U.O. e Sezione di Nefrologia, Brescia

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1 U.O. e Sezione di Nefrologia, Brescia
DIALISI PERITONEALE E TRAPIANTO Mister Chairmen, Dear Colleagues, I’d like to thank the Organizing Committee for inviting me to talk in this very important and historical Course. Claudio has asked me to talk about “TRANSPLANTATION OUTCOME IN PATIENTS ON PD and HD” Giovanni Cancarini U.O. e Sezione di Nefrologia, Brescia

2 pre-operation – operation – post-operation
Tx pre-operation – operation – post-operation HD necessità di seduta HD prima dell’intervento per: - distanza da dialisi precedente - iperkaliemia - Prolunga il tempo d’ischemia fredda - Espone a bioincompatibilità An advantage for PD patients consists on the fact that they are always ready for the transplant operation, they need only flushing out the peritoneal fluid. HD patients generally need to be dialyzed, for three-four hours before the operation and this could increase the cold ischemia time. PD: pazienti sempre pronti per il Tx (salvo intercorrente peritonite o ESI)

3 TEMPO D’ISCHEMIA FREDDA (ORE)
Tx pre-operation – operation – post-operation TEMPO D’ISCHEMIA FREDDA (ORE) PD HD p 20.5± ±8.3 <0.001 21.2± ± Chalem Y, et al. KI 2005;67: Bleyer AJ, et al. JASN 1999;10: The data from the French Collaborative study confirm that the cold ischemia time is statistically shorter in PD patients. Also in the study of Bleyer there is a significant difference, However, it must be defined the role of a so little difference on clinical results (two hours in the first study and less than half an hour in the Bleyer study. Statisticamente significativo; Clinicamente rilevante ?

4 PD: immediate removal of peritoneal catheter ?
Tx pre-operation – operation – post-operation PD: immediate removal of peritoneal catheter ? ESI/tunnel infection ? YES immediate removal NO removal only when PD is not considered as post-transplant modality

5 Time lag: Tx  peritoneal catheter removal
Arbeiter K, et al. (2001) Vanholder R, et al. (1999) Passalacqua J, et al. (1999) Bakir N, et al. (1998) Andreetta B, et al. (1996) Issad B, et al. (1994) O’Donoghue D, et al. (1992) 50 100 150 days

6 Chair and Division of Nephrology, Brescia Peritoneal catheter removal
immediate 4% not removed 1% 88 (95%) removed after 19 ± 15 days

7 Prevalence of peritonitis after Tx in patients previously on PD
Stefanidis CS Patel S Rycklynck JP Shapira Z Rigby RS Robinson RJ Fries D Evangelista JB Tsakiris D Wood CJ Hymes LC Leichter H Mc Donald MW Rubin J Malagon M Triolo G Chiaromonte S O'Donoghue S Maiorca R 60 10 70 20 80 30 90 40 100 50 %

8 Prevalence of peritonitis in patients who used PD after renal Tx
Stefanidis CS Patel S Rycklynck JP Shapira Z Rigby RS Robinson RJ Fries D Evangelista JB Tsakiris D Wood CJ Hymes LC Leichter H Mc Donald MW Rubin J Malagon M Triolo G Chiaromonte S O'Donoghue S Maiorca R 60 10 70 20 80 30 90 40 100 50 %

9 Tx in PD ES / Tunnel infection
Prevalence <10% Therapy catheter removal Outcome* recovery *1 death due to septicemia (Bakir N. et al. NDT 1998; 13:3178)

10 Tx in PD: Non-infectious complications
- ASCITIS - Time to occurrence: 2-3 weeks after Tx Patient age: adults: infrequent children: 10-30% Therapy: symptomatic or drainage Evolution: recovery in days/weeks Complications: not referred

11 Chair and Division of Nephrology, Brescia - EPS AFTER Tx -
Woman 63 y. PD: 10 years, # of peritonitis: 0 Tx 6° month 2 years 3.3 years CsA St Intestinal occlusion No symptom Rx Diagnosis: Sclerosing peritonitis After Tx: 1-2%

12 TX in PD vs. TX in HD In the past, some Nephrologists and Surgeons had a negative attitude towards Peritoneal Dialysis as a dialytic modality before kidney transplantatio . This opinion was probably based more on impression than on scientific data, even though, during the ‘80s and the beginning of the ‘90s PD was suggested in some papers as a “risk factor in renal transplantation”. Later, many papers did a methodologically correct approach to this topic, but their results did not fully agree; e.g., Passalacqua et al. strongly pointed out an advantage for patients receiving HD before K-Tx. On the contrary, Vanholder at al. considered PD as a first choice therapy, as a pre-transplantation therapeutic modality.

