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Abstract
BACKGROUND Epilepsy is a common neurological condition, with an estimated incidence of 50 per 100,000 persons. People with epilepsy may present with various types of immunological abnormalities, such as low serum immunoglobulin A (IgA) levels, lack of the immunoglobulin G (IgG) subclass and identification of certain types of antibodies. Intravenous immunoglobulin (IVIg) treatment may represent a valuable approach and its efficacy has important implications for epilepsy management. This is an update of a Cochrane review first published in 2011 and last updated in 2017. OBJECTIVES To examine the effects of IVIg on the frequency and duration of seizures, quality of life and adverse effects when used as monotherapy or as add-on treatment for people with epilepsy. SEARCH METHODS For the latest update, we searched the Cochrane Register of Studies (CRS Web) (20 December 2018), MEDLINE (Ovid, 1946 to 20 December 2018), Web of Science (1898 to 20 December 2018), ISRCTN registry (20 December 2018), WHO International Clinical Trials Registry Platform (ICTRP, 20 December 2018), the US National Institutes of Health ClinicalTrials.gov (20 December 2018), and reference lists of articles. SELECTION CRITERIA Randomised or quasi-randomised controlled trials of IVIg as monotherapy or add-on treatment in people with epilepsy. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the trials for inclusion and extracted data. We contacted study authors for additional information. Outcomes included percentage of people rendered seizure-free, 50% or greater reduction in seizure frequency, adverse effects, treatment withdrawal and quality of life. MAIN RESULTS We included one study (61 participants). The included study was a randomised, double-blind, placebo-controlled, multicentre trial which compared the treatment efficacy of IVIg as an add-on with a placebo add-on in patients with drug-resistant epilepsy. Seizure freedom was not reported in the study. There was no significant difference between IVIg and placebo in 50% or greater reduction in seizure frequency (RR 1.89, 95% CI 0.85 to 4.21; one study, 58 participants; low-certainty evidence). The study reported a statistically significant effect for global assessment in favour of IVIg (RR 3.29, 95% CI 1.13 to 9.57; one study, 60 participants; low-certainty evidence). No adverse effects were demonstrated. We found no randomised controlled trials that investigated the effects of IVIg monotherapy for epilepsy. Overall, the included study was rated at low to unclear risk of bias. Using GRADE methodology, the certainty of the evidence was rated as low. AUTHORS' CONCLUSIONS We cannot draw any reliable conclusions regarding the efficacy of IVIg as a treatment for epilepsy. Further randomised controlled trials are needed.
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Affiliation(s)
- JinSong Geng
- Medical School of Nantong UniversityEvidence‐based Medicine Center19 Qixiu Road, Medical School of NantongNantongJiangsuChina226001
| | - JianCheng Dong
- Medical School of Nantong UniversityEvidence‐based Medicine Center19 Qixiu Road, Medical School of NantongNantongJiangsuChina226001
| | - Youping Li
- West China Hospital, Sichuan UniversityChinese Cochrane Centre, Chinese Evidence‐Based Medicine CentreNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - HengJian Ni
- Medical School of Nantong UniversityEvidence‐based Medicine Center19 Qixiu Road, Medical School of NantongNantongJiangsuChina226001
| | - Kui Jiang
- Medical School of Nantong UniversityEvidence‐based Medicine Center19 Qixiu Road, Medical School of NantongNantongJiangsuChina226001
| | - Li Li Shi
- Evidence‐based Medicine Center, Medical School of Nantong UniversityNantongChina
| | - GuoHua Wang
- Nantong UniversityInstitute of Nautical Medicine19 Qixiu RoadNantongJiangsuChina226001
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Abstract
BACKGROUND Epilepsy is a common neurological condition, with an estimated incidence of 50 per 100,000 persons. People with epilepsy may present with various types of immunological abnormalities, such as low serum immunoglobulin A (IgA) levels, lack of the immunoglobulin G (IgG) subclass and identification of certain types of antibodies. Intravenous immunoglobulin (IVIg) treatment may represent a valuable approach and its efficacy has important implications for epilepsy management. This is an updated version of the original Cochrane review published in Issue 1, 2011. OBJECTIVES To examine the effects of IVIg on the frequency and duration of seizures, quality of life and adverse effects when used as monotherapy or as add-on treatment for people with epilepsy. SEARCH METHODS For the latest update, we searched the Cochrane Epilepsy Group Specialized Register (2 February 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Register of Studies Online (2 February 2017), MEDLINE (Ovid, 1946 to 2 February 2017), Web of Science (1898 to 2 February 2017), ISRCTN registry (2 February 2017), WHO International Clinical Trials Registry Platform (ICTRP, 2 February 2017), the US National Institutes of Health ClinicalTrials.gov (2 February 2017), and reference lists of articles. SELECTION CRITERIA Randomized or quasi-randomized controlled trials of IVIg as monotherapy or add-on treatment in people with epilepsy. