉ;&ŝŐƵƌĞϰͿ͘dŚŝƐŝŶĚŝĐĂƚĞƐƚŚĂƚŝŶƚŚĞŵĂũŽƌŝƚLJŽĨŝŶĚŝǀŝĚƵĂůƐ͕ƚŽůĞƌŽŐĞŶŝĐĂŶĚ

ƌĞŐƵůĂƚŽƌLJƉƌŽĐĞƐƐĞƐŝŶƚŚĞŝŶƚĞƐƟŶĞŬĞĞƉŐůƵƚĞŶͲƐƉĞĐŝĮĐdĐĞůůƌĞƐƉŽŶƐĞƐŝŶĐŚĞĐŬ͘dŚŝƐ

ƐƚĞĂĚLJƐƚĂƚĞĐĂŶďĞďƌĞĂĐŚĞĚďLJĨƌĞƋƵĞŶƚĞƉŝƐŽĚĞƐŽĨĞŶƚĞƌŽǀŝƌĂůŝŶĨĞĐƟŽŶƐĂƐƚŚŝƐůĞĂĚƐ

ƚŽ ƚŚĞ ƐĞĐƌĞƟŽŶ ŽĨ ŝŶŇĂŵŵĂƚŽƌLJ ĐLJƚŽŬŝŶĞƐ ĂŶĚ ĚŝīĞƌĞŶƟĂƟŽŶ ŽĨ dŚϭ ĐĞůůƐ

͕ ƚŚĞƌĞďLJ

ĞŶŚĂŶĐŝŶŐƚŚĞƌĞƐƉŽŶƐĞƚŽŐůƵƚĞŶ;&ŝŐƵƌĞϰͿ͘^ƵďƐĞƋƵĞŶƚůLJ͕ƚŚĞĐŽŵďŝŶĞĚĞīĞĐƚŽĨůŽǁͲ ůĞǀĞůŐůƵƚĞŶƌĞĂĐƟǀŝƚLJĂŶĚƉĂƚŚŽŐĞŶŝŶĚƵĐĞĚŝŶŇĂŵŵĂƟŽŶĐŽƵůĚůĞĂĚƚŽƟƐƐƵĞĚĂŵĂŐĞ

ĂŶĚƚŚĞƌĞůĞĂƐĞŽĨd'Ϯ͘/ŶƚƵƌŶ͕ƚŚĞĂĐƟǀŝƚLJŽĨd'ϮǁŽƵůĚŐĞŶĞƌĂƚĞĂůĂƌŐĞƌĞƉĞƌƚŽŝƌĞŽĨ

ĚĞĂŵŝĚĂƚĞĚŐůƵƚĞŶƉĞƉƟĚĞƐǁŝƚŚŚŝŐŚĂĸŶŝƚLJĨŽƌ,>ͲY͕ƚŚĞƌĞďLJƐƟŶŐƚŚĞŐůƵƚĞŶͲ ƐƉĞĐŝĮĐdĐĞůůƌĞƐƉŽŶƐĞ;&ŝŐƵƌĞϰͿ͘ƚƚŚŝƐƉŽŝŶƚŝŶĚĞǀĞůŽƉŵĞŶƚ͕ƐĞůĨͲĂŵƉůŝĨLJŝŶŐůŽŽƉƐ

ĂƌĞŝŶĂĐƟŽŶ͗ϰ

dĐĞůůƌĞƐƉŽŶƐĞƐĂŐĂŝŶƐƚŶĂƟǀĞŐůƵƚĞŶƉĞƉƟĚĞƐůĞĂĚƚŚƌŽƵŐŚ/&EͲɶ

ƉƌŽĚƵĐƟŽŶƚŽƵƉƌĞŐƵůĂƟŽŶŽĨ,>ĂŶĚĨƵƌƚŚĞƌĂŵƉůŝĮĐĂƟŽŶŽĨƚŚĞŐůƵƚĞŶͲƐƉĞĐŝĮĐdĐĞůů

ƌĞƐƉŽŶƐĞ͘ d'Ϯ ƌĞůĞĂƐĞĚ ƵƉŽŶ ƟƐƐƵĞ ĚĂŵĂŐĞ ĞdžƉĂŶĚƐ ƚŚĞ ƉƌĞƐĞŶƚĂďůĞ ŐůƵƚĞŶ ƉĞƉƟĚĞ

ƌĞƉĞƌƚŽŝƌĞ ǁŚŝĐŚ ǁŝůů ƵůƟŵĂƚĞůLJ ůĞĂĚ ƚŽ ŵŽƌĞ ƟƐƐƵĞ ĚĂŵĂŐĞ ;&ŝŐƵƌĞ ϮͿ͘ ƵĞ ƚŽ ƚŚĞ

ŵĂƐƐŝǀĞĞdžƉĂŶƐŝŽŶŽĨƚŚĞŐůƵƚĞŶͲƐƉĞĐŝĮĐdĐĞůůƉŽŽů͕ƌĞŐƵůĂƚŽƌLJƉƌŽĐĞƐƐĞƐĂƌĞŶŽůŽŶŐĞƌ

ĂďůĞ ƚŽ ĐŽŶƚĂŝŶ ƚŚĞ d ĐĞůů ƌĞƐƉŽŶƐĞƐ͕ ĂŶĚ ĞdžƉŽƐƵƌĞ ƚŽ ŐůƵƚĞŶ ƐƵĸĐĞƐ ƚŽ ƉĞƌƉĞƚƵĂƚĞ

