ORIGINAL ARTICLE

Serum C-reactive Protein and CRP Genotype in Pediatric

Inflammatory Bowel Disease: Influence on Phenotype, Natural
History, and Response to Therapy
Paul Henderson, PhD,* ,† Nicholas A. Kennedy, FRACP,‡ Johan E. Van Limbergen, PhD,§
Fiona L. Cameron, MBChB,† Jack Satsangi, FRCP,‡ Richard K. Russell, PhD,k and David C. Wilson, MD* ,†

Background: C-reactive protein (CRP) is an acute phase reactant. Patients with pediatric inflammatory bowel disease (PIBD) differ from adult patients
with inflammatory bowel disease with regard to phenotype, inflammatory profile, and treatment response. We hypothesized that variations in CRP and
CRP genotype influence PIBD phenotype, natural history, and remission after anti-tumor necrosis factor alpha therapy.
Methods: Six single nucleotide polymorphisms tagging CRP (rs1935193, rs1130864, rs1205, rs1417938, rs11265263, and rs1800947) were genotyped
in 465 patients with PIBD (diagnosed ,17 yr). Phenotyping was serially performed until last follow-up and serum CRP levels recorded at diagnosis and
before biological therapy in a subgroup.
Results: CRP haplotype (ATGCTC) differed in those diagnosed ,10 years, with rs1205T more frequent in Crohn’s disease (CD) than ulcerative colitis
(UC) (P ¼ 0.009); the haplotype ATGCTC was less frequent in UC (P ¼ 0.002). Three single nucleotide polymorphisms (rs1205, rs1130864, and
rs1417938) showed association with elevated CRP levels at diagnosis. CRP genotype had no association with CD phenotype or natural history. CRP was
more frequently raised at diagnosis in CD than UC (63% versus 22%, P , 0.0001). Elevated CRP at diagnosis was associated with a higher risk of
progression to surgery in patients with CD (P , 0.0001) and the need for azathioprine in the overall PIBD cohort (P ¼ 0.002). There was no effect of
CRP genotype or serum CRP on the achievement of remission using anti–tumor necrosis factor alpha therapy.
Conclusions: CRP and CRP genotype differ between pediatric patients with CD and UC with a high inflammatory burden at diagnosis suggesting
a worse prognosis. Additional evaluation of CRP in inflammatory bowel disease pathogenesis and natural history is now warranted.
(Inflamm Bowel Dis 2015;21:596–605)
Key Words: inflammatory bowel disease, pediatric, C-reactive protein, polymorphism, Crohn’s disease

acute phase reactant.3,4 Produced predominantly in the hepato-

I nflammatory bowel disease (IBD) is a chronic relapsing disease
of the gastrointestinal tract characterized by inflammation at the
mucosal surface. In response to proinflammatory cytokines, such
cyte, CRP monomers are assembled into a cyclic homopentameric
structure inside the endoplasmic reticulum before secretion into
as interleukin-6, interleukin-1-b, and tumor necrosis factor alpha the plasma through the transcription factors CCAAT/enhancer-
(TNF-a),1,2 serum C-reactive protein (CRP) can rise rapidly as an binding protein beta and the p50 subunit of nuclear factor

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on
the journal’s Web site (www.ibdjournal.org).
Received for publication September 25, 2014; Accepted October 23, 2014.
From the *Department of Pediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children, Edinburgh, United Kingdom; †Child Life and Health, University of
Edinburgh, Edinburgh, United Kingdom; ‡Gastrointestinal Unit, Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, United Kingdom; §IBD
Center, Division of Pediatric Gastroenterology and Nutrition, IWK Health Center, Dalhousie University, Halifax, NS, Canada; and kDepartment of Pediatric Gastroenterology,
Royal Hospital for Sick Children, Glasgow, United Kingdom.
P. Henderson was funded by a Medical Research Council project grant for Pediatric Inflammatory Bowel Disease Cohort and Treatment Study (No. G0800675) and
a Shire Innovation Award for Specialist Registrars. D. C. Wilson, R. K. Russell and J. Satsangi are grant holders of the Medical Research Council patient research cohorts
initiative grant (G0800675) for Pediatric Inflammatory Bowel Disease Cohort and Treatment Study. N. A. Kennedy is funded by a Research Training Fellowship from the
Wellcome Trust (WT097943MA). F. L. Cameron is supported by a CICRA Research Fellowship. R. K. Russell is supported by an NHS Research Scotland Career
Fellowship Award and J. E. V. Limbergen by a NASPGHAN/CCFA Young Investigator Development Award. Additional support was provided by the GI-Nutrition
Research fund, Child Life and Health, University of Edinburgh.
The authors have no conflicts of interest to disclose.
Reprints: Paul Henderson, PhD, Child Life and Health, University of Edinburgh, 20 Sylvan Place, EH9 1UW Edinburgh, United Kingdom (e-mail: paul.
henderson2@nhs.net).
Copyright © 2015 Crohn’s & Colitis Foundation of America, Inc.
DOI 10.1097/MIB.0000000000000296
Published online 29 January 2015.