13 TX in PD - il passato - (Guillou PJ, et al. Br J Surg. 1984; 71:878)
1984 CAPD: a risk factor in renal transplantation? (Guillou PJ, et al. Br J Surg. 1984; 71:878) 1999 Our data strongly suggest an advantage for patients receiving HD just before transplantation with significant decreases in rate of infections, rates of rejection, and length of hospital stay. (Passalacqua Jo-A, et al. Transplantation 1999; 68:535) … peritoneal dialysis should be considered as a first choice for pre-transplantation therapeutic modality (Vanholder R, et al. Am. J. Kidney Dis. 1999; 33:934) In the past, some Nephrologists and Surgeons had a negative attitude towards Peritoneal Dialysis as a dialytic modality before kidney transplantatio . This opinion was probably based more on impression than on scientific data, even though, during the ‘80s and the beginning of the ‘90s PD was suggested in some papers as a “risk factor in renal transplantation”. Later, many papers did a methodologically correct approach to this topic, but their results did not fully agree; e.g., Passalacqua et al. strongly pointed out an advantage for patients receiving HD before K-Tx. On the contrary, Vanholder at al. considered PD as a first choice therapy, as a pre-transplantation therapeutic modality. 13

14 PROBABILITY TO BE TRANSPLANTED HD (219,240 patients) vs
PROBABILITY TO BE TRANSPLANTED HD (219,240 patients) vs. PD (33,162 patients) (patients starting therapy for ESRD between ) PD (p<0.001) HD On the other hand, there is the observation of Snyder on the Medicare and Medicaid transplanted patients in the period After five years, the 32% of PD patients had been transplanted against only the 16% on HD. After adjustments were made for the differences between PD and HD patients, the relative probability of receiving a kidney transplant was about 40% greater for PD than for HD patients. Those Authors conclude that ”There may be a perception among patients and their physicians that peritoneal dialysis is the treatment of choice for transplant candidates. … transplant candidates were more likely to be placed on PD than HD.” Relative likelihood of receiving a kidney transplant was 1.39 times greater for PD than for HD patients. There may be a perception among patients and their physician that PD is the treatment of choice for transplant candidates. …. transplant candidates were more likely to be placed on PD than HD. (Snyder JJ et al. Kidney Int. 2002; 62: )

15 Characteristics of patients on waiting list according to the ESRD treatment modality
The French Collaborative Group found that PD patients on waiting list were younger, with an higher percentage of women, a lower prevalence of diabetes. It is very interesting to note that, at the time of registration, PD patients had spent 11 months on dialysis versus about 20 months of those on HD. This could bring to hypothesize that the physicians involved in PD programs are more efficient in enrolling their patients in the waiting list. Chalem Y et al. Kidney Int. 2005; 67:

16

17 IMMEDIATO POST-TRAPIANTO
About the short term outcome

18 INCIDENZA CUMULATIVA DI PAZIENTI CON DIMEZZAMENTO DELLA CREATININEMIA POST-TRAPIANTO
PD: 40 patients p=0.02 HD: 79 patients (Van Biesen et al, Transplantation 2000;69: )

19 RITARDATA RIPRESA FUNZIONALE DP vs. HD
PD HD 16% 31% p<0,05 Delayed graft function could depend on many factors related to donor (e.g.: age, non-heart-beating donor, clinical status just before operation), kidney (e.g.: cold ischemia time, difficulty in perfusion), recipient (fluid, vascular and cardiac status, ability to metabolize immunosuppressive drugs) and kind of immunosuppressive therapy . DGF could depend on either acute tubular necrosis or acute rejection which could be easily differentiated only when renal biopsy is done; unfortunately, many papers report all those data together. In our center the probability of delayed graft function is about twice in HD patients. Sezione Trapianto di Rene - Nefrologia Brescia

20 DELAYED GRAFT FUNCTION AND ACUTE RENAL FAILURE POST-TX
(%) 70 <0.01 <0.0001 60 <0.01 % <0.03 50 <0.05 ? 40 <0.05 <0.001 <0.001 PD HD 30 <0.01 ? 20 10 Our data fully agree with data reported by many Authors as you can see in this slide where the data are reported in chronological sequence. In the most of these papers the ratio of delayed graft function between HD and PD is about The reason for this beneficial effect of PD is not completely understood, but many authors claim the more expanded extracellular volume in PD patients, as the possible cause. Shapira Z, et al. 1985 Cardella CJ et al.* 1989 Triolo G, et al 1990 Koch KM et al. 1993 Cacciarelli TV et al 1993 Perez Fontan M et al. 1996 Escuin F et al. 1996 Vanholder R et al. 1999 Bleyer AJ et al. 1999 Van Biesen et al. (DGF) 2000 Van Biesen et al. (ARF) 2000 Vats AN et al° 2000 Joseph JT et al. 2002 Snyder J et al. 2002 Cancarini GC et al 2003 Fontana I et al.° (DGF) 2005 Fontana I et al.° (ARF) 2005 * = only patients over 50 years of age; °= only children