ŝŶŇĂŵŵĂƟŽŶ͘ůŝŵŝŶĂƟŶŐŐůƵƚĞŶĨƌŽŵƚŚĞĚŝĞƚŝƐƚŚĞŽŶůLJǁĂLJƚŽƐƚŽƉƚŚŝƐƉƌŽĐĞƐƐ͘ƚ

ĂůůƐƚĂŐĞƐŝŶƚŚŝƐƐĐĞŶĂƌŝŽƚŚĞƌŝƐŬƚŽĚĞǀĞůŽƉŝƐŝŶŇƵĞŶĐĞĚďLJƚŚĞ,>ͲYŐĞŶŽƚLJƉĞ

ĂƐ ,>ͲYϮ͘ϱ ŚŽŵŽnjLJŐŽƵƐ ŝŶĚŝǀŝĚƵĂůƐ ǁŝůů ƉƌĞƐĞŶƚ ŵŽƌĞ ,>ͲŐůƵƚĞŶ ĐŽŵƉůĞdžĞƐ ƚŚĂŶ

,>ͲYϮ͘ϱŚĞƚĞƌŽnjLJŐŽƵƐŝŶĚŝǀŝĚƵĂůƐ;&ŝŐƵƌĞϰͿ͘^ŝŵƵůƚĂŶĞŽƵƐůLJ͕ĂŶŝŶĮůƚƌĂƚĞŽĨ/>ƐŝƐ

ĨŽƌŵĞĚŝŶƚŚĞĞƉŝƚŚĞůŝƵŵ͕ǁŚŝĐŚŝƐƉŽƚĞŶƟĂůůLJĚƌŝǀĞŶďLJƚŚĞŝŶŇĂŵŵĂƚŽƌLJŵŝůŝĞƵĐƌĞĂƚĞĚ

Ϯϯ

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&®¦çٛ ϰ͘ d«Ù›Ý«Ê½— Ãʗ›½ ¥ÊÙ  —›ò›½ÊÖÛÄã͘ Ɛ ,>ͲYϮ͘ϱ ŚŽŵŽnjLJŐŽƵƐ ŝŶĚŝǀŝĚƵĂůƐ ĐĂŶ ƉƌĞƐĞŶƚ

ŵŽƌĞŐůƵƚĞŶƉĞƉƟĚĞƐŽŶƚŚĞŝƌWƚŚĂŶ,>ͲYϮ͘ϱŚĞƚĞƌŽnjLJŐŽƵƐŝŶĚŝǀŝĚƵĂůƐ͕,>ͲYϮ͘ϱŚŽŵŽnjLJŐŽƚĞƐŚĂǀĞ

ĂŚŝŐŚĞƌƌŝƐŬŽĨĚĞǀĞůŽƉŵĞŶƚĂƉƌŝŽƌŝ͘/ŶƐƚĞĂĚLJƐƚĂƚĞĐŽŶĚŝƟŽŶƐ͕ƉƌĞƐĞŶƚĂƟŽŶŽĨŶĂƟǀĞŐůƵƚĞŶƉĞƉƟĚĞƐ

ŝƐƵŶůŝŬĞůLJƚŽŝŶĚƵĐĞĚŝƐĞĂƐĞ͘dŚŝƐƐƚĞĂĚLJƐƚĂƚĞĐĂŶďĞďƌĞĂĐŚĞĚďLJĨƌĞƋƵĞŶƚǀŝƌĂůŝŶĨĞĐƟŽŶƐĂŶĚůŽǁͲŐƌĂĚĞ

d ĐĞůů ƌĞƐƉŽŶƐĞƐ ƚŽ ŶĂƟǀĞ ŐůƵƚĞŶ ƉĞƉƟĚĞƐ ƚŚĂƚ ůĞĂĚ ƚŽ ƌĞůĞĂƐĞ ŽĨ d'Ϯ ƵƉŽŶ ƟƐƐƵĞ ĚĂŵĂŐĞ͘ d'Ϯ ĂĐƟǀŝƚLJ

ǁŝůů ĞdžƉĂŶĚ ƚŚĞ ƉƌĞƐĞŶƚĂďůĞ ŐůƵƚĞŶ ƉĞƉƟĚĞ ƌĞƉĞƌƚŽŝƌĞ ĞdžƚĞŶƐŝǀĞůLJ͕ ƚŚĞƌĞďLJ ŝŶĐƌĞĂƐŝŶŐ ƚŚĞ ƌŝƐŬ ƚŽ ĚĞǀĞůŽƉ

͘ dŚĞ ƌĞĐĞŶƚůLJ ƵŶĐŽǀĞƌĞĚ ŶŽŶͲ,> ŐĞŶĞƐ ĂƐƐŽĐŝĂƚĞĚ ǁŝƚŚ  ůŝŬĞůLJ ůŽǁĞƌ ƚŚĞ ƚŚƌĞƐŚŽůĚ ƚŽ ĚĞǀĞůŽƉ ͘

