Efficient predictive diagnosis for endoscopic remission in Crohn’s diseases by the combination of three non-invasive markers

Efficient predictive diagnosis for endoscopic remission in Crohn’s diseases by the combination of three non-invasive markers | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Efficient predictive diagnosis for endoscopic remission in Crohn’s diseases by the combination of three non-invasive markers Kensuke Takei, Toshihiro Inokuchi, Sakiko Hiraoka, Mikako Ishiguro, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5322202/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 May, 2025 Read the published version in BMC Gastroenterology → Version 1 posted 4 You are reading this latest preprint version Abstract Background Serum C-reactive protein (CRP), leucine-rich alpha-2 glycoprotein (LRG), and fecal calprotectin (Fcal) are non-invasive markers used to diagnose the severity of Crohn’s disease (CD). However, the accuracy of these markers is not satisfactory, and most previous reports have evaluated the efficacy of each marker individually. We aimed to improve the diagnostic performance of endoscopic remission (ER) of CD by using a combination of these 3 markers. Methods We tested the diagnostic ability of various combinations of these 3 markers for endoscopic severity in 230 consecutive patients with CD from September 2014 to July 2023. The modified Simple Endoscopic Score for Crohn’s disease (mSES-CD) was used to determine endoscopic severity. Results Each of the 3 markers was correlated with mSED-CD (LRG: r = 0.69, CRP: r = 0.60, and Fcal: r = 0.67). A combination of 2 of the 3 markers did not increase the diagnostic accuracy of ER. However, by combining all 3 markers, the diagnostic ability for ER was improved in comparison to the diagnostic ability of the 3 individual markers, assuming that ER was obtained if 2 or 3 markers were negative. The sensitivity, specificity, and accuracy were 89%, 83%, and 86%, respectively. Additionally, we established a 2-step method using Fcal values after evaluating the 2 serum markers. This method was most useful for reducing both the patient burden and costs. Conclusions The newly established 2-step method allowed for a higher accuracy in the non-invasive predictive diagnosis of ER when the 3 markers were combined. CD Crohn’s disease LRG leucine-rich alpha-2 glycoprotein Fcal fecal calprotectin CRP C-reactive protein ER endoscopic remission Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 INTRODUCTION Crohn's disease (CD) is a progressive and intractable inflammatory bowel disease that affects the entire gastrointestinal tract, with small intestinal involvement in 75% of patients. 1 If the inflammation is not properly controlled, irreversible damage accumulates in the intestinal tract, eventually leading to strictures, fistulas, multiple surgeries, and a significant reduction in the patient's quality of life 23 . On the other hand, the emergence of advanced therapies has led to endoscopic remission with a decrease in surgical and admission rates and has brought the treatment to target conception 45 . Precise assessment of the disease status and timely therapeutic intervention can reduce the risk of recurrence 6 . Early detection of flare-ups and appropriate therapeutic intervention to minimize damage to the intestinal tract are paramount in treating CD 57 . In particular, monitoring the disease status of patients with CD, including small intestinal lesions, has become a major clinical concern. Serum C-reactive protein (CRP) and fecal calprotectin (Fcal) have been reported to be useful surrogate markers of bowel inflammation in patients with CD 8 – 12 . In particular, Fcal shows a high correlation with endoscopic severity and can non-invasively diagnose mucosal healing with high accuracy. Leucine-rich alpha-2 glycoprotein (LRG) is a novel serum marker for inflammatory bowel disease (IBD) and has been recently reported to be more accurate than CRP as a marker of endoscopic severity and might be equivalent to Fcal 13 – 16 . However, previous reports have been limited to evaluating the efficacy of individual markers or the combination of 2 markers, and the predictive ability of these markers for diagnosing endoscopic remission was not satisfactory. Because there have been no attempts to evaluate disease activity using 3 markers for monitoring patients with CD, we aimed to determine the efficacy of the predictive diagnostic performance by combining 3 markers: CRP, LRG, and Fcal. MATERIALS and METHODS Patients Consecutive CD patients who underwent endoscopy at Okayama University Hospital between September 2014 and July 2023 and whose stool and blood samples were scheduled to be collected were considered eligible for this study. All patients had undergone previous endoscopic examinations with findings of active inflammation in the colon, in the small bowel, or in both. CD patients with colonic lesions alone underwent colonoscopy, while CD patients with lesions in the small bowel underwent balloon-assisted enteroscopy (BAE). All patients provided blood samples for the determination of serum LRG and CRP levels on the morning of the day when endoscopy was performed. In addition, all patients were instructed to collect stool samples at home within 2 days before endoscopy and bring them to the hospital on the day of endoscopy to test the Fcal values. The patients’ clinical characteristics, including age at the diagnosis, sex, disease location, disease behavior, and current medications, were obtained. The clinical disease activity for patients with CD was evaluated using the Crohn’s disease activity index (CDAI), with clinical remission defined as CDAI < 150. The exclusion criteria were insufficient stool collection, having had a colostomy or ileostomy, and failure to achieve full endoscopic observation of the lesions. In addition, patients with background factors that could affect the levels of LRG, CRP, and Fcal, including uncontrolled perianal disease, extraintestinal complications, collagen disease, heart failure, infectious disease, immediate postvaccination, and malignancy at the time of endoscopy, were excluded. Endoscopy procedures and the assessment of endoscopic disease activity Bowel preparation was conducted using either a polyethylene glycol-based or magnesium citrate-based electrolyte solution, following the standard protocol of our hospital, and colonoscopy or BAE was performed. A double-balloon enteroscope EN-580T (Fujifilm, Tokyo, Japan) was used by experienced endoscopists (T.I. and S.K.). The DBE scope was inserted into the proximal small intestine as far as possible using a retrograde approach. Complete observation of the affected lesions was accomplished in all patients, and those in whom the affected lesions could not be fully evaluated (e.g., due to stenosis) were excluded. The endoscopic assessment was scored according to the modified simple endoscopic score for Crohn’s disease (mSES-CD), which was modified for the evaluation of small bowel lesions, as well as colonic lesions based on the original SES-CD 17 . The small intestine was divided into 2 segments: the distal and proximal ileum. The distal ileum was defined as the portion of the ileum within 40 cm from the ileocecal valve or anastomosis, whereas the proximal ileum was defined as the deeper part of the ileum ≥ 40 cm proximal to those points 17 . mSES-CD was calculated by determining sum of the scores of 6 bowel segments (proximal and distal parts of the small intestine, right colon, transverse colon, left colon, and rectum). We excluded the scoring item “strictures” from the original SES-CD because it represents bowel damage rather than active inflammation. Thus, we evaluated the scores for the size of the ulcers, ulcerated surface, and affected surface in each segment 10 , 11 . In addition, for anastomotic lesions, only ulcers (size score > 2) were defined as being derived from CD. Endoscopic remission was defined as an mSES-CD of 0–2. Endoscopic findings were evaluated with the endoscopist blinded to the results of serum and fecal markers. The measurement of serum LRG levels Serum samples were collected by centrifuging blood samples at 1,500 rpm for 15 min, divided into aliquots, and stored at -80°C until use. Serum LRG levels were analyzed in an in-hospital laboratory using a NANOPIA LRG (SEKISUI MEDICAL Company Limited, Tokyo, Japan). The measuring reagents were provided by the Laboratory for SEKISUI MEDICAL Company Limited. The Laboratory for Sekisui Medical funded a portion of the LRG-measuring reagent cost. Fecal calprotectin analysis The fecal samples collected by the patients were stored at − 30°C until shipment to the laboratory, where the calprotectin analysis was performed. The samples were sent to BML (Tokyo, Japan), where the level of calprotectin in stool specimens was measured with a fluorescence enzyme immunoassay using Phadia EliA™ Calprotectin 2 (Thermo Fisher Scientific, Phadia AB, Uppsala, Sweden). Patient prognosis The relationship between the results of 3 markers and patient prognosis, including relapse rate, CD-related hospitalization rate, and CD-related surgery rate, was evaluated during observation periods. Relapse was defined as a requirement for a change in treatment (i.e., the use of corticosteroids, the administration of a new biologic therapy, or a change in biologic therapy). Statistical analyses Spearman’s rank correlation test was performed to determine the correlation coefficient between the serum and fecal marker levels. A receiver operating characteristic curve (ROC) analysis was used to assess the discriminatory performance of Fcal, LRG, and CRP for detecting endoscopic status and to determine the cut-off levels of these markers for the non-invasive predictive diagnosis of endoscopic remission using the Youden’s index. The results are expressed as the area under the curve (AUC) with sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy, with 95% confidence intervals (CI). Two different classifiers were adopted: k-fold cross-validation and a support vector machine (SVM) to validate the predictive diagnostic ability of multiple markers. Regarding k-fold cross-validation, we performed cross-validation from 2-fold to 10-fold on each subject's data and adopted the k value with the highest diagnostic ability 19 , 20 , 21 . Analyses of relapse, hospitalization, and colectomy rates were carried out using the Kaplan and Meier method. Statistical comparison was carried out by Log-rank test. Univariate analysis using a Cox proportional hazard model were also conducted to evaluate the risks for prognosis. All P -values were 2-sided, and P -values < 0.05 were considered to indicate statistical significance. The data underlying this article will be shared upon reasonable request by the corresponding author. All statistical analyses were conducted using the JMP software program (version 16.0 pro for Windows, SAS Institute Inc., Cary, NC, USA). Ethical