21 RITARDATA RIPRESA FUNZIONALE IPOTESI PER SPIEGARE LE DIFFERENZE
più breve tempo d’ischemia fredda assenza d’ipoperfusione del rene tx dovuta all’UF della seduta dialitica Ruolo “per se” della DP assenza d’infiammazione acuta da incompatibilità della membrana dialitica usata subito prima dell’intervento Van Biesen et al. Transplantation 2000; 69: Other possible causes reported in literature are: shorter cold ischemia time, a role of PD “per se” or the absence of acute inflammation due to the dialysis done just before transplantation. Van Loo et al. J Am Soc Nephrol 1998; 9:

22 Pieringer H, Biesenbach G. Clin Transplant 2005: 19: 391–398
Risk factors before Tx IGF DGF Duration of dialysis (months) p<0.01 Vascular disease 12% 29% p<0.01 Systolic BP 158±25 136±24 p<0.001 Diastolic BP 89±14 78±16 p<0.01 Reanastomosis time (min) 44.2± ±17 p<0.01 Among the possible causes, Pieringer recently has focused the time spent on dialysis before transplantation, but we will come back on this point later. Pieringer H, Biesenbach G. Clin Transplant 2005: 19: 391–398

23 METODICA DIALITICA PRE TRAPIANTO E RIPRESA FUNZIONALE DEL TRAPIANTO RENALE
Scopo: valutare il tempo di ripresa funzionale dopo trapianto di rene in 37 coppie di pazienti (1 in DP e 1 in HD) che ricevevano reni da uno stesso donatore (reni gemelli) I due gruppi di pazienti erano sovrapponibili per: - età - durata dialisi pre trapianto - picco anticorpale pre-trapianto - incompatibilità HLA donatore/ricevente - tempo di ischemia fredda Mosconi G et al. SIN -Firenze, Maggio 2002

24 RIPRESA FUNZIONALE IMMEDIATA (= NON NECESSITA’ DI DIALISI) IN PAZIENTI RICEVENTI RENI GEMELLI
100 p<0.007 80 81% 60 % 40 48% 20 DP HD Mosconi G et al. SIN -Firenze, Maggio 2002

25 Sezione Trapianto di Rene - Nefrologia Brescia
Probabilità di ripresa della funzione renale dopo trapianto di rene in pazienti in DP (n=145) o in ED (n=679) al momento del trapianto 100 80 82% DP ED p=0,032 60 63% % 40 20 3 6 9 12 15 18 21 24 27 30 Giorni dal tx Sezione Trapianto di Rene - Nefrologia Brescia

26 ACUTE REJECTION POST-TRANSPLANTATION
(%) Author Year PD HD p Cardella CJ et al. Escuin F et al. Pérez Fontàn et al. Vanholder R et al. Joseph JT et al. Snyder JJ et al Cancarini GC et al. 1989 1996 1999 2002 2003 48 45 68 49 30 67 41 52 44 31 NS <0.05 So far, about all papers show no significant statistical difference between PD and HD as far as the prevalence of rejection in concerned. However, there is some point which needs to be clarified

27 PROBABILITA’ CUMULATIVA DEL 1° EPISODIO DI RIGETTO
100 80 PD = 67% HD= 67% 60 % 40 20 3 6 9 12 24 36 48 60 mesi dal Tx Sezione Trapianto di Rene - Nefrologia Brescia

28 EPISODI DI RIGETTO NEL 1° ANNO
PD 106 episodi = 1.1/paziente HD 101 episodi= 1.0/paziente p = NS 50 40 30 pazienti (%) 20 10 1 2 >3 Numero di episodi di rigetto acuto Sezione Trapianto di Rene - Nefrologia Brescia

29 RISCHIO AUMENTATO DI TROMBOSI ARTERIOSA ?
Autori Anno n° di paz. PD PD vs. HD (%) p Murphy BG, et al vs. 0 <0.01 Escuin F, et al vs. 3.5 NS Bakir N, et al vs. 6.0 NS Van der Vliet JA, et al vs. 3.6 <0.02 Pèrez Fontán M, et al vs. 6.1 NS Ojo OA, et al <0.001 Vats NA, et al. * vs. 1.7 =0.04 McDonald RA, et al. * vs. 1.9 <0.005 Renal artery thrombosis seems to be significantly more frequent in PD than on HD in many reports, above all in the studies on children as you can see in the last two refrences reported in this slide. * bambini