ďLJϰ

dĐĞůůƐŝŶƚŚĞůĂŵŝŶĂƉƌŽƉƌŝĂ͘dŚĞƐĞ/>ƐƵƉƌĞŐƵůĂƚĞĂĐƟǀĂƟŶŐE<ĐĞůůƌĞĐĞƉƚŽƌƐ

ĂŶĚĂĐƋƵŝƌĞƚŚĞĂďŝůŝƚLJƚŽůLJƐĞĞŶƚĞƌŽĐLJƚĞƐŝŶĚĞƉĞŶĚĞŶƚŽĨƚŚĞdZ͘

dŚĞĚĞǀĞůŽƉŵĞŶƚŽĨĨƵůůͲďůŽǁŶŝƐŵŽƐƚůŝŬĞůLJƚŚĞƌĞƐƵůƚŽĨĂŶƵŶĨŽƌƚƵŶĂƚĞƐĞƌŝĞƐŽĨ

ĞǀĞŶƚƐǁŚŝĐŚ͕ŝŶŝƐŽůĂƟŽŶ͕ǁŽƵůĚŶŽƚůĞĂĚƚŽĚŝƐĞĂƐĞ͕ďƵƚ͕ĐŽŵďŝŶĞĚŚĂǀĞĂĚĞƚƌŝŵĞŶƚĂů

ŽƵƚĐŽŵĞ͘/ƚŝƐŝŵƉŽƌƚĂŶƚƚŽŶŽƚĞƚŚĂƚĞdžƉŽƐƵƌĞƚŽŐůƵƚĞŶ͕ĨƌĞƋƵĞŶƚĞŶƚĞƌŽǀŝƌĂůŝŶĨĞĐƟŽŶƐ

ĂŶĚŽĐĐĂƐŝŽŶĂůd'ϮĂĐƟǀĂƟŽŶůŝŬĞůLJŽĐĐƵƌŝŶĞǀĞƌLJŝŶĚŝǀŝĚƵĂůďƵƚƵƐƵĂůůLJĚŽŶŽƚƌĞƐƵůƚŝŶ

ĚĞǀĞůŽƉŵĞŶƚ͕ĞǀĞŶŝŶ,>ͲYϮ

ĂŶĚͬŽƌ,>ͲYϴ

ŝŶĚŝǀŝĚƵĂůƐ;&ŝŐƵƌĞϭͿ͘/ƚŚĂƐŶŽǁ

ďĞĐŽŵĞĐůĞĂƌƚŚĂƚƚŚĞƉƌĞƐĞŶĐĞŽĨĂŚŝŐŚĞƌŶƵŵďĞƌŽĨĂĚĚŝƟŽŶĂůŶŽŶͲ,>ƌŝƐŬĂůůĞůĞƐ

;dĂďůĞϭͿŝƐĚŝƌĞĐƚůLJĐŽƌƌĞůĂƚĞĚǁŝƚŚĂŶŝŶĐƌĞĂƐĞŝŶƚŚĞƌŝƐŬƚŽĚĞǀĞůŽƉ

͘dŚŝƐƐƵŐŐĞƐƚƐ

ƚŚĂƚƚŚĞŝŶŇƵĞŶĐĞŽĨŶŽŶͲ,>ŐĞŶĞƐůŽǁĞƌƐƚŚĞƚŚƌĞƐŚŽůĚƚŽĚĞǀĞůŽƉĂŶĚĐŽƵůĚƐŬĞǁ

ƚŚĞďĂůĂŶĐĞƚŽǁĂƌĚƐĚŝƐĞĂƐĞĚĞǀĞůŽƉŵĞŶƚ;&ŝŐƵƌĞϰͿ͘/ƚŝƐƉůĂƵƐŝďůĞƚŚĂƚŶŽŶͲ,>ŐĞŶĞƐ

ĂůƐŽŝŶĐƌĞĂƐĞƚŚĞƌŝƐŬƚŽĚĞǀĞůŽƉĐŽŵƉůŝĐĂƚĞĚ͕ĂůƚŚŽƵŐŚƚŚŝƐŚLJƉŽƚŚĞƐŝƐǁŝůůďĞĚŝĸĐƵůƚ

ƚŽƚĞƐƚĂƐƚŚŝƐƉĂƟĞŶƚƉŽƉƵůĂƟŽŶŝƐǀĞƌLJƐŵĂůů͘dŚƵƐ͕ĞǀĞŶƚŚŽƵŐŚŬĞLJƉŝĞĐĞƐŽĨƚŚĞĐĞůŝĂĐ

ƉƵnjnjůĞŚĂǀĞďĞĞŶĐŽůůĞĐƚĞĚĂŶĚĂƐƐĞŵďůĞĚ͕ƚŚĞƉŝĐƚƵƌĞŝƐŶŽƚLJĞƚĐŽŵƉůĞƚĞ͘

Ϯϰ

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ůƚŚŽƵŐŚƚŚĞŵŽůĞĐƵůĂƌďĂƐŝƐĨŽƌƚŚĞŝŶǀŽůǀĞŵĞŶƚŽĨ,>ͲYŝŶŝƐŶŽǁǁĞůůĞƐƚĂďůŝƐŚĞĚ͕

ĂŶƵŵďĞƌŽĨŝƐƐƵĞƐƌĞŵĂŝŶƵŶĐůĞĂƌ͘

&ŝƌƐƚ͕ŝƚŝƐƐƟůůĐŽŶƚƌŽǀĞƌƐŝĂůŚŽǁŝŵŵƵŶŽŐĞŶŝĐŐůƵƚĞŶƉĞƉƟĚĞƐĨƌŽŵƚŚĞŝŶƚĞƐƟŶĂůůƵŵĞŶ

ƌĞĂĐŚ ƚŚĞ ůĂŵŝŶĂ ƉƌŽƉƌŝĂ ǁŚĞƌĞ ƚŚĞLJ ĐĂŶ ƉƌŝŵĞ ŐůƵƚĞŶͲƐƉĞĐŝĮĐ d ĐĞůůƐ͘ /ƚ ŚĂƐ ďĞĞŶ