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the trials for inclusion and extracted data. We contacted study authors for additional information. Outcomes included percentage of people rendered seizure-free, 50% or greater reduction in seizure frequency, adverse effects, treatment withdrawal and quality of life. MAIN RESULTS We included one study (61 participants). The included study was a randomized, double-blind, placebo-controlled, multi-centre trial which compared the treatment efficacy of IVIg as an add-on with a placebo add-on in patients with refractory epilepsy. There was no significant difference between IVIg and placebo in 50% or greater reduction in seizure frequency. The study reported a statistically significant effect for global assessment in favour of IVIg. No adverse effects were demonstrated. We found no randomized controlled trials that investigated the effects of IVIg monotherapy for epilepsy. Overall, the included study was rated as low/unclear risk of bias. Using GRADE methodology, the quality of the evidence was rated as low. AUTHORS' CONCLUSIONS We cannot draw any reliable conclusions regarding the efficacy of IVIg as a treatment for epilepsy. Further randomized controlled trials are needed.
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Affiliation(s)
- JinSong Geng
- Medical School of Nantong UniversityEvidence‐based Medicine Center19 Qixiu Road, Medical School of NantongNantongChina226001
| | - JianCheng Dong
- Medical School of Nantong UniversityEvidence‐based Medicine Center19 Qixiu Road, Medical School of NantongNantongChina226001
| | - Youping Li
- West China Hospital, Sichuan UniversityChinese Cochrane Centre, Chinese Evidence‐Based Medicine CentreNo. 37, Guo Xue XiangChengduChina610041
| | - Hengjian Ni
- Medical School of Nantong UniversityEvidence‐based Medicine Center19 Qixiu Road, Medical School of NantongNantongChina226001
| | - Kui Jiang
- Medical School of Nantong UniversityEvidence‐based Medicine Center19 Qixiu Road, Medical School of NantongNantongChina226001
| | - Li Li Shi
- Evidence‐based Medicine Center, Medical School of Nantong UniversityNantongChina
| | - GuoHua Wang
- Nantong UniversityInstitute of Nautical Medicine19 Qixiu RoadNantongChina226001
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Bello-Espinosa LE, Rajapakse T, Rho JM, Buchhalter J. Efficacy of intravenous immunoglobulin in a cohort of children with drug-resistant epilepsy. Pediatr Neurol 2015; 52:509-16. [PMID: 25882078 DOI: 10.1016/j.pediatrneurol.2014.11.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 11/15/2014] [Accepted: 11/18/2014] [Indexed: 11/18/2022]
Abstract
OBJECTIVES We describe the experience of a pediatric epilepsy center regarding the efficacy of intravenous immunoglobulin for drug-resistant seizures in children. METHODS A retrospective chart review of all children in a community-based, children's hospital neurology clinic from 2006 to 2012, inclusive, with intractable epilepsy who were treated with intravenous immunoglobulin for a minimum of six cycles was performed. Data collected included patient demographics, seizure and epilepsy syndrome type, presumed etiology for the seizures, and seizure frequency. Response to intravenous immunoglobulin was defined as "positive" if either seizure freedom or ≥50% reduction of seizures was achieved. RESULTS Twenty-seven children (3-17 years old) were identified and included in the analysis. Following treatment with intravenous immunoglobulin, the following outcomes were noted: four were seizure-free, eight had 90% reduction, five had 75% reduction, and five had 50% reduction. A total of 22 (81%) patients had a positive clinical response to treatment from baseline. Five patients (19%) were not responsive. No clear relationship of responsiveness to intravenous immunoglobulin with regard to age, gender, or epilepsy syndrome was apparent; however, the small numbers in each category precluded meaningful statistical analysis. SIGNIFICANCE Our findings and those of others suggest that intravenous immunoglobulin is a potentially high efficacy, low side effect profile therapy in the treatment of children with drug-resistant epilepsies. Intravenous immunoglobulin was able to reduce multiple seizure types in a variety of epilepsy etiologies, including those of unknown cause.