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Inflamm Bowel Dis  Volume 21, Number 3, March 2015 Pediatric Inflammatory Bowel Disease

kappa-light-chain-enhancer of activated B cells.5 Additionally,
other transcription factors at the CRP promoter site (such as
STAT3, cRel, Oct1, HNF-1, and HNF-3) have been shown to
be important during induction.628 Regarding the immunological
function of CRP, the highly conserved amino acid sequence sug-
gests a critical and nonredundant role.9 CRP has been shown to
interact with many molecules including C1q and factor H,10 in
addition to its primary ligand, phosphocholine, which is exposed
on damaged biological membranes and bacterial cell walls.11,12
A significant role for CRP in the clearance of apoptotic cells
and bacteria has also been postulated.13,14 An outline of the impor-
tant pathways involved in CRP formation, induction, and function
are shown in Figure 1.
In clinical practice, the predicted rise in serum CRP levels
allows its routine use as a diagnostic biomarker,15 as an indicator
of disease activity,16 and in monitoring therapeutic efficacy.17
However, it is commonly accepted that the absence of a rise in
serum CRP does not always indicate the lack of infectious or
inflammatory stimuli.18 Additionally, an individual patient’s
serum CRP response to these stimuli may be “inappropriately”
low despite the clinical history,19 with the CRP response to
effective treatment also varying widely20; the reasons for these
person-to-person variations are not yet clear. Specifically, regard-
ing IBD, serum CRP has been shown to have some utility at
diagnosis in patients suspected of having bowel inflammation
and to correlate to some extent with disease activity in those with
known disease.15,21 Of additional interest is the finding that adult
patients with IBD with a high serum CRP level show a superior
response to biological therapies,21,22 in addition to a possible cor-
relation of CRP levels with Crohn’s disease (CD) phenotype and
natural history.23,24
We therefore hypothesized that variations in CRP genotype and
serum CRP (particularly at diagnosis) influence pediatric IBD (PIBD)
phenotype (with variations between those with CD and ulcerative
colitis [UC]), natural history, and response to biological therapies.
METHODS
Subjects
Patients diagnosed with IBD before their 17th birthday
(Montreal25/Paris26 A1) were eligible for genotyping and subse-
quent phenotyping. All subjects were recruited in Scotland

FIGURE 1. Outline of the pathways involved in CRP induction, formation, and function in response to infection and/or inflammation. After an infectious or
inflammatory stimulus, the production of IL-1b and IL-6 leads to CRP synthesis in the liver. A complex arrangement of transcription factors are modified at
the CRP gene promoter, with the displacement of the C/EBPz-RBP-Jk complex by the CCAAT/enhancer-binding protein beta-p50 complex the most
critical step. After the synthesis of the pentameric molecule, serum CRP binds to various ligands to alter immune modulation and apoptosis.