ƐƵŐŐĞƐƚĞĚƚŚĂƚŐůƵƚĞŶƉĞƉƟĚĞƐĐĂŶďĞƚƌĂŶƐƉŽƌƚĞĚĚƵƌŝŶŐƚƌĂŶƐŝĞŶƚŝŶĐƌĞĂƐĞĚŝŶƚĞƐƟŶĂů

ƉĞƌŵĞĂďŝůŝƚLJĚƵƌŝŶŐĞŶƚĞƌŽǀŝƌĂůŝŶĨĞĐƟŽŶƐ

ŽƌďLJ/ŐͲŵĞĚŝĂƚĞĚƌĞƚƌŽƚƌĂŶƐĐLJƚŽƐŝƐ

͘zĞƚ͕

ƚŚŝƐŝƐƐƵĞŝƐĨĂƌĨƌŽŵƌĞƐŽůǀĞĚ͘

^ĞĐŽŶĚ͕ Ă ĚŝƌĞĐƚ ĞīĞĐƚ ŽĨ ŐůƵƚĞŶ ŽŶ ƚŚĞ ŝŶƚĞƐƟŶĂů ŵƵĐŽƐĂ ŚĂƐ ďĞĞŶ ĂƩƌŝďƵƚĞĚ ƚŽ Ă

ƉĞƉƟĚĞĨƌŽŵɲͲŐůŝĂĚŝŶ͕ƉϯϭͲϰϵ;ŽdžϯͿ͘/ƚƌĞŵĂŝŶƐƵŶĐůĞĂƌ͕ŚŽǁĞǀĞƌ͕ǁŚĞƚŚĞƌĂŶĚŚŽǁ

ƚŚŝƐƉĞƉƟĚĞǁŽƵůĚĞdžĞƌƚŝƚƐĂĐƟǀŝƚLJĂŶĚĐŽŶƚƌŝďƵƚĞƚŽƚŚĞĚŝƐĞĂƐĞĚĞǀĞůŽƉŵĞŶƚ;ŽdžϯͿ͘

dŚŝƌĚ͕d'ϮŝƐĂĐƌƵĐŝĂůĨĂĐƚŽƌŝŶĞdžƉĂŶĚŝŶŐƚŚĞƉƌĞƐĞŶƚĂďůĞŐůƵƚĞŶƉĞƉƟĚĞƌĞƉĞƌƚŽŝƌĞ͘

/ŶƐƚĞĂĚLJƐƚĂƚĞĐŽŶĚŝƟŽŶƐ͕d'ϮŝƐƉƌĞƐĞŶƚŝŶĂŶŝŶĂĐƟǀĞĨŽƌŵŝŶƚƌĂĐĞůůƵůĂƌĂŶĚŽŶƚŚĞ

ĐĞůůƐƵƌĨĂĐĞ͘ŶŝŶƚƌŝŐƵŝŶŐƋƵĞƐƟŽŶŝƐƚŚĞƌĞĨŽƌĞ͕ŚŽǁd'ϮŝƐĂĐƟǀĂƚĞĚĂŶĚƌĞůĞĂƐĞĚŝŶ

͘tĞƉƌŽƉŽƐĞƚŚĂƚd'ϮŝƐƌĞůĞĂƐĞĚƵƉŽŶƟƐƐƵĞĚĂŵĂŐĞŝŶĚƵĐĞĚďLJƚŚĞŝŶŝƟĂůϰ

$ dĐĞůůƌĞƐƉŽŶƐĞƚŽŶĂƟǀĞŐůƵƚĞŶƉĞƉƟĚĞƐ;&ŝŐƵƌĞϮĂŶĚϯͿ͘ůƚĞƌŶĂƟǀĞůLJ͕ĂƌĞĐĞŶƚƐƚƵĚLJ

ƉƌŽƉŽƐĞĚĂƌŽůĞĨŽƌd>ZϯůŝŐĂŶĚƐƌĞůĞĂƐĞĚĚƵƌŝŶŐĞŶƚĞƌŽǀŝƌĂůŝŶĨĞĐƟŽŶƐƚŚĂƚƵƉŽŶůŝŐĂƟŽŶ

ǁŝƚŚ d>Zϯ ĐŽƵůĚ ƌĞƐƵůƚ ŝŶ d'Ϯ ĂĐƟǀĂƟŽŶ

͘ dŚĞƐĞ ƚǁŽ ƉŽƐƐŝďŝůŝƟĞƐ ĂƌĞ ŶŽƚ ŵƵƚƵĂůůLJ

ĞdžĐůƵƐŝǀĞ͘

&ŽƵƌƚŚ͕ŝŶĂĐƟǀĞ͕ĚŝƐƌƵƉƚĞĚ/>ͲϭϱƌĞŐƵůĂƟŽŶƌĞƐƵůƚƐŝŶŵĂƐƐŝǀĞŽǀĞƌĞdžƉƌĞƐƐŝŽŶŽĨ/>Ͳ ϭϱ͘/ƚƌĞŵĂŝŶƐƵŶĐůĞĂƌǁŚĂƚĐĂƵƐĞƐƚŚŝƐĚŝƐƌƵƉƟŽŶ͘ƐŽŶĂŐůƵƚĞŶͲĨƌĞĞĚŝĞƚƚŚĞĂĚĂƉƟǀĞ