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Affiliation(s)
- Luis E Bello-Espinosa
- Department of Pediatrics, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada; Department of Clinical Neurosciences, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada
| | - Thilinie Rajapakse
- Department of Pediatrics, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada; Department of Clinical Neurosciences, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada
| | - Jong M Rho
- Department of Pediatrics, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada; Department of Clinical Neurosciences, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada; Alberta Children's Hospital Research Institute, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada
| | - Jeffrey Buchhalter
- Department of Pediatrics, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada; Department of Clinical Neurosciences, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada; Alberta Children's Hospital Research Institute, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada.
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Abstract
BACKGROUND Infantile spasms (West's Syndrome) is a syndrome that includes a peculiar type of epileptic seizure-the spasms-and an electroencephalographic (EEG) abnormality often called hypsarrhythmia. Psychomotor retardation is frequently found at follow-up. Approximately two-thirds of affected infants will have a detectable underlying neurological abnormality, but still little is known about the pathophysiological basis for infantile spasms, and treatment remains problematic. OBJECTIVES To compare the effects of single pharmaceutical therapies used to treat infantile spasms in terms of control of the spasms, resolution of the EEG, relapse rates, psychomotor development, subsequent epilepsy, side effects, and mortality. SEARCH METHODS To identify published data, we searched the Cochrane Epilepsy Group Specialised Register (October 2012), CENTRAL (The Cochrane Library 2012, Issue 9), MEDLINE (1946 to September Week 4, 2012), EMBASE (1980 to March 2003), and the reference lists of all retrieved articles.To identify unpublished data, we searched the ISRCTN Register (www.controlled-trials.com), corresponded with colleagues and drug companies, and made requests at international conferences. SELECTION CRITERIA All randomised controlled trials (RCTs) of the administration of drug therapy to patients with infantile spasms. DATA COLLECTION AND ANALYSIS Data collection from all relevant publications was independently undertaken by three review authors (before 2010) or by two review authors using a standard proforma. Analysis included assessment of study quality and a search for sources of heterogeneity. MAIN RESULTS We found 16 small RCTs (fewer than 100 patients enrolled) and 2 larger RCTs (more than 100 patients enrolled). These 18 studies looked at a total of 916 patients treated with a total of 12 different pharmaceutical agents. Overall methodology of the studies was poor, in part because of ethical dilemmas such as giving placebo injections to children. Two studies showed that placebo was not as good as active treatment in resolving the spasms. The strongest evidence suggested that hormonal treatment (prednisolone or tetracosactide depot) leads to resolution of spasms faster and in more infants than does vigabatrin. Responses without subsequent relapse may be no different. The same study suggests that hormonal treatments might improve the long-term developmental outcome compared with vigabatrin in infants not found to have an underlying cause for their infantile spasms. AUTHORS' CONCLUSIONS To date, few well-designed RCTs have considered the treatment of infantile spasms, and the numbers of patients enrolled have been small. In the majority, methodology has been poor, hence it is not clear which treatment is optimal in the treatment of this epilepsy syndrome. Hormonal treatment resolves spasms in more infants than vigabatrin, but this may or may not translate into better long-term outcomes. If prednisolone or vigabatrin is used, high dosage is recommended. Vigabatrin may be the treatment of choice in tuberous sclerosis. Resolution of the EEG features may be important, but this has not been proven. Further research using large studies with robust methodology is required.
