Zonulin as a Biomarker for the Development of Celiac Disease

Pediatrics. 2024 Jan 1;153(1):e2023063050. doi: 10.1542/peds.2023-063050.


Objectives: Increased intestinal permeability seems to be a key factor in the pathogenesis of autoimmune diseases, including celiac disease (CeD). However, it is unknown whether increased permeability precedes CeD onset. This study's objective was to determine whether intestinal permeability is altered before celiac disease autoimmunity (CDA) in at-risk children. We also examined whether environmental factors impacted zonulin, a widely used marker of gut permeability.

Methods: We evaluated 102 children in the CDGEMM study from 2014-2022. We included 51 CDA cases and matched controls, who were enrolled for 12 months or more and consumed gluten. We measured serum zonulin from age 12 months to time of CDA onset, and the corresponding time point in controls, and examined clinical factors of interest. We ran a mixed-effects longitudinal model with dependent variable zonulin.

Results: Children who developed CDA had a significant increase in zonulin in the 18.3 months (range 6-78) preceding CDA compared to those without CDA (slope differential = β = 0.1277, 95% CI: 0.001, 0.255). Among metadata considered, zonulin trajectory was only influenced by increasing number of antibiotic courses, which increased the slope of trajectory of zonulin over time in CDA subjects (P = .04).

Conclusions: Zonulin levels significantly rise in the months that precede CDA diagnosis. Exposure to a greater number of antibiotic courses was associated with an increase in zonulin levels in CDA subjects. This suggests zonulin may be used as a biomarker for preclinical CeD screening in at-risk children, and multiple antibiotic courses may increase their risk of CDA by increasing zonulin levels.

MeSH terms

  • Anti-Bacterial Agents / administration & dosage
  • Biomarkers*
  • Celiac Disease* / blood
  • Celiac Disease* / diagnosis
  • Child
  • Child, Preschool
  • Female
  • Haptoglobins* / analysis
  • Humans
  • Infant
  • Male
  • Protein Precursors* / blood


  • zonulin
  • Biomarkers
  • Haptoglobins
  • Anti-Bacterial Agents
  • Protein Precursors