statements This study was approved by the Institutional Review Board of the Okayama University Graduate School of Medicine (IRB number: 1904-035) conducted in accordance with the Declaration of Helsinki. All studies were performed in accordance with the relevant guidelines and regulations. Informed consent was obtained from each patient and/or their legal guardians. RESULTS Clinical characteristics of the enrolled patients Among 268 consecutive outpatients with CD enrolled in this study, 38 patients, whose Fcal values could not be measured due to insufficient stool specimens were excluded. The remaining 230 patients (149 males and 81 females; median age at diagnosis, 24 years) were included in this study. These patients underwent endoscopy and their serum and fecal markers were examined simultaneously. The clinical characteristics of the patients and their values are summarized in Table 1. Regarding the disease locations of the 230 cases, 50 (22%) had ileal lesions alone, 47 (20%) had colonic lesions alone, and 133 (58%) had ileocolonic lesions. All patients with ileal lesions underwent BAE, regardless of the presence or absence of lesions proximal to the terminal ileum. A tumor necrosis factor-alpha antagonist was administered to 125 patients (54%) and thiopurine was administered to 98 patients (43%). Of the 230 patients, 155 (67%) were in clinical remission, whereas 75 (33%) had clinically active disease. The endoscopic findings were as follows: mSES-CD 0, n=97 (42%); mSES-CD 1–2, , n=19 (8%); mSES-CD 3–4, n=54 (24%); mSES-CD 5-10, n=57 (25%); and mSES-CD 11-15, n=2 (1%). The median (interquartile range [IQR]) values of these biomarkers were 13.1 (8.5-16.7) μg/mL for LRG, 0.10 (0.04-0.22) mg/dL for CRP, and 202 (61-687) μg/g for Fcal. Correlations between LRG/CRP/Fcal values and mSES-CD in patients with CD Correlations between the mSES-CD and the values of each marker (LRG, CRP, and Fcal) were analyzed. Spearman’s rank correlation coefficients and p-values were as follows: LRG: r = 0.69, P < 0.0001; CRP: r = 0.60, P < 0.0001; and Fcal: r = 0.67, P < 0.0001 (Figure 1). These results indicated that all 3 markers are significantly correlated with mSES-CD and that LRG and Fcal show the highest correlations when limited to the cases with ileal lesions ( r = 0.63) and limited to the cases with ileocolonic lesions (r = 0.73, respectively (Supplementary Figure 1-3). Next, the predictive abilities of each marker for diagnosing endoscopic remission were assessed individually. When comparing the cases with endoscopic remission and the cases with endoscopically active lesions, the values of each marker were significantly lower in the endoscopic remission group than in the “endoscopic active” group (Figure 2A; LRG, P < 0.0001; CRP, P < 0.0001; and Fcal, P < 0.0001). The AUC values for endoscopic remission were as follows: LRG, 0.886; CRP, 0.816; and Fcal, 0.876. The optimal cut-off levels of each marker to diagnose non-invasively the endoscopic remission was as follows: LRG, 13.2 μg/mL; CRP, 0.15 mg/dL and Fcal, 180 μg/g (Figure 2B). Only LRG and CRP showed statistically significant differences in AUC values ( P = 0.02). A combinatorial method using 2 markers to diagnose endoscopic remission in patients with CD When evaluating the predictive diagnostic ability of the combination using only 2 of the 3 markers, the accuracy was not superior to any of the individual markers, regardless of the combination (Table 2; upper part). Among these, the combination of CRP and LRG had the best predictive ability for the diagnosis of endoscopic remission. The sensitivity, specificity, PPV, NPV, accuracy rate, and AUC were 74.2%, 90.0%, 89.0%, 76.2%, 81.7%, and 0.831, respectively. A combination method using all 3 markers to diagnose endoscopic remission in patients with CD Next, all 3 markers (CRP, LRG, and Fcal) were simultaneously used to predictively diagnose the endoscopic activity. In this case, “endoscopic remission” was predicted when 2 or more markers were negative, and “endoscopic active” disease was predicted when 2 or more markers were positive. The predictive diagnostic ability for endoscopic remission was improved in comparison to individual markers or the combination of any 2 markers. The sensitivity, specificity, PPV, NPV, and accuracy rates were 89.4%, 83.3%, 81.6%, 90.5%, and 86.1%, respectively (Table 2; lower part). Furthermore, if endoscopic remission was defined as all 3 negative markers with negative, the sensitivity, specificity, PPV, NPV, and accuracy in the diagnosis of endoscopic remission were 71.3%, 100%, 100%, 60.3%, and 80.0%, respectively. Validation of the predictive diagnostic ability of the combination method using 3 markers in patients with CD To validate the predictive diagnostic ability of the combination method using the 3 markers, we first performed k-fold cross-validation by comparing it with other combinations using CRP, LRG, and Fcal (Supplemental Table 1). The combination method using 3 markers was superior in terms of sensitivity, specificity, and accuracy compared to other combination methods, when the negativity of 2 or more markers predicted endoscopic remission. Next, we compared the predictive diagnostic abilities of the combination method using 3 markers and those of the existing 2-marker methods using a different classifier: support vector machines (SVM) (Figure 3). In these analyses, the 3-marker method, in which negativity of 2 or more markers was defined as endoscopic remission, had the highest AUC value (AUC: 0.856) and was significantly superior to the AUC values of the combination of CRP (-) and LRG (-), and of the combination of CRP (-) and Fcal (-), in terms of the ability to diagnose endoscopic remission (AUC: 0.772, P < 0.0005, and 0.777, P < 0.001, respectively). These results suggest that the 3-marker method is superior to other combination methods using any 2 of the 3 markers. The long-term prognosis of the patients with CD During the median observation period of 3.6 years (IQR; 1.8-4.7), 35 patients had a relapse requiring a change in treatment, 14 were hospitalized, and 13 underwent surgery due to the disease course of CD. Kaplan-Meier analysis showed that Patients with two or more negative of the three markers had a more favorable prognosis in terms of reduced risk of relapse, with a hazard ratio (HR) of 0.20 (95% CI: 0.09-0.45, P < 0.0001) (Figure 4A). Similarly, patients with two or more negative markers were significantly more likely to avoid hospitalization (HR: 0.21 (95% CI: 0.06-0.77, P < 0.001) and surgery (HR: 0.24 (95% CI: 0.07-0.88), P < 0.05) (Figure 4B and 4C). A 2-step method using 3 markers is the best predictive diagnostic method for endoscopic remission in patients with CD While LRG and CRP are convenient as serum markers, Fcal, a fecal marker, has some inconvenience because it requires stool and sample collection for testing. Therefore, from a practical perspective, we next examined the predictive diagnostic ability of a “2-step method” using the markers for the predictive diagnosis of endoscopic remission (Figure 5A). To establish the 2-step method, we first drew a scatterplot based on the values of serum markers, CRP, and LRG. Then, the patients were divided into four groups using the optimal cut-off values. The 2 groups with double-positive (CRP [+] and LRG [+]) or double-negative (CRP [-] and LRG [-]) were defined as “endoscopic remission” or “endoscopic active” (blue and red groups) (Figure 5B). For other groups that showed positivity for CRP or LRG (yellow groups), Fcal was measured as the second step. We determined whether the case was in “endoscopic remission” or “endoscopic active” based on the Fcal results. Using this “2-step method”, the sensitivity, specificity, PPV, NPV, and accuracy rate for endoscopic remission were 89.4%, 83.3%, 81.6%, 90.5%, and 86.1% (Figure 5C). As a result, this 2-step method had the highest predictive diagnostic ability among the measurement methods while minimizing the burden of the measurement of Fcal, which may be beneficial for the patient and from the viewpoint of medical economics. DISCUSSION The non-invasive predictive diagnosis of the endoscopic lesions is crucial for monitoring patients with CD. This study demonstrated that the predictive diagnostic accuracy for the non-invasive diagnosis of endoscopic remission was improved by the use of 3 markers: CRP, LRG, and Fcal. In particular, the 3-marker simultaneous measurement method was more effective than the single use of any individual marker or the 2-marker combination method and could predict the prognosis regarding relapse, hospitalization, and surgery. Moreover, instead of testing 3 markers simultaneously, it was possible by introducing the “2-step method” to reduce the number of Fcal measurements, which requires time and effort, without sacrificing the diagnostic accuracy. CD irreversibly causes inflammatory damage to the intestinal tract, and close and continuous monitoring is essential to prevent intestinal complications and implement a treat-to-target strategy 6 . In particular, approximately 80% of patients with CD have small intestinal lesions, and it is necessary to not only evaluate the terminal ileum but also perform a close examination of the small intestine using a small intestine endoscope 1 . However, endoscopic follow-up of the intestinal tract, including the small intestine, is highly invasive, making it difficult to perform frequent small intestine endoscopy, and less invasive and less costly markers are recommended for monitoring. The evidence of CRP and Fcal has been well established for monitoring disease activity in patients with CD. Additionally, based on recent reports, the accuracy rate of LRG alone for diagnosing endoscopic remission was estimated to be approximately 80%, which is more useful than CRP and has been reported to be at the same level as Fcal 14,15 . However, there have been no reports on the 3 types of combinations of markers, and this is the first report on the potential of the combination of LRG with CRP and Fcal to improve the accuracy rate for diagnosing endoscopic remission. Two distinct statistical validation methods (k-fold cross-validation and SVM) were employed to assess the predictive diagnostic ability of endoscopic remission using a combination of 3 distinct markers and it was demonstrated that the number of positive markers among the three significantly predicted the long-term prognosis, including relapse rate, hospitalization rate and surgery rate. Furthermore, the “2-step method” would be beneficial in determining whether a certain number of patients were in endoscopic remission based solely on blood markers, eliminating the inconvenience of treating stool samples. In fact, 38 patients whose Fcal levels could not be measured owing to insufficient stool specimens were excluded from this study. The present study was associated with several limitations. First, the study was conducted at a single