ϰ

dĐĞůůƌĞƐƉŽŶƐĞĂŶĚ/>ͲϭϱĞdžƉƌĞƐƐŝŽŶďŽƚŚĚĞĐƌĞĂƐĞ

͕ŝƚŝƐƉŽƐƐŝďůĞƚŚĂƚƚŚĞĂĚĂƉƟǀĞ

ϰ

 d ĐĞůů ƌĞƐƉŽŶƐĞ ŚĂƐ Ă ĚŝƌĞĐƚ ĞīĞĐƚ ŽŶ />Ͳϭϱ ĞdžƉƌĞƐƐŝŽŶ ;&ŝŐƵƌĞ ϯͿ͘ ůƚĞƌŶĂƟǀĞůLJ͕

ŝŶŶĂƚĞƐŝŐŶĂůƐĚĞůŝǀĞƌĞĚƚŚƌŽƵŐŚd>ZƐŵĂLJďĞƌĞƐƉŽŶƐŝďůĞĨŽƌĞůĞǀĂƚĞĚ/>ͲϭϱůĞǀĞůƐ͘

&ŝŶĂůůLJ͕ƚŚĞĞǀĞŶƚƐůĞĂĚŝŶŐĨƌŽŵƵŶĐŽŵƉůŝĐĂƚĞĚƚŽZ//ĂŶĚƐƵďƐĞƋƵĞŶƚůLJŵƉŚŽŵĂ

ĚĞǀĞůŽƉŵĞŶƚĂƌĞƐƟůůƉŽŽƌůLJƵŶĚĞƌƐƚŽŽĚ͘>LJŵƉŚŽŵĂĐĞůůƐĚĞǀĞůŽƉĨƌŽŵƚŚĞĂďĞƌƌĂŶƚ/>Ɛ

ŝŶZ//͘KŶĞǀŝĞǁŝƐƚŚĂƚĂďĞƌƌĂŶƚ/>ƐĚĞƌŝǀĞĨƌŽŵŵĂƚƵƌĞdZ

/>ƐƚŚĂƚŚĂǀĞƵŶĚĞƌŐŽŶĞ

ŽůŝŐŽĐůŽŶĂů ĞdžƉĂŶƐŝŽŶ ĂŶĚ ůŽƐƚ ƐƵƌĨĂĐĞ dZͲϯ ĞdžƉƌĞƐƐŝŽŶ ĚƵĞ ƚŽ ŽǀĞƌƐƟŵƵůĂƟŽŶ

͘

ůƚĞƌŶĂƟǀĞůLJ͕ĂďĞƌƌĂŶƚ/>ƐĐŽƵůĚĚĞƌŝǀĞĨƌŽŵĂĚŝƐƟŶĐƚƉŽƉƵůĂƟŽŶŽĨϯ

ϳ

ƉƌĞĐƵƌƐŽƌ

ĐĞůůƐƚŚĂƚĐĂŶĚĞǀĞůŽƉŝŶƚŽdĐĞůůƐĂŶĚE<ĐĞůůƐ

͘/ŶĨĂǀŽƌŽĨƚŚĞĮƌƐƚŚLJƉŽƚŚĞƐŝƐ͗ĂůƚŚŽƵŐŚ

Box 3. Direct effects of gluten

The role of gluten in the adaptive immune response in CD is well established. In addition, a direct (innate) effect of gluten

on the intestinal mucosa has been suggested. One of the first indications for the potential of gluten to elicit a response

in the epithelium came from in vivo challenges where administration of gliadin caused villous atrophy and increase

of IELs within 2-3 hours after gluten ingestion

. This effect was later attributed to the non-immunodominant peptide

p31-49 from alpha-gliadin

. In vitro studies with p31-49 showed that epithelial alterations were independent of CD4

T cell activation. Furthermore, p31-49 stimulated IL-15 production in the lamina propria of cultured biopsies from CD

patients

. The fact that p31-49 could activate the local immune system implied that a receptor for p31-49 should exist. A

transcellular transport pathway was proposed where anti-gliadin IgA antibodies were able to bind p31-49. This complex

would then bind the transferrin receptor CD71 which would provide protected trafficking across the intestinal epithelium

.

However, this mechanism would not function in all CD patients as a relatively large fraction of them is IgA deficient

.

We also assessed the hypothesis that a receptor for p31-49 is present on intestinal epithelial cells. Binding of p31-49 to

intestinal epithelial cell lines, however, could not be detected, neither directly nor by either UV-crosslinking or TG2

induced transamidation (Tjon et al. unpublished data). In the absence of a receptor through which p31-43 could exert

its activity, the molecular mechanism underlying the biological effects observed with this peptide remains unclear.