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Affiliation(s)
- Eleanor C Hancock
- c/o Cochrane Epilepsy Group, University of Liverpool, Liverpool, UK.
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Abstract
BACKGROUND Epilepsy is a common neurological condition, with an estimated incidence of 50 per 100,000 persons. People with epilepsy may present with various types of immunological abnormalities, such as low serum IgA level, lack of IgG subclass and identification of certain types of antibodies. Intravenous immunoglobulin (IVIg) treatment may represent a valuable approach and its efficacy has important implications for epilepsy management. OBJECTIVES To examine the effects of IVIg on the frequency and duration of seizures, quality of life and adverse effects, when used as monotherapy or as add-on treatment for people with epilepsy. SEARCH STRATEGY We searched the Cochrane Epilepsy Group Specialized Register (14 June 2010), the Cochrane Central Register of Controlled Trials (Issue 2 of 4, The Cochrane Library, 2010), MEDLINE (1950 to June 2010), Web of Science (14 June 2010), Current Controlled Trials (11 June 2010), the National Research Register (NRR) archive (11 June 2010), the US National Institutes of Health (Clinicaltrials.gov) (11 June 2010) and reference lists of articles. SELECTION CRITERIA Randomized or quasi-randomized controlled trials of IVIg as monotherapy or add-on treatment in people with epilepsy. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the trials for inclusion and extracted data. We contacted study authors for additional information. Outcomes included percentage of people rendered seizure-free, 50% or greater reduction in seizure frequency, adverse effects, treatment withdrawal and quality of life. MAIN RESULTS We included one study (61 patients). We found no randomized controlled trials that investigated the effects of IVIg monotherapy for epilepsy. The included study was a randomized, double-blind, placebo-controlled, multi-center trial which compared the treatment efficacy of IVIg as an add-on with a placebo add-on in patients with refractory epilepsy. There was no significant difference between IVIg and placebo in 50% or greater reduction in seizure frequency. The study reported a statistically significant effect for global assessment in favor of IVIg. No adverse effects were demonstrated. AUTHORS' CONCLUSIONS No reliable conclusions can be drawn regarding the efficacy of IVIg as a treatment for epilepsy. Further randomized controlled trials are needed.
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Affiliation(s)
- Jinsong Geng
- Evidence-based Medicine Center, Medical School of Nantong University, 19 Qixiu Road, Nantong, Jiangsu, China, 226001
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Abstract
This epileptic disorder has become a classic topic for neuropediatricians and the interest is documented by the large number of publications on this subject.The relative frequency among the epileptic syndromes is an another reason why not only neuropediatricians but also general pediatricians must be fully informed about diagnostic, clinical, imaging and genetic aspects.Early diagnosis is of paramount importance in order to obtain even complete results in patients with so called idiopathic situations. A number of problems are still to be solved. There is no agreement on the type and the schedule of treatment. A common denominator about this problem is not jet available even if some advances in this regard have been accomplished. Of paramount importance is an accurate clinical and laboratory examination as a prerequisite regarding prognosis and results of therapy in every single case.However, even if more than 170 years have elapsed since the first communication of dr. West on the peculiar syndrome that his child was suffering of, the interest of scientists on this subject has now been enriched and rewarded.
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Affiliation(s)
- Alberto Fois
- Institute of Clinical Pediatrics, University of Siena, Siena, Italy.