hospital, which may introduce bias, as the patient group may be dominated by those with mild disease activities. Approximately 70% of the patients in this study were treated with biologics, possibly because of their generally mild endoscopic severity. To demonstrate the reproducibility and universality of the results, studies should be conducted at multiple institutions. Further verification of the LRG cut-off value for the diagnosis of endoscopic remission is necessary. Although previous reports commonly use a cut-off value of 13-14 ng/dl, because there are various evaluation methods for small intestinal lesions in CD, more investigation is required 14,15,16 . Third, currently in Japan, the medical insurance system does not allow simultaneous measurement of all 3 markers. In light of these circumstances, the implementation of a 2-step methodology allows for the identification of high-risk cases, followed by additional fecal calprotectin testing in cases suspected of being at risk in actual clinical practice. This approach offers the potential for more cost-effective and patient-centered care. In conclusion, our study demonstrated that combining CRP, Fcal, and LRG can be a non-invasive diagnostic tool that can predict endoscopic remission with greater accuracy and long-term prognosis. Further research is necessary to determine more appropriate cut-off values and to identify more effective ways of utilizing these markers. Declarations ACKOWLEDGMENTS Financial Support: None. Conflict of Interest: The authors have no conflicts of interest to declare. Funding Source: This work was supported by JSPS KAKENHI [Grant Number JP20K12669, JP23K11871] to S.H. Conflict of interest: The authors declare no conflicts of interest in association with the present study. Data availability statement: The data supporting the findings of this study are available on reasonable request to the corresponding author. Author contributions: Conceptualization, SH; data curation, MI, JT, YA, SI, KT, YY, HK, MT, and SK; validation, formal analysis, investigation, and resources, SH; writing—original draft preparation, KT; writing—review and editing, TI; supervision, MO. All authors read, reviewed, and approved the final manuscript. References Matsuoka K, Fujii T, Okamoto R, Yamada A, Kunisaki R, Matsuura M, Watanabe K, Shiga H, Takatsu N, Bamba S, et al. 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Patients Total n = 230 (%) Gender Male/Female 149 (65)/81 (35) Median (IQR) age of undergoing endoscopy (years) 44 (34-57) Median (IQR) duration of disease (years) 12 (4.4-21) Median (IQR) age at diagnosis (years) 24 (19-34) A1: 40 36 (16)/166 (72)/28 (12) Number of endoscopy procedures 1/2/ >3 84 (59)/40 (28)/19 (13) Disease location L1: ileal /L2: colonic /L3: ileocolonic 50 (22)/47 (20) /133 (58) Disease behavior B1: inflammation /B2: stricturing /B3: penetrating 75 (33)/94 (41)/61 (26) Perianal disease 98 (43) CDAI score (IQR) 135 (58-179) Clinical remission* 155 (67) Previous intestinal resection 130 (57) Smoking (current/ex/never) 12 (5)/25 (11)/ 193 (84) Concomitant medications 5-aminosalycylic acid 153 (67) Corticosteroids 31 (13) Thiopurine 98 (43) TNF-alpha antagonist 125 (54) Vedolizumab 1 (0.4) Ustekinumab 32 (14) Elemental diet 128 (56) (continued) Endoscopy Total colonoscopy /Balloon-assisted enteroscopy 47 (20)/183 (80) Endoscopy findings mSES-CD 0 /1-2 /3-4 /5-10 /11-15 97 (42) /19 (8) /54 (24) /57 (25) /3 (1) endoscopic remission (≤2) 116 (50%) Values of biomarkers, median (IQR) Leucin rich alpha-2 glycoprotein (µg/mL) 13.1 (8.5-16.7) C-reactive protein (mg/dL) 0.10 (0.04-0.22) Fecal calprotectin (μg/g) 202 (61-687) IQR, interquartile range; mSES-CD, modified simple endoscopic score for Crohn’s disease; CDAI, Crohn’s disease activity index; TNF, tumor necrosis factor. * Clinical remission was defined as a CDAI score of < 150. Table 2. Predictive diagnostic performance of the combination of CRP, Fcal and LRG for predicting endoscopic remission. Sensitivity Specificity PPV NPV Accuracy AUC Combination of 2 markers CRP (-) and LRG (-) 74.2% (66.3-82.0) 90.0% (84.4-95.6) 89.0% (82.9-95.1) 76.2% (68.8-83.5) 81.7% (76.7-86.7) 0.831 (0.7823-0.879) CRP (-) and Fcal (-) 69.0% (60.5-77.4) 93.9% (89.5-98.3) 92.0% (86.2-97.7) 74.8% (67.7-81.9) 81.3% (76.3-86.3) 0.814 (0.764-0.864) Fcal (-) and LRG (-) 65.5% (56.9-74.2) 97.4% (94.4-1.00) 96.2% (92.0-1.00) 73.5% (66.5-80.5) 81.3% (76.3-86.3) 0.814 (0.764-0.864) Combination of 3 markers Two or more markers (-) of the 3 markers 89.4% (83.5-95.3) 83.3% (76.8-89.8) 81.6% (74.5-88.7) 90.5% (85.2-95.8) 86.1% (81.6-90.6) 0.860 (0.816-0.905) CRP (-) and Fcal (-) and LRG (-) 71.3% (64.2-78.3) 100% (100-100) 100% (100-100) 60.3% (51.4-69.2) 80.0% (74.8-85.1) 0.794 (0.742-0.846) AUC, area under the curve; PPV, positive predictive value; NPV, negative predictive value; LRG, leucine-rich alpha-2 glycoprotein; CRP, C-reactive protein; Fcal, fecal calprotectin Additional Declarations No competing interests reported. Supplementary Files SupplementaryFigure.pptx Cite Share Download PDF Status: Published Journal Publication published 13 May, 2025 Read the published version in BMC Gastroenterology → Version 1 posted Editorial decision: Revision requested 11 Nov, 2024 Editor assigned by journal 25 Oct, 2024 Submission checks completed at journal 25 Oct, 2024 First submitted to journal 23 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5322202","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":370233907,"identity":"57dfad51-a4eb-4372-842d-8743774b90c8","order_by":0,"name":"Kensuke Takei","email":"","orcid":"","institution":"Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Kensuke","middleName":"","lastName":"Takei","suffix":""},{"id":370233908,"identity":"edb58188-e16a-4a01-8628-dad9cbdfd323","order_by":1,"name":"Toshihiro Inokuchi","email":"","orcid":"","institution":"Research Center for Intestinal Health Science, Okayama University, Okayama, Japan","correspondingAuthor":false,"prefix":"","firstName":"Toshihiro","middleName":"","lastName":"Inokuchi","suffix":""},{"id":370233909,"identity":"921f6123-eacb-472c-83bf-574e29ce54e7","order_by":2,"name":"Sakiko Hiraoka","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDUlEQVRIiWNgGAWjYFACNoaDDQwH5EBMxgYkcWZCWoxJ0wJUeSCxAV0LTiDffizx4IyKO+n97QcYH86oORzN38BjwPCjhoHdHIcWgzNpBw5uOPMsd8aZBGbDDccO5844wGPA2HOMgdkSh50GDOkNBx+2Hc7dIMHAJvmA7XBuw/03Bgy8DQzMBgdwOKz/OVhLugFYy7/DufNBtvzFo4XhBtBhG9sOJ4C1bARZB9TCjM8WgxvPEg7OOHPYcMaZxGbDmX3puRsPsBUcljkmgdMv8v1pxh97Kg7L87cfPviw55t17rwDzBsfvqmxScYVYkgAHCvNYCbQSRLJBoS1gEEdnGVHrJZRMApGwSgY9gAAiNtluw0i6mUAAAAASUVORK5CYII=","orcid":"","institution":"Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Sakiko","middleName":"","lastName":"Hiraoka","suffix":""},{"id":370233910,"identity":"c1e81916-3a41-42c9-a7f9-45dc139c609b","order_by":3,"name":"Mikako Ishiguro","email":"","orcid":"","institution":"Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mikako","middleName":"","lastName":"Ishiguro","suffix":""},{"id":370233911,"identity":"46d4e706-1cbe-4ef9-b9a8-16156912b3a6","order_by":4,"name":"Junki Toyosawa","email":"","orcid":"","institution":"Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Junki","middleName":"","lastName":"Toyosawa","suffix":""},{"id":370233912,"identity":"1a15c681-661a-43d4-93be-bd37946b4688","order_by":5,"name":"Yuki Aoyama","email":"","orcid":"","institution":"Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Yuki","middleName":"","lastName":"Aoyama","suffix":""},{"id":370233913,"identity":"65f5dea9-d95a-4f14-b721-b661e6a5a656","order_by":6,"name":"Shoko Igawa","email":"","orcid":"","institution":"Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Shoko","middleName":"","lastName":"Igawa","suffix":""},{"id":370233914,"identity":"5d98a0a5-ac87-49e1-8929-dde6b43001c9","order_by":7,"name":"Keiko Takeuchi","email":"","orcid":"","institution":"Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Keiko","middleName":"","lastName":"Takeuchi","suffix":""},{"id":370233915,"identity":"82ea98eb-06ac-4484-9f19-c909eb97ec3b","order_by":8,"name":"Yasushi Yamasaki","email":"","orcid":"","institution":"Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Yasushi","middleName":"","lastName":"Yamasaki","suffix":""},{"id":370233916,"identity":"379868e1-8d9f-4d58-9175-fe948dbe50f9","order_by":9,"name":"Hideaki Kinugasa","email":"","orcid":"","institution":"Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Hideaki","middleName":"","lastName":"Kinugasa","suffix":""},{"id":370233917,"identity":"ae7bc258-4daa-4cde-8b83-31baf51705d5","order_by":10,"name":"Masahiro Takahara","email":"","orcid":"","institution":"Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Masahiro","middleName":"","lastName":"Takahara","suffix":""},{"id":370233918,"identity":"01fb3336-9059-412a-a068-f81b3e83b205","order_by":11,"name":"Seiji Kawano","email":"","orcid":"","institution":"Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Seiji","middleName":"","lastName":"Kawano","suffix":""},{"id":370233919,"identity":"03fc80b8-57e0-4ff3-91f1-883f57f0bc1b","order_by":12,"name":"Motoyuki Otsuka","email":"","orcid":"","institution":"Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Motoyuki","middleName":"","lastName":"Otsuka","suffix":""}],"badges":[],"createdAt":"2024-10-24 02:53:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5322202/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5322202/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12876-025-03880-5","type":"published","date":"2025-05-13T15:56:57+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":69238682,"identity":"60f78189-0a55-430b-ab32-d115483e9ef6","added_by":"auto","created_at":"2024-11-18 10:01:58","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":66502,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCorrelation between the values of the single use of non-invasive markers and the mSES-CD.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe values of each marker (\u003cstrong\u003eA, \u003c/strong\u003eLRG, \u003cstrong\u003eB, \u003c/strong\u003eCRP, and \u003cstrong\u003eC,\u003c/strong\u003e Fcal) and mSES-CD in the enrolled cases. LRG, leucine-rich alpha-2 glycoprotein; CRP, C-reactive protein; Fcal, fecal calprotectin; mSES-CD, modified simple endoscopic score for Crohn’s disease. Parallel dotted lines show the cut-off values of the non-invasive markers used in this study. The cut-off values were as follows: LRG, 13.2 µg/mL; CRP, 0.15 mg/dL; and Fcal, 180 µg/g.\u003c/p\u003e","description":"","filename":"Slide1.png","url":"https://assets-eu.researchsquare.com/files/rs-5322202/v1/fdaa157b8976d297225b4347.png"},{"id":69238686,"identity":"afb360dd-5c16-4bf1-a255-c03b079ecf08","added_by":"auto","created_at":"2024-11-18 10:01:58","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":150747,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePredictive diagnostic ability by the single use of the individual non-invasive markers for predicting endoscopic remission in CD\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(A) \u003c/strong\u003eThe values of each marker were significantly decreased in the group with endoscopic remission. Parallel dotted lines show the cutoff values of the serum/fecal biomarkers in this study: LRG, 13.2 µg/mL; CRP, 0.15 mg/dL; and Fcal, 180 µg/g.