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between October 2002 and July 2009 as part of ongoing research genome-wide association study (GWAS; described below) was
and latterly through the Medical Research Council–funded Pae- also examined.34 Using the “tag SNP picker” function on the
diatric Inflammatory Bowel Disease Cohort and Treatment Study HapMap project Web site (http://hapmap.ncbi.nlm.nih.gov/),
(PICTS). Recruitment was carried out at all sites across Scotland 8 SNPs tagging 3 genes (CEBPZ [C/EBPz], HNF1A [HNF-1],
by convenience sampling of patients, usually during their initial and POU2F1 [Oct-1]) were identified. It was then ensured that
work-up or induction therapy in their respective tertiary referral these SNPs (or a suitable proxy, D0 ¼ 1 and r2 ¼ 1.0, determined
center or during outpatient reviews; there were no exclusion cri- using SNAP [http://www.broadinstitute.org/mpg/snap/index.php])35
teria. PIBD was diagnosed according to standard clinical, histo- was present on the HumanHap550 BeadChip (Illumina, San
logical, and radiological findings.27,28 Diego, CA) with full results therefore available within the GWAS
data. Brief details of all 8 SNPs are shown in Table, Supplemental
Single Nucleotide Polymorphism Selection Digital Content 2, http://links.lww.com/IBD/A700.
The CRP gene is located on chromosome 1 between posi-
tions 159,682,079 and 159,684,379 (Ensembl Release 68— DNA Extraction and Genotyping
ENSG00000132693; Build 37) flanked by 2 genes, APCS and DNA was extracted from venous whole blood from patients
DUSP23, which are 124 kb and 68 kb downstream and upstream by either a modified salting out technique36 or by using the Nucleon
of CRP, respectively. CRP tagging single nucleotide polymor- BACC2 kit (Gen-Probe Life Sciences, Manchester, United King-
phisms (SNPs) were selected using genotypic data from the Cen- dom) and resuspended in ·1 Tris-ethylenediaminetetraacetic acid
tre d’Etude du Polymorphisme Humain (Utah Residents with buffer (10 mM Tris, pH 7.5, and 1 mM ethylenediaminetetraacetic
Northern and Western European Ancestry; abbreviated CEU) acid) at a final concentration of 100 ng/mL. Primer sequences of the
study available from the HapMap project (Phase III/Release 3; 6 SNPs tagging CRP are shown in Table, Supplemental Digital
http://www.broad.mit.edu/mpg/haploview)29 and identified using Content 3, http://links.lww.com/IBD/A701; all genotyping was car-
Haploview software version 4.230 based on solid spine of linkage ried out in a single batch with random plate allocation in August
disequilibrium (r2 .0.8, haplotype frequency .5%, minor allele 2009. The mean genotyping call rate for all SNPs in all patients was
frequency .10%) (see Fig. A, Supplemental Digital Content 1, 98.6%. Additional genotyping data were also obtained from a pre-
http://links.lww.com/IBD/A699).This process identified 5 tagging vious GWAS (the major PIBD GWAS, published by Imielinski
SNPs spanning a 46 kb region: rs1935193, rs1130864, rs1205, et al34), which included a subset of the Scottish patients with PIBD.
rs1417938, and rs11265263 (see Fig. B, Supplemental Digital Con- This genotyping was performed using the Illumina Infinium II
tent 1, http://links.lww.com/IBD/A699). It is important to note that HumanHap550 BeadChip Technology (Illumina), at the Center
3 of these SNPs (rs1130864, rs1205, and rs1417938) were spe- for Applied Genomics at the Children’s Hospital of Philadelphia.
cifically chosen as tagging SNPs as they had previously been The data contained genotyping results on a representative sample of
demonstrated to influence basal CRP levels.31233 An additional 359 of the patients described above (239 CD, 91 UC, and 29
SNP previously shown to influence serum CRP levels, colonic IBD, type unclassified [IBDU]) for approximately
rs1800947,31 was also genotyped. Details of all genotyped SNPs 550,000 SNPs on the platform.
are presented in Table 1. For all patients, SNPs conformed to the
Hardy–Weinberg equilibrium. Phenotyping and Serum CRP Level
To assess the contribution of genes encoding various CRP at Diagnosis
transcription factors, SNP data from a previously performed Rigorous disease phenotyping of the PICTS cohort was
carried out as previously described.37 Briefly, phenotyping was
performed by detailed examination of case notes, computerized
records, laboratory results, and radiological imaging. As part of
TABLE 1. Details of the 6 SNPs Genotyped to Tag CRP our standard phenotyping study protocol, serum CRP levels are
Marker Chromosomal recorded for the PICTS database at the time of diagnosis
Number dbSNPa Positionb Location MAF Alleles (i.e., during the initial workup of symptoms suggestive of PIBD
and closest to the primary diagnostic endoscopic assessment).
1 rs1935193 159664090 Upstream 0.301 A:T As CRP reference ranges have differed marginally both geo-
2 rs1205 159682233 30 flanking 0.329 C:T graphically and with time throughout Scotland, in addition
3 rs1130864 159683091 30 flanking 0.299 G:A to minor variations in the biochemical assay, results are simply
4 rs1800947 159683438 Exon 2 0.063 C:G recorded as “raised” or “normal” (i.e., above normal range or
5 rs1417938 159684186 Intronic 0.298 T:A not) at diagnosis. The highest normal cutoff value in use at any
6 rs11265263 159710517 Downstream 0.072 C:A time was 10 mg/L. Last date of follow-up was defined as the last
review of clinical notes for patients still under the care of their
a
Based on NCBI Human Build 135.
b PIBD team, the date of transition/transfer to adult services or
Ensembl Release 68, July 2012.
MAF, minimum allele frequency. relocation to an area out with Scotland while in pediatric
services.