30 Stepwise proportional hazards modeling: HR p
PRE-TX PD AND GRAFT THROMBOSIS FOLLOWING PEDIATRIC KIDNEY TRANSPLANTATION: A NAPRTCS REPORT Thrombosis = 3° cause of graft loss (2.7%) in 7247 pediatric renal Tx (1987–2001) The most common cause of graft failure (21%) in the cohort: (decrease in the incidence of acute rejection) Percentages of grafts lost as a result of thrombosis: PD 3.4% HD 1.9% pre-emptive transplant 2.4% patients who received both dialysis modalities 4.1% p = 0.005 Stepwise proportional hazards modeling: HR p Pretransplant PD cold ischemia time >24 h <0.001 prior transplant donor age <6 yr 2.51 <0.001 Mc Donald et al. report that artery thrombosis is the third cause of graft loss in transplanted children. The percentages of graft lost as a result of thrombosis were 3,4 in PD and only 1,9 in HD. In the multivariate analysis, PD plays a significant role, by increasing the risk of thrombosis of about 50%. The authors conclude that, since pretransplant PD is associated with an increased risk of graft thrombosis, special precautions should be undertaken in pediatric renal transplant patients who have received PD, especially infants and young children. McDonald RA, et al. Pediatr Transplant. 2003;7:

31 Sezione Trapianto di Rene - Nefrologia Brescia
Sezione Trapianto di Rene - Nefrologia Brescia Impatto della terapia dialitica (DP vs ED) sulla sopravvivenza del trapianto (esclusi i decessi con rene funzionante) 1 2 3 60 80 100 DP (97%) ED (94%) mesi dopotx % 60 120 180 20 40 80 100 HD:62% DP:57% p=NS N° pazienti DP ED Mesi dopo trapianto % Perdita del trapianto per trombosi vascolare n°espianti trombosi vascolari Totale 192 8 DP 24 1 (4,1%) ED (4,1%) Sezione Trapianto di Rene - Nefrologia Brescia

32 OSPEDALIZZAZIONE NEL 1° ANNO
HD PD p 1st ricovero (giorni) 29 ± ± 18 NS successivi (giorni) 13 ± ± 16 NS Probabilità di un 2° ricovero nel 1° anno HD=65 % PD= 62 % 20 40 60 80 3 6 9 12 p = NS mesi % The number of hospitalizations as well as the duration of stay were similar between the two groups. In the lower panel you can see that there is no difference, over the time, in the probability to be admitted. Cattedra e Divisione di Nefrologia Brescia

33 RISULTATI A LUNGO TERMINE
About the long term outcome

34 FUNZIONE RENALE AL FOLLOW-UP PD vs. HD
PD HD p N. Pazienti Follow-up (mesi) 79 ± ± 44 NS Creatininemia (mg/dL) 1.5 ± ± 0.5 NS Proteinuria (> 1 gr/die) 16 % 16 % NS Intervallo alla comparsa di proteinuria 76 ± ± 41 NS (mesi) In two group of patients matched for age, sex and year of transplantation, the first coming from PD and the second from HD, the serum creatinine concentrations at follow-up (7 years) were similar as well as the percentages of patients with proteinuria higher than 1 g/day Cattedra e Divisione di Nefrologia Brescia

35 Cattedra e Divisione di Nefrologia
p= ns 10 20 30 40 50 6 12 18 24 36 42 48 54 60 % Mesi dal Tx PD: 22 % HD: 19 % Polmonite Cattedra e Divisione di Nefrologia Brescia 10 20 30 40 50 12 24 36 48 60 p=NS Mesi dal Tx % PD=27% HD=20% Infezione virale HD= 10% 10 20 30 12 24 36 48 60 72 84 Mesi dal TX % PD= 13% p=NS Neoplasia As far as the main complications are concerned, occurrence of pneumonia, and virus infections were similar in the two groups. After 84 months, the probability for suffering of malignacy was not statistically different. Among the other complications, no statistically significant difference was observed, even if the prevalence of acute pancreatitis was about twice in PD. OTHER COMPLICATIONS in the first 5 years PD HD p Acute pancreatitis 14 % 7 % NS Myocardial infarction 9 % 8 % NS Vasculopathy 5 % 4 % NS Diabetes 3 % 6 % NS