\u003cstrong\u003e (B) \u003c/strong\u003eThe\u003cstrong\u003e \u003c/strong\u003ediagnostic ability of the single use of each marker for endoscopic remission. \u003cstrong\u003e(C) \u003c/strong\u003eThe\u003cstrong\u003e \u003c/strong\u003ereceiver operating characteristic curve for the diagnosis of endoscopic remission by single use of each marker. LRG, leucine-rich alpha-2 glycoprotein; CRP, C-reactive protein; Fcal, fecal calprotectin; Sens, sensitivity; Spec, specificity; PPV, positive predictive value; NPV, negative predictive value; AUC, area under the curve.\u003c/p\u003e","description":"","filename":"Slide2.png","url":"https://assets-eu.researchsquare.com/files/rs-5322202/v1/8240a74550551cf1c1c5a66f.png"},{"id":69238687,"identity":"8836d419-3779-46da-980c-a08db7d1945b","added_by":"auto","created_at":"2024-11-18 10:01:58","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":89757,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe 3-marker method is superior to other combination methods using any 2 of the 3 markers\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe receiver operating characteristic curves for predicting endoscopic remission using combinations of 2 or 3 markers. The results of the comparison of AUCs using the support vector machine for validation are shown. LRG, leucine-rich alpha-2 glycoprotein; CRP, C-reactive protein; Fcal, fecal calprotectin; AUC, area under the curve.\u003c/p\u003e","description":"","filename":"Slide3.png","url":"https://assets-eu.researchsquare.com/files/rs-5322202/v1/f454abf12cce7a6f02d8438a.png"},{"id":69238683,"identity":"b4786124-85b7-420c-90a5-238b684cedb3","added_by":"auto","created_at":"2024-11-18 10:01:58","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":82653,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eKaplan-Meier curves for the rate of relapse, hospitalization, and surgery stratified with the results of 3 markers.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(A)\u003c/strong\u003e \u003cstrong\u003eRelapse (B) Hospitalization (C) Surgery\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients with two or more negative markers had a more favorable prognosis, including a reduced risk of relapse, hospitalization, and surgery (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.0001, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001, and \u003cem\u003eP\u003c/em\u003e\u0026lt; 0.05, respectively).\u003c/p\u003e","description":"","filename":"Slide4.png","url":"https://assets-eu.researchsquare.com/files/rs-5322202/v1/21a03a1c11f7637f111b57fe.png"},{"id":69238684,"identity":"36bff51d-ddd7-4da9-816f-6562f50f0953","added_by":"auto","created_at":"2024-11-18 10:01:58","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":178036,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe “2-step method” using 3 markers showed the best predictive diagnostic ability for predicting endoscopic remission in CD.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(A)\u003c/strong\u003e The flow of the “2-step method” for predicting endoscopic remission in CD patients. (\u003cstrong\u003eB) \u003c/strong\u003eA scatter plot using the CRP and LRG results and additional evaluation by Fcal in the discordant groups. (\u003cstrong\u003eC) \u003c/strong\u003eThe diagnostic ability of the 2-step method for prediction of endoscopic remission in patients with CD. LRG, leucine-rich alpha-2 glycoprotein; CRP, C-reactive protein; Fcal, fecal calprotectin; Sens, sensitivity; spec, specificity; PPV, positive predictive value; NPV, negative predictive value.\u003c/p\u003e","description":"","filename":"Slide5.png","url":"https://assets-eu.researchsquare.com/files/rs-5322202/v1/92fc83c5e9d3f0aad1ef0cd5.png"},{"id":83067760,"identity":"6eecc98a-053a-44d1-b675-edcb61d0d41b","added_by":"auto","created_at":"2025-05-19 16:05:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1841232,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5322202/v1/6bf74ef4-5dc5-4bfa-a0d4-3a832fb564d6.pdf"},{"id":69238689,"identity":"a75a66c8-5ee3-46b2-bc15-04da37fefa24","added_by":"auto","created_at":"2024-11-18 10:01:58","extension":"pptx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":100186,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFigure.pptx","url":"https://assets-eu.researchsquare.com/files/rs-5322202/v1/b9dc7bd43faf9067f9beae9e.pptx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Efficient predictive diagnosis for endoscopic remission in Crohn’s diseases by the combination of three non-invasive markers","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eCrohn's disease (CD) is a progressive and intractable inflammatory bowel disease that affects the entire gastrointestinal tract, with small intestinal involvement in 75% of patients.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e If the inflammation is not properly controlled, irreversible damage accumulates in the intestinal tract, eventually leading to strictures, fistulas, multiple surgeries, and a significant reduction in the patient's quality of life\u003csup\u003e23\u003c/sup\u003e. On the other hand, the emergence of advanced therapies has led to endoscopic remission with a decrease in surgical and admission rates and has brought the treatment to target conception\u003csup\u003e45\u003c/sup\u003e. Precise assessment of the disease status and timely therapeutic intervention can reduce the risk of recurrence\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Early detection of flare-ups and appropriate therapeutic intervention to minimize damage to the intestinal tract are paramount in treating CD\u003csup\u003e57\u003c/sup\u003e. In particular, monitoring the disease status of patients with CD, including small intestinal lesions, has become a major clinical concern.\u003c/p\u003e \u003cp\u003eSerum C-reactive protein (CRP) and fecal calprotectin (Fcal) have been reported to be useful surrogate markers of bowel inflammation in patients with CD\u003csup\u003e\u003cspan additionalcitationids=\"CR9 CR10 CR11\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. In particular, Fcal shows a high correlation with endoscopic severity and can non-invasively diagnose mucosal healing with high accuracy. Leucine-rich alpha-2 glycoprotein (LRG) is a novel serum marker for inflammatory bowel disease (IBD) and has been recently reported to be more accurate than CRP as a marker of endoscopic severity and might be equivalent to Fcal\u003csup\u003e\u003cspan additionalcitationids=\"CR14 CR15\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. However, previous reports have been limited to evaluating the efficacy of individual markers or the combination of 2 markers, and the predictive ability of these markers for diagnosing endoscopic remission was not satisfactory. Because there have been no attempts to evaluate disease activity using 3 markers for monitoring patients with CD, we aimed to determine the efficacy of the predictive diagnostic performance by combining 3 markers: CRP, LRG, and Fcal.\u003c/p\u003e"},{"header":"MATERIALS and METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eConsecutive CD patients who underwent endoscopy at Okayama University Hospital between September 2014 and July 2023 and whose stool and blood samples were scheduled to be collected were considered eligible for this study. All patients had undergone previous endoscopic examinations with findings of active inflammation in the colon, in the small bowel, or in both. CD patients with colonic lesions alone underwent colonoscopy, while CD patients with lesions in the small bowel underwent balloon-assisted enteroscopy (BAE). All patients provided blood samples for the determination of serum LRG and CRP levels on the morning of the day when endoscopy was performed. In addition, all patients were instructed to collect stool samples at home within 2 days before endoscopy and bring them to the hospital on the day of endoscopy to test the Fcal values. The patients\u0026rsquo; clinical characteristics, including age at the diagnosis, sex, disease location, disease behavior, and current medications, were obtained. The clinical disease activity for patients with CD was evaluated using the Crohn\u0026rsquo;s disease activity index (CDAI), with clinical remission defined as CDAI\u0026thinsp;\u0026lt;\u0026thinsp;150.\u003c/p\u003e \u003cp\u003eThe exclusion criteria were insufficient stool collection, having had a colostomy or ileostomy, and failure to achieve full endoscopic observation of the lesions. In addition, patients with background factors that could affect the levels of LRG, CRP, and Fcal, including uncontrolled perianal disease, extraintestinal complications, collagen disease, heart failure, infectious disease, immediate postvaccination, and malignancy at the time of endoscopy, were excluded.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEndoscopy procedures and the assessment of endoscopic disease activity\u003c/h3\u003e\n\u003cp\u003eBowel preparation was conducted using either a polyethylene glycol-based or magnesium citrate-based electrolyte solution, following the standard protocol of our hospital, and colonoscopy or BAE was performed. A double-balloon enteroscope EN-580T (Fujifilm, Tokyo, Japan) was used by experienced endoscopists (T.I. and S.K.). The DBE scope was inserted into the proximal small intestine as far as possible using a retrograde approach. Complete observation of the affected lesions was accomplished in all patients, and those in whom the affected lesions could not be fully evaluated (e.g., due to stenosis) were excluded.\u003c/p\u003e \u003cp\u003eThe endoscopic assessment was scored according to the modified simple endoscopic score for Crohn\u0026rsquo;s disease (mSES-CD), which was modified for the evaluation of small bowel lesions, as well as colonic lesions based on the original SES-CD\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. The small intestine was divided into 2 segments: the distal and proximal ileum. The distal ileum was defined as the portion of the ileum within 40 cm from the ileocecal valve or anastomosis, whereas the proximal ileum was defined as the deeper part of the ileum\u0026thinsp;\u0026ge;\u0026thinsp;40 cm proximal to those points\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. mSES-CD was calculated by determining sum of the scores of 6 bowel segments (proximal and distal parts of the small intestine, right colon, transverse colon, left colon, and rectum). We excluded the scoring item \u0026ldquo;strictures\u0026rdquo; from the original SES-CD because it represents bowel damage rather than active inflammation. Thus, we evaluated the scores for the size of the ulcers, ulcerated surface, and affected surface in each segment\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. In addition, for anastomotic lesions, only ulcers (size score\u0026thinsp;\u0026gt;\u0026thinsp;2) were defined as being derived from CD. Endoscopic remission was defined as an mSES-CD of 0\u0026ndash;2. Endoscopic findings were evaluated with the endoscopist blinded to the results of serum and fecal markers.