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Inflamm Bowel Dis  Volume 21, Number 3, March 2015 Pediatric Inflammatory Bowel Disease

Response to Anti–TNF-a Monoclonal Antibody
Physician global assessment (determining status as remis-
sion or mild, moderate, or severely active disease38) was used to
assess disease activity of patients naive to anti–TNF-a monoclonal
antibody following their induction course, regardless of whether
remission was then sustained in those who had achieved it
(as worsening disease and other factors may contribute to loss of
response). Remission was recorded at 10 to 12 weeks after com-
mencement of the induction course of infliximab (3 infusions at wk
0, 2, and 6—unless infusions were discontinued for severe infusion
reaction) or adalimumab (6 fortnightly doses at wk 0–10 unless
treatment discontinued for severe adverse effects or absolute lack
of response; UK pediatric clinical experience has been that many
children and young people need longer than 4 weeks to judge
induction response with adalimumab39). Remission was defined
by physician global assessment after individual review of all case
notes, clinic letters, and laboratory values performed at the regional
site where anti-TNF was administered; if there was any doubt, the
case was reviewed with the clinical team members at the site.40 In
a subcohort of these cases, the pediatric CD activity index38 or
pediatric UC activity index41 score for CD and UC/IBDU, respec-
tively, were also used to complement the physician global assess-
ment analysis to define remission; a senior clinician with
experience of providing the routine care of these patients (D.C.
W.; lead of the Scottish Pediatric IBD Biological Registry) made
the final decision on whether remission was achieved based on all
available data and discussion to ensure that in all cases, evidence of
remission (as opposed to response) was robust. Serum CRP results,
taken immediately before the first anti–TNF-a induction dose, were
also obtained.
Statistical Analyses
Haplotype and single SNP analyses were carried out using
Haploview v4.230 (with correction for multiple testing achieved
using 100,000 permutations) and additional analyzes performed
using SNPStats42 and R v3.1.1 (R Foundation for Statistical Com-
puting, Vienna, Austria). For anti-TNF-a response, all 6 SNPs
were tested in a multivariate model to determine any effect of
CRP genotype on response, with all analyses corrected for IBD
type (categorical) and age at diagnosis (quantitative) if appropri-
ate. Chi-squared, Fisher’s exact and Mann–Whitney U tests were
carried out as appropriate. In the genetic analyses, corrected
P values are presented unless otherwise stated. Analysis of
requirement for surgery and azathioprine was carried out using
the survival package in R. Multivariable analysis was performed
using Cox proportional hazards and backwards stepwise regres-
sion with Akaike Information Criterion as the criterion for exclud-
ing variables. Variables were excluded from the final model if
their P value was greater than 0.05. A 2-sided P value of 0.05
was considered significant throughout.
Ethics
All patients and/or their parents provided full written
consent as part of the Medical Research Council–funded PICTS
cohort, which was approved by local ethics committees at all
3 participating clinical networks: South-East Scotland (LREC/
2002/6/18), West of Scotland (YREC/P12/03), and North of
Scotland (GREC/03/0273).
RESULTS
Patients
A total of 465 patients had full CRP genotyping data
available (cohort 1); the basic demographics of this PIBD group
are shown in Table 2. Although convenience sampling was used
for recruitment, the composition of the study cohort was com-
parable with our previously published population-based Scottish
data,43,44 with a similar proportion of IBD types (i.e., approxi-
mately two-thirds CD) and median age at diagnosis; there was
also a slight male preponderance and comparable disease loca-
tion and behavior. In the entire cohort, 92% of patients had
phenotype data available and 75% had a recorded CRP level
at diagnosis. For the analysis of CD phenotype, a subgroup of
cohort 1 consisting of 232 patients with CD (74% of all patients
with CD), had both full phenotyping and CRP data available at
diagnosis (cohort 2). A further nested cohort (a subgroup of
cohort 2) consisting of 181 patients had at least 2 years of
follow-up data available (median follow-up 5.2 yr) and were
therefore used in the analyses of natural history (cohort 3). De-
tails of cohorts 2 and 3 are shown in Table, Supplemental Digital
Content 4, http://links.lww.com/IBD/A702. There was no differ-
ence in the length of follow-up for those with or without a raised
CRP at diagnosis (P ¼ 0.551).