Ϯϱ

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ĚŝƐƉůĂLJdZͲɶŐĞŶĞƌĞĂƌƌĂŶŐĞŵĞŶƚƐ

͘&ƵƌƚŚĞƌŵŽƌĞ͕ŵŝĐƌŽĂƌƌĂLJĂŶĂůLJƐŝƐŝŶŽŶĞƐƚƵĚLJŽŶ

dZͲϯ

/>ůŝŶĞƐĨƌŽŵƉĂƟĞŶƚƐƌĞǀĞĂůĞĚĂƐŝŐŶŝĮĐĂŶƚĚĞĐƌĞĂƐĞŝŶƚŚĞƚƌĂŶƐĐƌŝƉƚůĞǀĞůƐ

ŽĨdZɲͲĂŶĚdZɴͲĐŚĂŝŶƐ

͕ŝŶĚŝĐĂƟŶŐƚŚĂƚ/>ƐŵĂLJůŽǁĞƌdZĞdžƉƌĞƐƐŝŽŶŝŶ͘tĞ

ĨŽƵŶĚƚŚĂƚĂďĞƌƌĂŶƚ/>ƐŶŽƚŽŶůLJĞdžƉƌĞƐƐϯɸŝŶƚƌĂĐĞůůƵůĂƌůLJ͕ďƵƚĂůƐŽŚĂǀĞŝŶƚƌĂĐĞůůƵůĂƌ

ĞdžƉƌĞƐƐŝŽŶ ŽĨ ƚŚĞ ϯɶ͕ ϯɷ ĂŶĚ ɺͲĐŚĂŝŶƐ

͘ /Ŷ ĨĂǀŽƌ ŽĨ ƚŚĞ ƐĞĐŽŶĚ ŚLJƉŽƚŚĞƐŝƐ͗ ƚŚĞ

dZͲĐŚĂŝŶƐǁĞƌĞŶŽƚĂůǁĂLJƐƉƌĞƐĞŶƚ

ĂŶĚdZͲƌĞĂƌƌĂŶŐĞŵĞŶƚƐǁĞƌĞŽŌĞŶŝŶĐŽŵƉůĞƚĞ

;dũŽŶĞƚ͘Ăů͘ƵŶƉƵďůŝƐŚĞĚĚĂƚĂͿ͘&ƵƌƚŚĞƌŵŽƌĞ͕ƚŚĞĨƵůůĐŽŵƉůĞŵĞŶƚŽĨϯĐŚĂŝŶƐĂŶĚ

ŝŶĐŽŵƉůĞƚĞ dZ ƌĞĂƌƌĂŶŐĞŵĞŶƚƐ ŚĂǀĞ ĂůƐŽ ďĞĞŶ ŽďƐĞƌǀĞĚ ŝŶ E< ĐĞůů ƉƌĞĐƵƌƐŽƌƐ͕ ĂŶĚ

ĞǀĞŶŵĂƚƵƌĞE<ĐĞůůƐĐĂŶĐĂƌƌLJƉĂƌƟĂůůLJƌĞĂƌƌĂŶŐĞĚdZƐ͘ƌĞĐĞŶƚƐƚƵĚLJŝŶĚŝĐĂƚĞĚƚŚĂƚ

ĞdžƚƌĂƚŚLJŵŝĐdZŐĞŶĞƌĞĂƌƌĂŶŐĞŵĞŶƚŝƐĂŶŽŶŐŽŝŶŐĞǀĞŶƚŝŶƚŚĞŚƵŵĂŶƐŵĂůůŝŶƚĞƐƟŶĞ

ƚŚƌŽƵŐŚŽƵƚůŝĨĞ

͘dŚŝƐƌĂŝƐĞƐƚŚĞƉŽƐƐŝďŝůŝƚLJƚŚĂƚĂďĞƌƌĂŶƚ/>ƐĚĞƌŝǀĞĨƌŽŵĐĞůůƐŝŶĂŶ

ĞĂƌůLJƐƚĂŐĞŽĨĞdžƚƌĂƚŚLJŵŝĐůLJŵƉŚŽĐLJƚĞĚĞǀĞůŽƉŵĞŶƚ͘

Êđ½ç—®Ä¦ٛÃٻÝ

>ŝĨĞ ƵƐĞĚ ƚŽ ďĞ ƐŝŵƉůĞ͗  ǁĂƐ Ă ƌĂƌĞ ĚŝƐĞĂƐĞ͕ ĚŝĂŐŶŽƐĞĚ ŝŶ ϭ ŝŶ Ă ϭϬϬϬ ŝŶĚŝǀŝĚƵĂůƐ͘