\u003c/p\u003e\n\u003ch3\u003eThe measurement of serum LRG levels\u003c/h3\u003e\n\u003cp\u003eSerum samples were collected by centrifuging blood samples at 1,500 rpm for 15 min, divided into aliquots, and stored at -80\u0026deg;C until use. Serum LRG levels were analyzed in an in-hospital laboratory using a NANOPIA LRG (SEKISUI MEDICAL Company Limited, Tokyo, Japan). The measuring reagents were provided by the Laboratory for SEKISUI MEDICAL Company Limited. The Laboratory for Sekisui Medical funded a portion of the LRG-measuring reagent cost.\u003c/p\u003e\n\u003ch3\u003eFecal calprotectin analysis\u003c/h3\u003e\n\u003cp\u003eThe fecal samples collected by the patients were stored at \u0026minus;\u0026thinsp;30\u0026deg;C until shipment to the laboratory, where the calprotectin analysis was performed. The samples were sent to BML (Tokyo, Japan), where the level of calprotectin in stool specimens was measured with a fluorescence enzyme immunoassay using Phadia EliA\u0026trade; Calprotectin 2 (Thermo Fisher Scientific, Phadia AB, Uppsala, Sweden).\u003c/p\u003e\n\u003ch3\u003ePatient prognosis\u003c/h3\u003e\n\u003cp\u003eThe relationship between the results of 3 markers and patient prognosis, including relapse rate, CD-related hospitalization rate, and CD-related surgery rate, was evaluated during observation periods. Relapse was defined as a requirement for a change in treatment (i.e., the use of corticosteroids, the administration of a new biologic therapy, or a change in biologic therapy).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analyses\u003c/h2\u003e \u003cp\u003eSpearman\u0026rsquo;s rank correlation test was performed to determine the correlation coefficient between the serum and fecal marker levels. A receiver operating characteristic curve (ROC) analysis was used to assess the discriminatory performance of Fcal, LRG, and CRP for detecting endoscopic status and to determine the cut-off levels of these markers for the non-invasive predictive diagnosis of endoscopic remission using the Youden\u0026rsquo;s index. The results are expressed as the area under the curve (AUC) with sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy, with 95% confidence intervals (CI). Two different classifiers were adopted: k-fold cross-validation and a support vector machine (SVM) to validate the predictive diagnostic ability of multiple markers. Regarding k-fold cross-validation, we performed cross-validation from 2-fold to 10-fold on each subject's data and adopted the k value with the highest diagnostic ability\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. Analyses of relapse, hospitalization, and colectomy rates were carried out using the Kaplan and Meier method. Statistical comparison was carried out by Log-rank test. Univariate analysis using a Cox proportional hazard model were also conducted to evaluate the risks for prognosis. All \u003cem\u003eP\u003c/em\u003e-values were 2-sided, and \u003cem\u003eP\u003c/em\u003e-values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered to indicate statistical significance. The data underlying this article will be shared upon reasonable request by the corresponding author. All statistical analyses were conducted using the JMP software program (version 16.0 pro for Windows, SAS Institute Inc., Cary, NC, USA).\u003c/p\u003e \u003c/div\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthical statements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board of the Okayama University Graduate School of Medicine (IRB number: 1904-035) conducted in accordance\u0026nbsp;with the Declaration of Helsinki. All studies were performed in accordance with the relevant guidelines and regulations. Informed consent was obtained from each patient\u0026nbsp;and/or their legal guardians.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eClinical characteristics of the enrolled patients\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong 268 consecutive outpatients with CD enrolled in this study, 38 patients, whose Fcal values could not be measured due to insufficient stool specimens were excluded. The remaining 230 patients (149 males and 81 females; median age at diagnosis, 24 years) were included in this study. These patients underwent endoscopy and their serum and fecal markers were examined simultaneously. The clinical characteristics of the patients and their values are summarized in Table 1. Regarding the disease locations of the 230 cases, 50 (22%) had ileal lesions alone, 47 (20%) had colonic lesions alone, and 133 (58%) had ileocolonic lesions. All patients with ileal lesions underwent BAE, regardless of the presence or absence of lesions proximal to the terminal ileum. A tumor necrosis factor-alpha antagonist was administered to 125 patients (54%) and thiopurine was administered to 98 patients (43%). Of the 230 patients, 155 (67%) were in clinical remission, whereas 75 (33%) had clinically active disease. The endoscopic findings were as follows: mSES-CD 0, n=97 (42%); mSES-CD 1\u0026ndash;2, , n=19 (8%); mSES-CD 3\u0026ndash;4, n=54 (24%);\u0026nbsp;mSES-CD 5-10, n=57 (25%); and mSES-CD 11-15, n=2 (1%). The median (interquartile range [IQR]) values of these biomarkers were 13.1 (8.5-16.7) \u0026mu;g/mL for LRG, 0.10 (0.04-0.22) mg/dL for CRP, and 202 (61-687) \u0026mu;g/g for Fcal.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCorrelations between LRG/CRP/Fcal values and mSES-CD in patients with CD\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCorrelations between the mSES-CD and the values of each marker (LRG, CRP, and Fcal) were analyzed.\u0026nbsp;Spearman\u0026rsquo;s rank correlation coefficients and p-values\u0026nbsp;were as follows: LRG: \u003cem\u003er\u0026nbsp;\u003c/em\u003e= 0.69, \u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u0026lt; 0.0001; CRP: \u003cem\u003er\u0026nbsp;\u003c/em\u003e= 0.60, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.0001; and Fcal: \u003cem\u003er\u003c/em\u003e = 0.67, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.0001 (Figure 1). These results indicated that all 3 markers are significantly correlated with mSES-CD and that LRG and Fcal show the highest correlations when limited to the cases with ileal lesions (\u003cem\u003er\u0026nbsp;\u003c/em\u003e= 0.63) and limited to the cases with ileocolonic lesions\u003cem\u003e\u0026nbsp;(r\u0026nbsp;\u003c/em\u003e= 0.73, respectively (Supplementary Figure 1-3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNext, the predictive abilities of each marker for diagnosing endoscopic remission were assessed individually.\u0026nbsp;When comparing the cases with endoscopic remission and the cases with endoscopically active lesions, the values of each marker were significantly lower in the endoscopic remission group than in the \u0026ldquo;endoscopic active\u0026rdquo; group (Figure 2A; LRG, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.0001; CRP, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.0001; and Fcal, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.0001). The AUC values for endoscopic remission were as follows: LRG, 0.886; CRP, 0.816; and Fcal, 0.876. The optimal cut-off levels of each marker to diagnose non-invasively the\u0026nbsp;endoscopic remission\u0026nbsp;was as follows: LRG, 13.2\u0026nbsp;\u0026mu;g/mL; CRP, 0.15 mg/dL and Fcal, 180 \u0026mu;g/g (Figure 2B). Only LRG and CRP showed statistically significant differences in AUC values (\u003cem\u003eP\u003c/em\u003e = 0.02).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eA combinatorial method using 2 markers to diagnose endoscopic remission in patients with CD\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhen evaluating the predictive diagnostic ability of the combination using only 2 of the 3 markers, the accuracy was not superior to any of the individual markers, regardless of the combination (Table 2; upper part). Among these, the combination of CRP and LRG had the best predictive ability for the diagnosis of endoscopic remission. The sensitivity, specificity, PPV, NPV, accuracy rate, and AUC were 74.2%, 90.0%, 89.0%, 76.2%, 81.7%, and 0.831, respectively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eA combination method using all 3 markers to diagnose endoscopic remission in patients with CD\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNext, all 3 markers (CRP, LRG, and Fcal) were simultaneously used to predictively diagnose the endoscopic activity. In this case, \u0026ldquo;endoscopic remission\u0026rdquo; was predicted when 2 or more markers were negative, and \u0026ldquo;endoscopic active\u0026rdquo; disease was predicted when 2 or more markers were positive. The predictive diagnostic ability for endoscopic remission was improved in comparison to individual markers or the combination of any 2 markers. The sensitivity, specificity, PPV, NPV, and accuracy rates were 89.4%, 83.3%, 81.6%, 90.5%, and 86.1%, respectively (Table 2; lower part). Furthermore, if endoscopic remission was defined as all 3 negative markers with negative, the sensitivity, specificity, PPV, NPV, and accuracy in the diagnosis of endoscopic remission were 71.3%, 100%, 100%, 60.3%, and 80.0%, respectively.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eValidation of the predictive diagnostic ability of the combination method using 3 markers in patients with CD\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo validate the predictive diagnostic ability of the combination method using the 3 markers, we first performed k-fold cross-validation by comparing it with other combinations using CRP, LRG, and Fcal (Supplemental Table 1). The combination method using 3 markers was superior in terms of sensitivity, specificity, and accuracy compared to other combination methods, when the negativity of 2 or more markers predicted endoscopic remission.