TABLE 2. Characteristics of the Patients with PIBD Included in the Analysis of CRP Genotype
IBD CD UC IBDU

Number (%) 465 (100) 313 (67) 111 (24) 41 (9)

Median age at diagnosis ([IQR]), yr 11.5 (9.0–13.2) 11.7 (9.2–13.4) 11.0 (8.9–12.9) 10.3 (8.5–12.4)
Male sex, n (%) 267 (57) 186 (59) 58 (52) 23 (56)
White European, n (%) 450 (97) 303 (97) 107 (96) 40 (98)

IBDU, colonic IBD, type unclassified; IQR, interquartile range.

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CRP Haplotype Differs Between Pediatric
Patients with CD Diagnosed Less than 10
Years of Age
There were no SNPs significantly associated with either age
at symptom onset or age at diagnosis when evaluated as
a quantitative trait for either total IBD or any IBD type. Recent
consensus guidelines have highlighted that CD phenotype differs
between those diagnosed aged 0 to 9 years of age (Paris A1a)
and between 10 to 16 years (Paris A1b).26 Genotypic analyses
between those diagnosed in these 2 age brackets was therefore
assessed revealing that the haplotype ATGCTC was associated
with age at diagnosis less than 10 years in patients with CD
(P ¼ 0.040).
Pediatric Patients with CD and UC Differ
Regarding Serum CRP at Diagnosis and
CRP Genotype
Serum CRP results showed that patients with CD were
more likely to have a raised CRP at diagnosis than patients with
UC (63% versus 22%, P , 0.001). Evaluating the genotypic
differences between patients with CD and UC only (i.e., exclud-
ing patients with IBDU), there was an increased frequency of the
T allele of rs1205 in patients with CD (34% and 22% in CD and
UC, respectively; Table 3). Haplotype analyses of these 2 IBD
types also demonstrated significant differences in haplotype
structure, with the strongest difference seen in the 6-marker
haplotype ATGCTC (Table 3 and see Fig., Supplemental Digital
Content 5, http://links.lww.com/IBD/A703). To further eluci-
date the potential reasons for the differences in serum CRP at
diagnosis between patients with CD and UC, tagging SNPs of 3
genes encoding CRP transcription factors (POU2F1 [OCT1],
CEBPZ [C/EBPz], and HNF1A [HNF-1]) were also evaluated.
This demonstrated that none of the 8 individual SNPs were
overrepresented in either CD or UC; similarly, none of the hap-
lotype analyses demonstrated differences between CD and UC
(data not shown).
CRP Genotype Influences Serum CRP Levels
at Diagnosis
The influence of CRP genotype on the presence of an ele-
vated CRP response at diagnosis was assessed. To achieve this,
potential confounders demonstrated above (i.e., IBD type and age
at diagnosis) were used as covariates in a multivariate model.
Raised or normal serum CRP at diagnosis was used as a binary
outcome from patients in cohort 2. In this analysis, rs1205,
rs1130864, and rs1417938 showed association with serum CRP
elevation in a dominant model (Table 4).
CRP Genotype Does not Influence CD
Phenotype or Natural History
The effect of CRP genotype on major CD phenotypes was
also evaluated regarding presenting phenotype (cohort 2) and natural
history (cohort 3). There were no significant differences in CRP
genotype (either individual SNPs or haplotypes) in patients with
CD with or without ileal disease (i.e., Montreal L1 or L3 versus
L2), with or without upper gastrointestinal disease (i.e., 6Montreal
L4), or with or without pure colonic disease (i.e., Montreal L2 versus
L1 6 L4 or L3 6 L4) either at diagnosis (cohort 2) or at last follow-
up (cohort 3). Similarly, patients with CD with stricturing or pene-
trating disease behavior (Montreal B2 and/or B3) did not differ with