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Mikati MA, Kurdi R, El-Khoury Z, Rahi A, Raad W. Intravenous immunoglobulin therapy in intractable childhood epilepsy: open-label study and review of the literature. Epilepsy Behav 2010; 17:90-4. [PMID: 20004620 DOI: 10.1016/j.yebeh.2009.10.020] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2009] [Revised: 10/20/2009] [Accepted: 10/21/2009] [Indexed: 12/24/2022]
Abstract
Our aim was to investigate the long term effectiveness of intravenous immunoglobulin (IVIG) against intractable childhood epilepsy in the era of new antiepileptics and to determine the predictors of a favorable response in a prospective open-label add-on study. Of thirty-seven 9.9+/-0.9-year-old patients (11 with partial seizures, 26 with generalized seizures of whom 9 had West syndrome and 17 Lennox-Gastaut syndrome) followed for 15+/-3 months, 43% had a >50% decrease in seizures (including 15% seizure free, 229+/-58 compared with 104+/-3 seizures/month, P=0.035: generalized 246+/-318 to 117+/-200, P=0.025, partial 191+/-437 to 72+/-179, P>0.05; power=0.2). Males were more likely to respond than females (P=0.011, odds ratio=9.3). Review of the literature revealed nine other articles reporting efficacy of IVIG against epileptic seizures. Only one other used statistical methods and, unlike ours, showed only a trend toward seizure frequency reduction without achieving statistical significance, presumably because it was underpowered. These results indicate large-scale controlled studies of IVIG in epilepsy are still needed.
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Affiliation(s)
- Mohamad A Mikati
- Adult and Pediatric Epilepsy Program, Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
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Abstract
BACKGROUND Infantile spasms (West's Syndrome) is a syndrome which includes a peculiar type of epileptic seizure, the spasms, and an electroencephalogram (EEG) abnormality often called hypsarrhythmia. Psychomotor retardation is frequently found at follow up. Approximately two thirds of affected infants will have a detectable underlying neurological abnormality, but still little is known about the pathophysiological basis for infantile spasms and treatment remains problematic. OBJECTIVES To compare the effects of single pharmaceutical therapies used to treat infantile spasms in terms of control of the spasms, resolution of the EEG, relapse rates, psychomotor development, subsequent epilepsy, side effects, and mortality. SEARCH STRATEGY Published data: Cochrane Epilepsy Group Specialised Register, CENTRAL (The Cochrane Library 2007, Issue 4), MEDLINE, EMBASE, and the reference lists of all retrieved articles.Unpublished data: ISRCTN Register (www.controlled-trials.com), correspondence with colleagues and drug companies, and requests at international conferences. SELECTION CRITERIA All randomised controlled trials of the administration of drug therapy to patients with infantile spasms. DATA COLLECTION AND ANALYSIS Data collection from all relevant publications was independently undertaken by three review authors using a standard proforma. Analysis included assessment of study quality and looking for sources of heterogeneity. MAIN RESULTS We found 12 small RCTs (less than 60 patients enrolled) and two larger RCT (more than 100 patients enrolled). These 14 studies looked at a total of 681 patients treated with a total of nine different pharmaceutical agents. Overall methodology of the studies was poor, partly because of ethical dilemmas such as giving placebo injections to children. Two studies showed that placebo was not as good as active treatment in resolving the spasms. The strongest evidence suggested that hormonal treatment leads to resolution of spasms faster and in more infants than does vigabatrin. Responses without subsequent relapse may be no different. The same study suggests that hormonal treatments (prednisolone or tetracosactide) might improve the long-term developmental outcome compared with vigabatrin in infants not found to have an underlying cause for their infantile spasms. AUTHORS' CONCLUSIONS To date, there have been few well-designed RCTs that considered the treatment of infantile spasms, and the numbers of patients enrolled have been small. Overall methodology has been poor, hence it is not clear which treatment is optimal in the treatment of this epilepsy syndrome. Hormonal treatment resolves spasms in more infants than vigabatrin but this may or may not translate into a better long-term outcome. If prednisone or vigabatrin are used then high dosage is recommended. Vigabatrin may be the treatment of choice in tuberous sclerosis. Resolution of the EEG features may be important but this has not been proven. Further research using large studies with robust methodology is still required.
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Affiliation(s)
- Eleanor C Hancock
- Child and Familiy Health Services, Goldsworth Park Health Centre, Denton Way, Woking, UK, GU21 3LQ.