\u0026nbsp;Next, we compared the predictive diagnostic abilities of the combination method using 3 markers and those of the existing 2-marker methods using a different classifier: support vector machines (SVM) (Figure 3). In these analyses, the 3-marker method, in which negativity of 2 or more markers was defined as endoscopic remission, had the highest AUC value (AUC: 0.856) and was significantly superior to the AUC values of the combination of CRP (-) and LRG (-), and of the combination of CRP (-) and Fcal (-), in terms of the ability to diagnose endoscopic remission (AUC: 0.772, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.0005, and 0.777, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001, respectively). These results suggest that the 3-marker method is superior to other combination methods using any 2 of the 3 markers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eThe long-term prognosis of the patients with CD\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the median observation period of 3.6 years (IQR; 1.8-4.7), 35 patients had a relapse requiring a change in treatment, 14 were hospitalized, and 13 underwent surgery due to the disease course of CD. Kaplan-Meier analysis showed that Patients with two or more negative of the three markers had a more favorable prognosis in terms of reduced risk of relapse, with a hazard ratio (HR) of 0.20 (95% CI: 0.09-0.45, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.0001) (Figure 4A). Similarly, patients with two or more negative markers were significantly more likely to avoid hospitalization (HR: 0.21 (95% CI: 0.06-0.77, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001) and surgery (HR: 0.24 (95% CI: 0.07-0.88),\u003cem\u003e\u0026nbsp;P\u003c/em\u003e \u0026lt; 0.05) (Figure 4B and 4C).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eA 2-step method using 3 markers is the best predictive diagnostic method for endoscopic remission in patients with CD\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhile LRG and CRP are convenient as serum markers, Fcal, a fecal marker, has some inconvenience because it requires stool and sample collection for testing. Therefore, from a practical perspective, we next examined the predictive diagnostic ability of a \u0026ldquo;2-step method\u0026rdquo; using the markers for the predictive diagnosis of endoscopic remission (Figure 5A). To establish the 2-step method, we first drew a scatterplot based on the values of serum markers, CRP, and LRG. Then, the patients were divided into four groups using the optimal cut-off values. The 2 groups with double-positive (CRP [+] and LRG [+]) or double-negative (CRP [-] and LRG [-]) were defined as \u0026ldquo;endoscopic remission\u0026rdquo; or \u0026ldquo;endoscopic active\u0026rdquo; (blue and red groups) (Figure 5B). For other groups that showed positivity for CRP or LRG (yellow groups), Fcal was measured as the second step. We determined whether the case was in \u0026ldquo;endoscopic remission\u0026rdquo; or \u0026ldquo;endoscopic active\u0026rdquo; based on the Fcal results. Using this \u0026ldquo;2-step method\u0026rdquo;, the sensitivity, specificity, PPV, NPV, and accuracy rate for endoscopic remission were 89.4%, 83.3%, 81.6%, 90.5%, and 86.1% (Figure 5C). As a result, this 2-step method had the highest predictive diagnostic ability among the measurement methods while minimizing the burden of the measurement of Fcal, which may be beneficial for the patient and from the viewpoint of medical economics.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe non-invasive predictive diagnosis of the endoscopic lesions is crucial for monitoring patients with CD. This study demonstrated that the predictive diagnostic accuracy for the non-invasive diagnosis of endoscopic remission was improved by the use of 3 markers: CRP, LRG, and Fcal. In particular, the 3-marker simultaneous measurement method was more effective than the single use of any individual marker or the 2-marker combination method and could predict the prognosis regarding relapse, hospitalization, and surgery. Moreover, instead of testing 3 markers simultaneously, it was possible by introducing the \u0026ldquo;2-step method\u0026rdquo; to reduce the number of Fcal measurements, which requires time and effort, without sacrificing the diagnostic accuracy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCD irreversibly causes inflammatory damage to the intestinal tract, and close and continuous monitoring is essential to prevent intestinal complications and implement a treat-to-target strategy\u003csup\u003e6\u003c/sup\u003e. In particular, approximately 80% of patients with CD have small intestinal lesions, and it is necessary to not only evaluate the terminal ileum but also perform a close examination of the small intestine using a small intestine endoscope\u003csup\u003e1\u003c/sup\u003e. However, endoscopic follow-up of the intestinal tract, including the small intestine, is highly invasive, making it difficult to perform frequent small intestine endoscopy, and less invasive and less costly markers are recommended for monitoring. The evidence of CRP and Fcal has been well established for monitoring disease activity in patients with CD. Additionally, based on recent reports, the accuracy rate of LRG alone for diagnosing endoscopic remission was estimated to be approximately 80%, which is more useful than CRP and has been reported to be at the same level as Fcal\u003csup\u003e14,15\u003c/sup\u003e. However, there have been no reports on the 3 types of combinations of markers, and this is the first report on the potential of the combination of LRG with CRP and Fcal to improve the accuracy rate for diagnosing endoscopic remission. Two distinct statistical validation methods (k-fold cross-validation and SVM) were employed to assess the predictive diagnostic ability of endoscopic remission using a combination of 3 distinct markers and it was demonstrated that the number of positive markers among the three significantly predicted the long-term prognosis, including relapse rate, hospitalization rate and surgery rate. Furthermore, the \u0026ldquo;2-step method\u0026rdquo; would be beneficial in determining whether a certain number of patients were in endoscopic remission based solely on blood markers, eliminating the inconvenience of treating stool samples. In fact, 38 patients whose Fcal levels could not be measured owing to insufficient stool specimens were excluded from this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe present study was associated with several limitations. First, the study was conducted at a single hospital, which may introduce bias, as the patient group may be dominated by those with mild disease activities. Approximately 70% of the patients in this study were treated with biologics, possibly because of their generally mild endoscopic severity. To demonstrate the reproducibility and universality of the results, studies should be conducted at multiple institutions. Further verification of the LRG cut-off value for the diagnosis of endoscopic remission is necessary. Although previous reports commonly use a cut-off value of 13-14 ng/dl, because there are various evaluation methods for small intestinal lesions in CD, more investigation is required\u003csup\u003e14,15,16\u003c/sup\u003e. Third, currently in Japan, the medical insurance system does not allow simultaneous measurement of all 3 markers. In light of these circumstances, the implementation of a 2-step methodology allows for the identification of high-risk cases, followed by additional fecal calprotectin testing in cases suspected of being at risk in actual clinical practice. This approach offers the potential for more cost-effective and patient-centered care.\u003c/p\u003e\n\u003cp\u003eIn conclusion, our study demonstrated that combining CRP, Fcal, and LRG can be a non-invasive diagnostic tool that can predict endoscopic remission with greater accuracy and long-term prognosis. Further research is necessary to determine more appropriate cut-off values and to identify more effective ways of utilizing these markers.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eACKOWLEDGMENTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinancial Support:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Source:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by JSPS KAKENHI [Grant Number JP20K12669, JP23K11871] to S.H.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest in association with the present study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data supporting the findings of this study are available on reasonable request to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization, SH; data curation, MI, JT, YA, SI, KT, YY, HK, MT, and SK; validation, formal analysis, investigation, and resources, SH; writing\u0026mdash;original draft preparation, KT; writing\u0026mdash;review and editing, TI; supervision, MO. All authors read, reviewed, and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMatsuoka K, Fujii T, Okamoto R, Yamada A, Kunisaki R, Matsuura M, Watanabe K, Shiga H, Takatsu N, Bamba S, et al. Characteristics of adult patients newly diagnosed with Crohn's disease: interim analysis of the nation-wide inception cohort registry study of patients with Crohn's disease in Japan (iCREST-CD). J Gastroenterol. 2022;57(1):867\u0026ndash;78.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGomoll\u0026oacute;n F, Dignass A, Annese V, Tilg H, Van Assche G, Lindsay JO, Peyrin-Biroulet L, Cullen GJ, Daperno M, Kucharzik T, et al. 3rd European Evidence-based Consensus on the Diagnosis and Management of Crohn's Disease 2016: Part 1: Diagnosis and Medical Management. J Crohns Colitis. 2017;11(1):3\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRutgeerts P, Geboes K, Vantrappen G, Beyls J, Kerremans R, Hiele M. Predictability of the postoperative course of Crohn\u0026rsquo;s disease. Gastroenterology. 1990;99(4):956\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eColombel JF, Narula N, Peyrin-Biroulet L. Management strategies to improve outcomes of patients with inflammatory bowel diseases. Gastroenterology. 2017;152(2):351\u0026ndash;e615.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDittrich AE, Sutton RT, Haynes K, Wang H, Fedorak RN, Kroeker KI. Incidence rates for surgery in Crohn's disease have decreased: a population-based time-trend analysis. Inflamm Bowel Dis. 2020;26(12):1909\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTurner D, Ricciuto A, Lewis A, D'Amico F, Dhaliwal J, Griffiths AM, Bettenworth D, Sandborn WJ, Sands BE, Reinisch W, et al. STRIDE-II: An Update on the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) Initiative of the International Organization for the Study of IBD (IOIBD): Determining Therapeutic Goals for Treat-to-Target strategies in IBD. Gastroenterology. 2021;160(5):1570\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Cruz P, Kamm MA, Hamilton AL, Ritchie KJ, Krejany EO, Gorelik A, Liew D, Prideaux L, Lawrance IC, Andrews JM, Bampton PA, Gibson PR, Sparrow M, et al. Crohn\u0026rsquo;s disease management after intestinal resection: a randomised trial. Lancet. 2015;385(9976):1406\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchoepfer AM, Beglinger C, Straumann A, Trummler M, Vavricka SR, Bruegger LE, Seibold F. Fecal calprotectin correlates more closely with the Simple Endoscopic Score for Crohn's disease (SES-CD) than CRP, blood leukocytes, and the CDAI. Am J Gastroenterol. 