WĂƟĞŶƚƐǁĞƌĞ,>ͲYϮ

Žƌ,>ͲYϴ

ĂŶĚĐŽƵůĚďĞƚƌĞĂƚĞĚĞīĞĐƟǀĞůLJǁŝƚŚĂŐůƵƚĞŶͲĨƌĞĞ

ĚŝĞƚ͘dŚĂƚǁĂƐĂďŽƵƚŝƚ͘

EŽǁǁĞŬŶŽǁƚŚĂƚĂīĞĐƚƐΕϭйŽĨƚŚĞƉŽƉƵůĂƟŽŶŝŶtĞƐƚĞƌŶƵƌŽƉĞĂŶĚƚŚĞh^͕

ŵŽƐƚ ŽĨ ǁŚŝĐŚ ƌĞŵĂŝŶ ƵŶĚŝĂŐŶŽƐĞĚ͘ ůƚŚŽƵŐŚ ŐŽŽĚ ŝŶƐŝŐŚƚ ŚĂƐ ďĞĞŶ ŐĂŝŶĞĚ ŽŶ ƚŚĞ

ŝŵŵƵŶŽƉĂƚŚŽůŽŐLJŽĨͲŝŶŇĂŵŵĂƟŽŶŝŶďŽƚŚůĂŵŝŶĂƉƌŽƉƌŝĂĂŶĚĞƉŝƚŚĞůŝƵŵͲŝƚƌĞŵĂŝŶƐ

ƵŶĐůĞĂƌ ǁŚĂƚ ƚƌŝŐŐĞƌƐ ƚŚĞ ĚĞǀĞůŽƉŵĞŶƚ ŽĨ  ĂŶĚ ǁŚLJ ŶŽƚ ĞǀĞƌLJ ƉĂƟĞŶƚ ŝƐ ĞƋƵĂůůLJ

ĂīĞĐƚĞĚ͘/ŶĂĚĚŝƟŽŶ͕ǁŝƚŚƚŚĞƌĞĐŽŐŶŝƟŽŶŽĨZĂŶĚZͲĂƐƐŽĐŝĂƚĞĚůLJŵƉŚŽŵĂƚŚĂƚ

ĚŽŶŽƚƌĞƐƉŽŶĚƚŽĂŐůƵƚĞŶͲĨƌĞĞĚŝĞƚ͕ŚĂƐďĞĐŽŵĞĂĨĂƌŵŽƌĞĐŽŵƉůŝĐĂƚĞĚĚŝƐĞĂƐĞ͘

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$ ϭ͘ 'ƌĞĞŶW,͕ĞůůŝĞƌ͘ĞůŝĂĐĚŝƐĞĂƐĞ͘E͘ŶŐů͘:͘DĞĚ͘ϮϬϬϳ͖ϯϱϳ͗ϭϳϯϭͲϭϳϰϯ͘

 Ϯ͘ sŝůƉƉƵůĂ͕<ĂƵŬŝŶĞŶ<͕>ƵŽƐƚĂƌŝŶĞŶ>ĞƚĂů͘/ŶĐƌĞĂƐŝŶŐƉƌĞǀĂůĞŶĐĞĂŶĚŚŝŐŚŝŶĐŝĚĞŶĐĞ

ŽĨ ĐĞůŝĂĐ ĚŝƐĞĂƐĞ ŝŶ ĞůĚĞƌůLJ ƉĞŽƉůĞ͗ Ă ƉŽƉƵůĂƟŽŶͲďĂƐĞĚ ƐƚƵĚLJ͘ D͘'ĂƐƚƌŽĞŶƚĞƌŽů͘

ϮϬϬϵ͖ϵ͗ϰϵ͘

 ϯ͘ ĂƵŵ ^͕ ĞůůŝĞƌ ͕ DƵůĚĞƌ :͘ ZĞĨƌĂĐƚŽƌLJ ĐŽĞůŝĂĐ ĚŝƐĞĂƐĞ͘ ĞƐƚ͘WƌĂĐƚ͘ZĞƐ͘ůŝŶ͘

'ĂƐƚƌŽĞŶƚĞƌŽů͘ϮϬϬϱ͖ϭϵ͗ϰϭϯͲϰϮϰ͘

 ϰ͘ ĞůůŝĞƌ͕WĂƚĞLJE͕DĂƵǀŝĞƵdž>ĞƚĂů͘ďŶŽƌŵĂůŝŶƚĞƐƟŶĂůŝŶƚƌĂĞƉŝƚŚĞůŝĂůůLJŵƉŚŽĐLJƚĞƐŝŶ

ƌĞĨƌĂĐƚŽƌLJƐƉƌƵĞ͘'ĂƐƚƌŽĞŶƚĞƌŽůŽŐLJϭϵϵϴ͖ϭϭϰ͗ϰϳϭͲϰϴϭ͘

 ϱ͘ sĞƌŬĂƌƌĞ s͕ ZŽŵĂŶĂ ^W͕ ĞůůŝĞƌ  Ğƚ Ăů͘ ZĞĐƵƌƌĞŶƚ ƉĂƌƟĂů ƚƌŝƐŽŵLJ ϭƋϮϮͲƋϰϰ ŝŶ ĐůŽŶĂů

ŝŶƚƌĂĞƉŝƚŚĞůŝĂů ůLJŵƉŚŽĐLJƚĞƐ ŝŶ ƌĞĨƌĂĐƚŽƌLJ ĐĞůŝĂĐ ƐƉƌƵĞ͘ 'ĂƐƚƌŽĞŶƚĞƌŽůŽŐLJ ϮϬϬϯ͖ϭϮϱ͗ϰϬͲ ϰϲ͘

 ϲ͘ ĞůĞĞƵǁ Z:͕ ĞƩů ͕ <ůŝŶŬĞƌ  Ğƚ Ăů͘ tŚŽůĞͲŐĞŶŽŵĞ ĂŶĂůLJƐŝƐ ĂŶĚ ,> ŐĞŶŽƚLJƉŝŶŐ

ŽĨ ĞŶƚĞƌŽƉĂƚŚLJͲƚLJƉĞ dͲĐĞůů ůLJŵƉŚŽŵĂ ƌĞǀĞĂůƐ Ϯ ĚŝƐƟŶĐƚ ůLJŵƉŚŽŵĂ ƐƵďƚLJƉĞƐ͘

'ĂƐƚƌŽĞŶƚĞƌŽůŽŐLJϮϬϬϳ͖ϭϯϮ͗ϭϵϬϮͲϭϵϭϭ͘

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ŽĨƐŝŶŐůĞͲĐĞŶƚƌĞĞdžƉĞƌŝĞŶĐĞ͘'ƵƚϮϬϬϳ͖ϱϲ͗ϭϯϳϯͲϭϯϳϴ͘