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Billiau AD, Witters P, Ceulemans B, Kasran A, Wouters C, Lagae L. Intravenous Immunoglobulins in Refractory Childhood-Onset Epilepsy: Effects on Seizure Frequency, EEG Activity, and Cerebrospinal Fluid Cytokine Profile. Epilepsia 2007; 48:1739-1749. [PMID: 17521345 DOI: 10.1111/j.1528-1167.2007.01134.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE Several studies have reported favorable effects of intravenous immunoglobulins (IVIG) in refractory epilepsy. Evidence substantiating an immunomodulatory action is scarce. In an open-label study, we prospectively investigated the effect of IVIG on clinical, EEG and serum/CSF immunological parameters in patients with refractory childhood-onset epilepsy. METHODS Thirteen patients (median age 6.9 years; range 1.6-25.8) with refractory seizures despite 3-4 antiepileptic drug regimens were given IVIG (Sandoglobulin, ZLB-Behring, add-on, 4 x 400 mg/kg/3 weeks). Seizure frequency, 24-h video-EEG, and CSF/serum immunological parameters and cytokine profiles (IL-6/IL-8/IL-12/IL-10) were documented before and after completion of the course. RESULTS Seizure frequency was reduced by > or = 50% in four, and by 25%-50% in three patients. In contrast, variation in automatically recorded spike counts (1-h-wake and -sleep) did not correlate with clinical improvement. Serum immunological parameters showed variable deviations in eight patients (e.g., IgG(2) deficiency) and CSF immunoblotting showed oligoclonal bands in two patients. Blood-brain barrier permeability was normal in 12 patients. IL-6 and IL-8 were clearly detectable in CSF of all patients; the levels were significantly higher than those in plasma but remained unaffected by IVIG treatment. CONCLUSIONS Despite unchanged EEG spike counts, substantial reductions in seizure frequency occurred in 7 of 13 patients, suggesting that IVIG hinder progression of central epileptic activity into clinical seizures. Intrathecal presence of IL-8 and IL-6 was documented in all patients, but was unaffected by IVIG, suggesting that their production is directly related to electrical seizure activity and that IVIG may act through interference with immune pathways downstream to IL-6 and IL-8.
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Affiliation(s)
- An D Billiau
- Laboratory of Experimental Transplantation, University of Leuven, Leuven, BelgiumPediatric Rheumatology, University Hospital Gasthuisberg, Leuven, BelgiumPediatric Rheumatology, University Hospital Gasthuisberg, Leuven, BelgiumLab of Experimental Immunology, KULeuven, Leuven, Belgium
| | - Peter Witters
- Laboratory of Experimental Transplantation, University of Leuven, Leuven, BelgiumPediatric Rheumatology, University Hospital Gasthuisberg, Leuven, BelgiumPediatric Rheumatology, University Hospital Gasthuisberg, Leuven, BelgiumLab of Experimental Immunology, KULeuven, Leuven, Belgium
| | - Berten Ceulemans
- Laboratory of Experimental Transplantation, University of Leuven, Leuven, BelgiumPediatric Rheumatology, University Hospital Gasthuisberg, Leuven, BelgiumPediatric Rheumatology, University Hospital Gasthuisberg, Leuven, BelgiumLab of Experimental Immunology, KULeuven, Leuven, Belgium
| | - Ahmad Kasran
- Laboratory of Experimental Transplantation, University of Leuven, Leuven, BelgiumPediatric Rheumatology, University Hospital Gasthuisberg, Leuven, BelgiumPediatric Rheumatology, University Hospital Gasthuisberg, Leuven, BelgiumLab of Experimental Immunology, KULeuven, Leuven, Belgium
| | - Carine Wouters
- Laboratory of Experimental Transplantation, University of Leuven, Leuven, BelgiumPediatric Rheumatology, University Hospital Gasthuisberg, Leuven, BelgiumPediatric Rheumatology, University Hospital Gasthuisberg, Leuven, BelgiumLab of Experimental Immunology, KULeuven, Leuven, Belgium
| | - Lieven Lagae
- Laboratory of Experimental Transplantation, University of Leuven, Leuven, BelgiumPediatric Rheumatology, University Hospital Gasthuisberg, Leuven, BelgiumPediatric Rheumatology, University Hospital Gasthuisberg, Leuven, BelgiumLab of Experimental Immunology, KULeuven, Leuven, Belgium
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