TABLE 3. Differences in CRP Genotype Between Pediatric Patients with CD and UC

dbSNPa Associated Allele Allele Frequency in CD, % Allele Frequency in UC, % Uncorrected P Corrected P

rs1935193 A 74.2 65.4 0.016 0.066

rs1205 T 34.2 22.6 0.002 0.009
rs1130864 G 67.4 63.3 0.290 0.733
rs1800947 G 6.2 5.7 0.799 0.799
rs1417938 T 67.2 63.1 0.296 0.740
rs11265263 C 93.2 92.7 0.811 0.999

Haplotypeb Haplotype Frequency, % Haplotype Frequency in CD, % Haplotype Frequency in UC, % Uncorrected P Corrected P

ACACAC 33.6 32.6 36.2 0.351 0.841

TCGCTC 28.1 25.8 34.2 0.021 0.082
ATGCTC 24.3 27.5 15.6 6 · 1024 0.002
ACGCTC 7.0 7.3 5.9 0.494 0.935
ATGGTA 6.0 6.1 5.7 0.825 1.000

Significant results are highlighted in bold.

a
Based on NCBI Human Build 135.
b
Based on the SNP order above.

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TABLE 4. Influence of SNPs on Serum CRP Levels at Diagnosis in Patients with PIBD
dbSNPa Genotype CRP ¼ Normal, %
rs1417938 T/T 49.5
A/T–A/A 50.6
rs1130864 G/G 50.6
A/G–A/A 49.4
rs1205 C/C 43.0
C/T–T/T 57.0
a
Based on NCBI Human Build 135.
CI, confidence interval; OR, odds ratio.
respect to CRP genotype compared with those with inflammatory
disease only (i.e., Montreal B1) either at diagnosis or last follow-up.
There were insufficient numbers to perform comparison analyses on
patients with CD with pure colonic disease versus those with UC or
IBDU. Similarly, need for surgical resection, exposure to azathio-
prine, or need for biological therapy was not associated with certain
CRP genotypes or haplotypes.
Serum CRP Elevation at PIBD Diagnosis Is
Associated with CD Behavior and the Need
for Azathioprine and Surgical Resection
Among patients with CD, elevated serum CRP at diagnosis
was associated with a greater risk of progression to surgery
(P , 0.0001, logrank test; Fig. 2A). When assessed in the overall
cohort, there was also a greater risk of requiring azathioprine
(P ¼ 0.002, Fig. 2B), but this did not reach statistical significance
in the CD or UC cohorts alone (P ¼ 0.052 [CD], P ¼ 0.795 [UC], see
Figs., Supplemental Digital Content 6 and 7, http://links.lww.com/
IBD/A704 and http://links.lww.com/IBD/A705).
Multivariable Cox proportional hazards analysis was per-
formed of surgical risk in CD incorporating disease location and
behavior at diagnosis, CRP at diagnosis, age at diagnosis, and the
genotype data. The final model suggested increased risk in those
with raised CRP at diagnosis and with increasing age at diagnosis
after backwards stepwise regression (Table 5).
CRP Genotype Does not Influence Anti-TNF-
a Response in PIBD
Genotyping and clinical data regarding the achievement of
initial remission using anti-TNF-a therapy was available in 93 anti-
TNF-a–naive patients with PIBD (81 CD, 9 UC, and 3 IBDU). Of
the 93 included cases, 50 (53%) patients achieved initial remission;
this remission rate was identical when analyzing patients with CD
only (i.e., 44/81, 53%). There was no difference in the concurrent
use of other medications/therapies (e.g., corticosteroids, azathio-