2010;105(1):162\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLanghorst J, Elsenbruch S, Koelzer J, Rueffer A, Michalsen A, Dobos GJ. Noninvasive markers in the assessment of intestinal inflammation in inflammatory bowel diseases: performance of fecal lactoferrin, calprotectin, and PMN-elastase, CRP, and clinical indices. Am J Gastroenterol. 2008;103(1):162\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMosli MH, Zou G, Garg SK, Feagan SG, MacDonald JK, Chande N, Sandborn WJ, Feagan BG. C-Reactive protein, fecal calprotectin, and stool lactoferrin for detection of endoscopic activity in symptomatic inflammatory bowel disease patients: a systematic review and meta-analysis. Am J Gastroenterol. 2015;110(6):802\u0026ndash;19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInokuchi T, Kato J, Hiraoka S, Takashima S, Nakarai A, Takei D, Sugihara Y, Takahara M, Kawano S, Harada K, et al. Fecal immunochemical test versus fecal calprotectin for prediction of mucosal healing in Crohn's disease. Inflamm Bowel Dis. 2016;22(5):1078\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMa C, Lumb R, Walker EV, Foshaug RR, Dang TT, Verma S, Huang VW, Kroeker KI, Wong K, Dieleman LA, et al. Noninvasive fecal immunochemical testing and fecal calprotectin predict mucosal healing in inflammatory bowel disease: A prospective cohort study. Inflamm Bowel Dis. 2017;23(9):1643\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNaka T, Fujimoto M. LRG is a novel inflammatory marker clinically useful for the evaluation of disease activity in rheumatoid arthritis and inflammatory bowel disease. Immunol Med. 2018;41(2):62\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYasutomi E, Inokuchi T, Hiraoka S, Takei K, Igawa S, Yamamoto S, Ohmori M, Oka S, Yamasaki Y, Kinugasa H, et al. Leucine-rich alpha-2 glycoprotein as a marker of mucosal healing in inflammatory bowel disease. Sci Rep. 2021;11(1):11086.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTakenaka K, Kitazume Y, Kawamoto A, Fujii T, Udagawa Y, Watanaabe R, Shimizu H, Hibiya S, Nagahori M, Ohtsuka K, et al. Serum leucine-rich α2 glycoprotein: a novel biomarker for transmural inflammation in Crohn's disease. Am J Gastroenterol. 2023;118(6):1028\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKawamoto A, Takenaka K, Hibiya S, Kitazume Y, Shimizu H, Fujii T, Saito E, Ohtsuka K, Okamoto R. Combination of leucine-rich alpha-2 glycoprotein and fecal markers detect Crohn's disease activity confirmed by balloon-assisted enteroscopy. Intest Res. 2024;2(12):65\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDaperno M, D\u0026rsquo;Hans G, Van Assche G, Baert F, Bulois P, Maunoury V, Sostegni R, Rocca R, Pera A, Gevers A, et al. Development and validation of a new, simplified endoscopic activity score for Crohn's disease: the SES-CD. Gastrointest Endosc. 2004;60(4):505\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorise K, Ando T, Watanabe O, Nakamura M, Miyahara R, Maeda O, Ishiguro K, Hirooka Y, Goto H. Clinical utility of a new endoscopic scoring system for Crohn's disease. World J Gastroenterol. 2015;21(34):9974\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerre CL, Sandborn WJ, Ardhi S, Devignes MD, Fournier L, Sma\u0026iuml;l-Tabbone M, Danese S, Peyrin-Biroulet L. Application of artificial intelligence to gastroenterology and hepatology. Gastroenterol. 2020;158(1):76\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFialoke S, Malarstig A, Miller MR, Dumitriu A. Application of machine learning methods to predict non-alcoholic steatohepatitis (NASH) in non-alcoholic fatty liver (NAFL) patients. AMIA Annu Symp Proc. 2018;2018(12):430\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMao J, Chao K, Jiang FL, Ye XP, Yang T, Li P, Zhu X, Hu PJ, Zhou BJ, Huang M, et al. Comparison and development of machine learning for thalidomide-induced peripheral neuropathy prediction of refractory Crohn's disease in Chinese population. World J Gastroenterol. 2023;29(24):3855\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. Characteristics of the patients enrolled in this study.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"614\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 341px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 274px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 327px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 274px;\"\u003e\n \u003cp\u003en = 230 (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 327px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 274px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 314px;\"\u003e\n \u003cp\u003e\u0026nbsp; Male/Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 274px;\"\u003e\n \u003cp\u003e149 (65)/81 (35)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 327px;\"\u003e\n \u003cp\u003eMedian (IQR) age of undergoing endoscopy (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 274px;\"\u003e\n \u003cp\u003e44 (34-57)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 327px;\"\u003e\n \u003cp\u003eMedian (IQR) duration of disease (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 274px;\"\u003e\n \u003cp\u003e12 (4.4-21)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 327px;\"\u003e\n \u003cp\u003eMedian (IQR) age at diagnosis (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 274px;\"\u003e\n \u003cp\u003e24 (19-34)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 313px;\"\u003e\n \u003cp\u003e\u0026nbsp; A1: \u0026lt;16 /A2:16-40 /A3:\u0026gt;40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 274px;\"\u003e\n \u003cp\u003e36 (16)/166 (72)/28 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 327px;\"\u003e\n \u003cp\u003eNumber of endoscopy procedures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 274px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 314px;\"\u003e\n \u003cp\u003e\u0026nbsp; 1/2/ \u0026gt;3\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 274px;\"\u003e\n \u003cp\u003e84 (59)/40 (28)/19 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 327px;\"\u003e\n \u003cp\u003eDisease location\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 274px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 314px;\"\u003e\n \u003cp\u003e\u0026nbsp; L1: ileal /L2: colonic /L3: ileocolonic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 274px;\"\u003e\n \u003cp\u003e50 (22)/47 (20) /133 (58)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 327px;\"\u003e\n \u003cp\u003eDisease behavior\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 274px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 314px;\"\u003e\n \u003cp\u003e\u0026nbsp; B1: inflammation /B2: stricturing /B3: penetrating\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 274px;\"\u003e\n \u003cp\u003e75 (33)/94 (41)/61 (26)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 314px;\"\u003e\n \u003cp\u003ePerianal disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 274px;\"\u003e\n \u003cp\u003e98 (43)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 327px;\"\u003e\n \u003cp\u003eCDAI score (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 274px;\"\u003e\n \u003cp\u003e135 (58-179)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 327px;\"\u003e\n \u003cp\u003eClinical remission*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 274px;\"\u003e\n \u003cp\u003e155 (67)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 327px;\"\u003e\n \u003cp\u003ePrevious intestinal resection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 274px;\"\u003e\n \u003cp\u003e130 (57)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 327px;\"\u003e\n \u003cp\u003eSmoking (current/ex/never)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 274px;\"\u003e\n \u003cp\u003e12 (5)/25 (11)/ 193 (84)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 327px;\"\u003e\n \u003cp\u003eConcomitant medications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 274px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 314px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;5-aminosalycylic acid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 274px;\"\u003e\n \u003cp\u003e153 (67)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 314px;\"\u003e\n \u003cp\u003e\u0026nbsp; Corticosteroids\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 274px;\"\u003e\n \u003cp\u003e31 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 314px;\"\u003e\n \u003cp\u003e\u0026nbsp; Thiopurine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 274px;\"\u003e\n \u003cp\u003e98 (43)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 314px;\"\u003e\n \u003cp\u003e\u0026nbsp; TNF-alpha antagonist\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 274px;\"\u003e\n \u003cp\u003e125 (54)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 314px;\"\u003e\n \u003cp\u003e\u0026nbsp; Vedolizumab\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 274px;\"\u003e\n \u003cp\u003e1 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 314px;\"\u003e\n \u003cp\u003e\u0026nbsp; Ustekinumab\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 274px;\"\u003e\n \u003cp\u003e32 (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 314px;\"\u003e\n \u003cp\u003e\u0026nbsp; Elemental diet\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 274px;\"\u003e\n \u003cp\u003e128 (56)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e(continued)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"614\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 55.2846%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEndoscopy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 44.7154%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.43902%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 52.8455%;\"\u003e\n \u003cp\u003eTotal colonoscopy /Balloon-assisted enteroscopy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 44.7154%;\"\u003e\n \u003cp\u003e47 (20)/183 (80)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.43902%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 52.8455%;\"\u003e\n \u003cp\u003eEndoscopy findings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 44.7154%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.43902%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 2.43902%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 50.4065%;\"\u003e\n \u003cp\u003emSES-CD 0 /1-2 /3-4 /5-10 /11-15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 44.7154%;\"\u003e\n \u003cp\u003e97 (42) /19 (8) /54 (24) /57 (25) /3 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.43902%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2.43902%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50.4065%;\"\u003e\n \u003cp\u003eendoscopic remission (\u0026le;2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 44.7154%;\"\u003e\n \u003cp\u003e116 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 55.2846%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 44.7154%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 55.2846%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eValues of biomarkers, median (IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 44.7154%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.43902%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 52.8455%;\"\u003e\n \u003cp\u003eLeucin rich alpha-2 glycoprotein (\u0026micro;g/mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 44.7154%;\"\u003e\n \u003cp\u003e13.1 (8.5-16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.43902%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 52.8455%;\"\u003e\n \u003cp\u003eC-reactive protein (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 44.7154%;\"\u003e\n \u003cp\u003e0.10 (0.04-0.