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ĐĞůŝĂĐĚŝƐĞĂƐĞ͗ĐŽŵƉĂƌŝƐŽŶŽĨƚLJƉĞ/ǁŝƚŚƚLJƉĞ//͘'ĂƐƚƌŽĞŶƚĞƌŽůŽŐLJϮϬϬϵ͖ϭϯϲ͗ϴϭͲϵϬ͘

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ĨĂĐƚŽƌŚĂǀŝŶŐĂĚĞůĞƚĞƌŝŽƵƐĞīĞĐƚŝŶĐĂƐĞƐŽĨĐŽĞůŝĂĐĚŝƐĞĂƐĞ͘ĐƚĂWĂĞĚŝĂƚƌ͘ϭϵϱϯ͖ϰϮ͗ϯϰͲ ϰϮ͘

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ǁŝƚŚŝŶƚŚĞƐŵĂůůͲŝŶƚĞƐƟŶĂůŵƵĐŽƐĂŝŶĐŽĞůŝĂĐĚŝƐĞĂƐĞ͘>ĂŶĐĞƚϭϵϳϱ͖ϭ͗ϴϵϱͲϴϵϳ͘

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ďŽƚŚƉƌŝŵĂƌŝůLJĂƐƐŽĐŝĂƚĞĚǁŝƚŚƚŚĞ,>ͲY;ĂůƉŚĂϭΎϬϱϬϭ͕ďĞƚĂϭΎϬϮͿŽƌƚŚĞ,>ͲY

;ĂůƉŚĂϭΎϬϯ͕ďĞƚĂϭΎϬϯϬϮͿŚĞƚĞƌŽĚŝŵĞƌƐ͘dŝƐƐƵĞŶƟŐĞŶƐϭϵϵϳ͖ϰϵ͗ϮϵͲϯϰ͘

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ϮϬϬϳ͖ϱϲ͗ϭϬϱϰͲϭϬϱϵ͘

 ϭϯ͘ tŽůƚĞƌƐ sD͕ tŝũŵĞŶŐĂ ͘ 'ĞŶĞƟĐ ďĂĐŬŐƌŽƵŶĚ ŽĨ ĐĞůŝĂĐ ĚŝƐĞĂƐĞ ĂŶĚ ŝƚƐ ĐůŝŶŝĐĂů

ŝŵƉůŝĐĂƟŽŶƐ͘ŵ͘:͘'ĂƐƚƌŽĞŶƚĞƌŽů͘ϮϬϬϴ͖ϭϬϯ͗ϭϵϬͲϭϵϱ͘

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YϭΎϬϱͲYϭΎϬϮ;YϮͿŚĞƚĞƌŽĚŝŵĞƌ͗ƌĞƐƵůƚƐĨƌŽŵƚŚĞƵƌŽƉĞĂŶ'ĞŶĞƟĐƐůƵƐƚĞƌŽŶ

ĞůŝĂĐŝƐĞĂƐĞ͘,Ƶŵ͘/ŵŵƵŶŽů͘ϮϬϬϯ͖ϲϰ͗ϰϲϵͲϰϳϳ͘

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ƌĞƐƚƌŝĐƚĞĚdĐĞůůƐŝƐŽůĂƚĞĚĨƌŽŵƚŚĞƐŵĂůůŝŶƚĞƐƟŶĂůŵƵĐŽƐĂŽĨĐĞůŝĂĐĚŝƐĞĂƐĞƉĂƟĞŶƚƐ͘

:͘džƉ͘DĞĚ͘ϭϵϵϯ͖ϭϳϴ͗ϭϴϳͲϭϵϲ͘

 ϭϲ͘ >ƵŶĚŝŶ<͕^ĐŽƩ,͕&ĂƵƐĂK͕dŚŽƌƐďLJ͕^ŽůůŝĚ>D͘dĐĞůůƐĨƌŽŵƚŚĞƐŵĂůůŝŶƚĞƐƟŶĂůŵƵĐŽƐĂ

ŽĨĂZϰ͕YϳͬZϰ͕YϴĐĞůŝĂĐĚŝƐĞĂƐĞƉĂƟĞŶƚƉƌĞĨĞƌĞŶƟĂůůLJƌĞĐŽŐŶŝnjĞŐůŝĂĚŝŶ ǁŚĞŶ

ƉƌĞƐĞŶƚĞĚďLJYϴ͘,Ƶŵ͘/ŵŵƵŶŽů͘ϭϵϵϰ͖ϰϭ͗ϮϴϱͲϮϵϭ͘

 ϭϳ͘ ůͲdŽŵĂ͕'ŽĞƌƌĞƐD^͕DĞŝũĞƌ:tĞƚĂů͘,ƵŵĂŶůĞƵŬŽĐLJƚĞĂŶƟŐĞŶͲYϮŚŽŵŽnjLJŐŽƐŝƚLJ

ĂŶĚ ƚŚĞ ĚĞǀĞůŽƉŵĞŶƚ ŽĨ ƌĞĨƌĂĐƚŽƌLJ ĐĞůŝĂĐ ĚŝƐĞĂƐĞ ĂŶĚ ĞŶƚĞƌŽƉĂƚŚLJͲĂƐƐŽĐŝĂƚĞĚ dͲĐĞůů

ůLJŵƉŚŽŵĂ͘ůŝŶ͘'ĂƐƚƌŽĞŶƚĞƌŽů͘,ĞƉĂƚŽů͘ϮϬϬϲ͖ϰ͗ϯϭϱͲϯϭϵ͘