prine, exclusive enteral nutrition) in those achieving or not
achieving remission (see Table, Supplemental Digital Content 8,
http://links.lww.com/IBD/A706). There were also no significant
associations with any of the measured SNPs.
2015
Pediatric Inflammatory Bowel Disease
CRP ¼ Raised, % Or (95% CI) Uncorrected P
38.4 1.67 (1.01–2.77) 0.045
61.6
38.9 1.73 (1.06–2.83) 0.029
61.1
51.3 0.57 (0.34–0.94) 0.025
48.7
In 90 patients, serum CRP levels were available in the 7
days before the first dose of anti-TNF-a agent. There was no
difference in CRP at anti-TNF induction between those who at-
tained remission and those who did not, either stratified as raised
($10 mg/L) or normal (P ¼ 1.00) or when assessed as a contin-
uous variable (median 15 mg/L versus 14.5 mg/L, respectively,
P ¼ 0.334).
DISCUSSION
Using robust genetic analysis of a well-phenotyped cohort
of patients with PIBD from a stable population, our data suggest
that CRP genotype has potential effects on age at diagnosis but
has no discernible effect on major disease phenotypes in a sub-
group of patients with CD. Additionally, we show that CRP
genotype (especially haplotype structure) and serum CRP at diag-
nosis differs significantly between patients with CD and UC and
between patients with CD older and younger than 10 years old at
diagnosis in the same Scottish PIBD population. CRP elevation at
diagnosis was also associated with poorer outcomes, in particular
with a requirement for surgery in CD. We demonstrated no effect
of CRP or CRP genotype on the ability to attain remission after
anti-TNF therapy.
The impetus for carrying out gene analysis on CRP in this
Scottish PIBD population was four-fold. First, several studies in
inflammatory conditions have identified CRP as a susceptibility
gene.33,45 Second, we have observed, along with others,19 that
children across all IBD types differ significantly in their ability
to produce a serum CRP response, even in the presence of overt
clinical disease. Interestingly, recent evidence has shown that
mesenteric fat (hyperplasia of mesenteric fat is characteristic of
CD) is an important source of CRP, with CRP production by
mesenteric adipocytes triggered by bacterial and inflammatory
stimuli, such as E. coli and interleukin-6.4 Third, regarding car-
diovascular risk and systemic lupus erythematosus, studies have
suggested that failure to respond appropriately to inflammation
with a rise in serum CRP may be a factor in disease pathogene-
sis.5,46 This may be especially important in light of the fact that
pediatric patients with CD and UC differ significantly regarding
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FIGURE 2. A, Survival plot showing risk of progression to surgery in pediatric patients with CD with normal and raised serum CRP at diagnosis.
B, Survival plot showing risk of progression to azathioprine therapy in patients with PIBD with normal and raised serum CRP at diagnosis. Normal,
CRP ,10 mg/L; raised, CRP .10 mg/L.