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.43902%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 52.8455%;\"\u003e\n \u003cp\u003eFecal calprotectin (\u0026mu;g/g)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 44.7154%;\"\u003e\n \u003cp\u003e202 (61-687)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIQR, interquartile range; mSES-CD, modified simple endoscopic score for Crohn\u0026rsquo;s disease; CDAI, Crohn\u0026rsquo;s disease activity index; TNF, tumor necrosis factor.\u003c/p\u003e\n\u003cp\u003e* Clinical remission was defined as a CDAI score of \u0026lt; 150.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Predictive diagnostic performance of the combination of CRP, Fcal and LRG for predicting endoscopic remission.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"left\" width=\"1002\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.5529%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\n \u003cp\u003eSensitivity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\n \u003cp\u003eSpecificity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\n \u003cp\u003ePPV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\n \u003cp\u003eNPV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\n \u003cp\u003eAccuracy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.0679%;\"\u003e\n \u003cp\u003eAUC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.5529%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCombination of 2 markers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 16.0679%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23.5529%;\"\u003e\n \u003cp\u003eCRP (-) and LRG (-)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\n \u003cp\u003e74.2%\u003c/p\u003e\n \u003cp\u003e(66.3-82.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\n \u003cp\u003e90.0%\u003c/p\u003e\n \u003cp\u003e(84.4-95.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\n \u003cp\u003e89.0%\u003c/p\u003e\n \u003cp\u003e(82.9-95.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\n \u003cp\u003e76.2%\u003c/p\u003e\n \u003cp\u003e(68.8-83.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\n \u003cp\u003e81.7%\u003c/p\u003e\n \u003cp\u003e(76.7-86.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.0679%;\"\u003e\n \u003cp\u003e0.831\u003c/p\u003e\n \u003cp\u003e(0.7823-0.879)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23.5529%;\"\u003e\n \u003cp\u003eCRP (-) and Fcal (-)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\n \u003cp\u003e69.0%\u003c/p\u003e\n \u003cp\u003e(60.5-77.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\n \u003cp\u003e93.9%\u003c/p\u003e\n \u003cp\u003e(89.5-98.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\n \u003cp\u003e92.0%\u003c/p\u003e\n \u003cp\u003e(86.2-97.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\n \u003cp\u003e74.8%\u003c/p\u003e\n \u003cp\u003e(67.7-81.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\n \u003cp\u003e81.3%\u003c/p\u003e\n \u003cp\u003e(76.3-86.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.0679%;\"\u003e\n \u003cp\u003e0.814\u003c/p\u003e\n \u003cp\u003e(0.764-0.864)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23.5529%;\"\u003e\n \u003cp\u003eFcal (-) and LRG (-)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\n \u003cp\u003e65.5%\u003c/p\u003e\n \u003cp\u003e(56.9-74.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\n \u003cp\u003e97.4%\u003c/p\u003e\n \u003cp\u003e(94.4-1.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\n \u003cp\u003e96.2%\u003c/p\u003e\n \u003cp\u003e(92.0-1.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\n \u003cp\u003e73.5%\u003c/p\u003e\n \u003cp\u003e(66.5-80.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\n \u003cp\u003e81.3%\u003c/p\u003e\n \u003cp\u003e(76.3-86.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.0679%;\"\u003e\n \u003cp\u003e0.814\u003c/p\u003e\n \u003cp\u003e(0.764-0.864)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.5529%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCombination of 3 markers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 16.0679%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23.5529%;\"\u003e\n \u003cp\u003eTwo or more markers (-)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eof the 3 markers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\n \u003cp\u003e89.4%\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(83.5-95.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\n \u003cp\u003e83.3%\u003c/p\u003e\n \u003cp\u003e(76.8-89.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\n \u003cp\u003e81.6%\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(74.5-88.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\n \u003cp\u003e90.5%\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(85.2-95.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\n \u003cp\u003e86.1%\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(81.6-90.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.0679%;\"\u003e\n \u003cp\u003e0.860\u003c/p\u003e\n \u003cp\u003e(0.816-0.905)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23.5529%;\"\u003e\n \u003cp\u003eCRP (-) and Fcal (-) and LRG (-)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\n \u003cp\u003e71.3%\u003c/p\u003e\n \u003cp\u003e(64.2-78.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003cp\u003e(100-100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003cp\u003e(100-100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\n \u003cp\u003e60.3%\u003c/p\u003e\n \u003cp\u003e(51.4-69.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.0758%;\"\u003e\n \u003cp\u003e80.0%\u003c/p\u003e\n \u003cp\u003e(74.8-85.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.0679%;\"\u003e\n \u003cp\u003e0.794\u003c/p\u003e\n \u003cp\u003e(0.742-0.846)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAUC, area under the curve; PPV, positive predictive value; NPV, negative predictive value; LRG, leucine-rich alpha-2 glycoprotein; CRP, C-reactive protein; Fcal, fecal calprotectin\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-gastroenterology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmge","sideBox":"Learn more about [BMC Gastroenterology](http://bmcgastroenterol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmge/default.aspx","title":"BMC Gastroenterology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"CD, Crohn’s disease; LRG, leucine-rich alpha-2 glycoprotein; Fcal, fecal calprotectin; CRP, C-reactive protein; ER, endoscopic remission","lastPublishedDoi":"10.21203/rs.3.rs-5322202/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5322202/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSerum C-reactive protein (CRP), leucine-rich alpha-2 glycoprotein (LRG), and fecal calprotectin (Fcal) are non-invasive markers used to diagnose the severity of Crohn\u0026rsquo;s disease (CD). However, the accuracy of these markers is not satisfactory, and most previous reports have evaluated the efficacy of each marker individually. We aimed to improve the diagnostic performance of endoscopic remission (ER) of CD by using a combination of these 3 markers.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe tested the diagnostic ability of various combinations of these 3 markers for endoscopic severity in 230 consecutive patients with CD from September 2014 to July 2023. The modified Simple Endoscopic Score for Crohn\u0026rsquo;s disease (mSES-CD) was used to determine endoscopic severity.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eEach of the 3 markers was correlated with mSED-CD (LRG: r\u0026thinsp;=\u0026thinsp;0.69, CRP: r\u0026thinsp;=\u0026thinsp;0.60, and Fcal: r\u0026thinsp;=\u0026thinsp;0.67). A combination of 2 of the 3 markers did not increase the diagnostic accuracy of ER. However, by combining all 3 markers, the diagnostic ability for ER was improved in comparison to the diagnostic ability of the 3 individual markers, assuming that ER was obtained if 2 or 3 markers were negative. The sensitivity, specificity, and accuracy were 89%, 83%, and 86%, respectively. Additionally, we established a 2-step method using Fcal values after evaluating the 2 serum markers. This method was most useful for reducing both the patient burden and costs.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe newly established 2-step method allowed for a higher accuracy in the non-invasive predictive diagnosis of ER when the 3 markers were combined.\u003c/p\u003e","manuscriptTitle":"Efficient predictive diagnosis for endoscopic remission in Crohn’s diseases by the combination of three non-invasive markers","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-18 10:01:53","doi":"10.21203/rs.3.rs-5322202/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-11T10:30:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-25T05:45:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-25T05:45:19+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Gastroenterology","date":"2024-10-24T02:44:40+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-gastroenterology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmge","sideBox":"Learn more about [BMC Gastroenterology](http://bmcgastroenterol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmge/default.aspx","title":"BMC Gastroenterology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d4e60d5e-0382-4cc2-b5af-b5ef24b840bb","owner":[],"postedDate":"November 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-05-19T15:59:31+00:00","versionOfRecord":{"articleIdentity":"rs-5322202","link":"https://doi.org/10.1186/s12876-025-03880-5","journal":{"identity":"bmc-gastroenterology","isVorOnly":false,"title":"BMC Gastroenterology"},"publishedOn":"2025-05-13 15:56:57","publishedOnDateReadable":"May 13th, 2025"},"versionCreatedAt":"2024-11-18 10:01:53","video":"","vorDoi":"10.1186/s12876-025-03880-5","vorDoiUrl":"https://doi.org/10.1186/s12876-025-03880-5","workflowStages":[]},"version":"v1","identity":"rs-5322202","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5322202","identity":"rs-5322202","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}