CRP genotype/haplotype structure and serum CRP response at
diagnosis. Finally, recent evidence has suggested that adult
patients with IBD with a high baseline CRP level at induction
demonstrate a better primary response to biological therapies,
with early normalization of CRP levels correlating with sustained
long-term response21,47; however, these results are variable.48
The strengths of this study were the large number of
children included and also our ability to rigorously phenotype
a distinct population of patients with PIBD, allowing their
progress to be followed over time and enabling detailed analyses
of IBD subgroups, in addition to the collection of laboratory
parameters49 and response to therapies.50 Additionally, use of
correction for multiple testing ensured that significance was not
unduly placed on individual SNPs or haplotypes.
Although convenience sampling was used as the recruit-
ment method, we are confident that although there is potential for
recruitment bias, there are several reasons why we believe this
cohort to be truly representative of the Scottish PIBD population.
First, we have previously published accurate Scottish incidence43
and regional prevalence rates,44 allowing us to determine the

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Inflamm Bowel Dis  Volume 21, Number 3, March 2015
TABLE 5. Final Cox Proportional Hazards Model of
Risk of Requirement of Surgery in Pediatric Patients
with CD
Variable OR (95% CI) P 189 anti-TNF-a–naive adult patients.48 They concluded that
Age at diagnosis, yr 1.26 (1.11–1.43) ,0.001
CRP raised at diagnosis 3.88 (1.72–8.76) 0.001
CI, confidence interval; OR, odds ratio.
success of our recruitment (e.g., of the 436 incident cases of PIBD
diagnosed between 2003 and 2008, 83% were recruited to this
study). Second, as we know the demographic and phenotypic
characteristics of the Scottish PIBD population, we are able to
demonstrate that the current cohort have a similar proportion of
IBD types (e.g., majority CD), identical median age at diagnosis
(i.e., 11.5 yr), slight male preponderance, and with our more
detailed population-based regional work,44 comparable disease
location, and behavior (e.g., 75% pancolitis in patients with UC).
We also recognize that relatively small numbers of patients
exposed to anti-TNF may have limited the power to dissect
clinical and genetic factors predictive of response. Additionally,
the lack of precise serum CRP levels (i.e., high sensitivity CRP)
may have influenced the ability to detect relationships between
serum CRP and phenotype/genotype. We also acknowledge that
remission in those treated with anti-TNFs was ultimately
determined at the discretion of a single physician (albeit with
extensive knowledge and experience in the care of these children)
if any doubt existed on whether remission (as opposed to
response) had been achieved; this decision, however, was guided
by full review of clinical case notes on site, patient letters,
laboratory parameters, discussion with the clinical team admin-
istering the anti-TNF agent along with validated activity scores in
a significant minority.40
Regarding the role of CRP genotype and inflammatory
disease pathogenesis, the evidence is substantial but often
contradictory. The first stimulus to dissect the effect of CRP
genotype with basal CRP levels came after the observation of
a strong correlation between CRP levels and cardiovascular
disease risk.51 Although recent evidence has suggested that
no causal link is likely to exist between CRP genotype, plasma
CRP, and cardiovascular disease,52 extensive efforts to exam-
ine this link have provided a detailed insight into how
inherited CRP variants influence basal CRP levels.5 The role
of CRP in IBD in particular has been mostly detailed from
a clinical perspective. However, 2 studies have evaluated the
contribution of CRP genotype to disease phenotype and treat-
ment response. Thalmaier et al 23 evaluated the role of the
rs1800847 (+1059 G/C) polymorphism in CD susceptibility
and disease phenotype in 241 adult patients with CD and
199 healthy controls. They reported that C allele homozygos-
ity was associated with ileal disease involvement at diagnosis,
2015
Pediatric Inflammatory Bowel Disease
with no effect on disease susceptibility; this study was limited
by evaluating only 1 SNP without replication. The second
study evaluated the role of 3 SNPs in CRP (rs2794521,
rs1130864, and rs1205) regarding response to infliximab in
none of these polymorphisms had a significant effect on either
biological (as defined as a decrease in serum CRP) or clinical
response to infliximab or indeed any effect on CRP levels
before commencing treatment.
Regarding the clinical use of serum CRP in patients with
IBD, studies have looked at its utility at diagnosis, during the
assessment of disease activity,53 response to biological thera-
pies,54 and its association with disease outcomes, such as sur-
gery.24 Several studies have alluded to the fact that a low CRP
at diagnosis can predict milder disease phenotype55 with elevated
high sensitivity CRP having been shown to be associated with
noninflammatory behavior, the need for azathioprine and biolog-
ical therapy, and risk of disease flares in adult IBD.56 Our data
suggest similar utility in the pediatric population. The potential
effect of CRP genotype on the clinical ability to use serum CRP as
a disease marker is particularly relevant and may provide suffi-
cient reason to discount or place less weight on serum CRP levels
in certain individuals. Additionally, although this study was
unable to replicate adult studies in which patients with an elevated
CRP responded better to biological therapies,54 this may reflect
the smaller numbers presented, the extensive disease phenotype of
childhood-onset patients,37 or differing response rates to biologi-
cal therapies in children.57
CONCLUSIONS
This study has demonstrated that there are clear differences
in serum CRP levels and CRP genotype in CD and UC patients
with PIBD with potential effects on age at onset. The clinical
utility of CRP elevation at diagnosis regarding prognosis is also
of interest, possibly allowing early stratification of children with
a more severe phenotype. The evidence that CRP bridges both
innate and adaptive immune pathways is intriguing in the context
of our current knowledge of disease pathogenesis; and with CRP
already widely used in the clinical setting, there may be potential
to optimize the utilization of this biomarker during the care of
patients with IBD regarding elucidating etiopathogeneis and pre-
dicting natural history.
ACKNOWLEDGMENTS
The authors wish to specifically acknowledge the help of
Dr. Richard Hansen and Dr. Eilidh Cameron who kindly helped
collect a significant number of serum CRP values in their
respective centers and other members of the Scottish Society of
Pediatric Gastroenterology, Hepatology, and Nutrition, with
additional thanks to Sean O’Neil (University of Edinburgh) for
his expertise in DNA extraction. The IBD team at Yorkhill Hos-
pital, Glasgow, is supported by the Catherine McEwan Founda-
tion and the Yorkhill IBD fund.
www.ibdjournal.org | 603
Henderson et al
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