36 VARIABILI PRE-TRAPIANTO E SOPRAVVIVENZA DEL PAZIENTE
Variabili Univariata Multivariata Età < <.0001 Razza ns - Sesso ns - Peso ns - Diabete P.A. ns - Cardiomegalia Fumo Tipo di dialisi ns - Tempo in dialisi By taking into consideration the patient survival, in this paper of 1998, Cosio showed that neither at univariate analysis nor at multivariate analysis, the previous dialysis modality plays a significant role. On the contrary, the time on dialysis is a significant factor with a higher level of probability. (Cosio FG et al. Kidney Int. 1998, 53: 767)

37 SOPRAVVIVENZA DEL PAZIENTE PD vs. HD
Author (reference) year Follow-up (years) PD HD p SOPRAVVIVENZA DEL PAZIENTE PD vs. HD Lambert MC et al. 1995 4 92 88 na Cosio FG et al. 1998 7 83 77 NS Snyder JJ et al. 2002 5 85 85 NS Joseph JT et al. 2002 5 79 81 NS Cancarini GC et al. 2003 10 88 83 NS Chalem Y et al. 2005 2 na na NS 100 80 60 40 20 10 8 6 4 2 years Patient survival % Lambert MC et al. 1985 Cancarini GC et al. 2003 Chalem Y et al. 2005 Snyder JJ et al. 2002 ? NS Joseph JT Cosio FG et al. 1998 HD PD

38 SOPRAVVIVENZA DEL RENE
Author year Follow-up (years) PD HD p SOPRAVVIVENZA DEL RENE PD vs. HD Lambert MC et al. 1995 4 92 77 na Vats AN et al. * 2000 3 82 82 NS Joseph JT et al. 2002 5 61 64 NS Cancarini GC et al. 2003 10 74 76 NS Chalem Y et al. 2005 2 91 89 NS Chalem Y et al. 2005 Lambert MC et al. 1985 100 Cancarini GC et al. 2003 Joseph JT et al. 2002 80 60 Vats AN et al.* 2000 Functionning graft % 40 20 PD HD 2 4 6 8 10 years * = children; ° only pts with SLE na = not available; NS= not significant

39 FATTORI DEL RICEVENTE ASSOCIATI CON PERDITA DEL TX
(ANALISI UNIVARIATA) RR Durata dialisi pre-Tx (per ogni anno) (1.04–1.05) Tipo di dialisi all’inizio del trattamento PD vs. HD (0.88–0.93) Tipo di dialisi pre-Tx PD vs. HD (0.85–1.00) The finding of no effect of dialysis modality does not agree with the results of this more recent paper. At the univariate analysis both the use of PD at the ESRD initiation, and the use of PD just before transplantation plays a protective role. (Chakkera HA et al. JASN J Am Soc Nephrol 16: 269–277, 2005)

40 Influence of dialysis modality on renal transplant complications and outcomes.
Yang Q, et al. Clin Nephrol 2009;72:62-68. 402 cadaveric renal transplant patients: 303 HD 99 PD on dialysis for more than 3 months No significant difference in the incidence rates of: DGF acute rejection chronic rejection cytomegalovirus other infections PD: longer dialysis duration (p < 0.05) less hepatitis B infection (p < 0.05) less post-transplant infection (p < 0.05) Overall patient and graft survival rates at 5 years: NS

41 ASSOCIAZIONE TRA TIPO DI DIALISI
E SOPRAVVIVENZA DEL PAZIENTE E DEL RENE SOPRAVVIVENZA DEL RENE SOPRAVVIVENZA DEL PAZIENTE A better outcome in patients coming from PD has been suggested by Goldfarb in this recent paper. However, this Author showed also… (Goldfarb-Rumyantzev AS, et al. Am J Kidney Dis. 2005;46: )

42 ASSOCIAZIONE TRA DURATA DELLA DIALISI
E SOPRAVVIVENZA DEL PAZIENTE E DEL RENE sopravvivenza del rene sopravvivenza del paziente That the time spent on dialysis before transplantation plays a significant role. The first line in that of patients transplanted after a very short course on PD (less than 2 weeks); the last line refers to patient on dialysis for more than 5 years. You can se that duration of dialysis has a negative effect both on graft and patient survival. (Goldfarb-Rumyantzev A, et al. NDT 2005; 20: 167–175

43 Impatto negativo su sopravvivenza del rene e del paziente PD:
Durata della dialisi: Impatto negativo su sopravvivenza del rene e del paziente PD: Minor sopravvivenza della tecnica Un possibile effetto negativo della DP potrebbe essere mascherato dalla più breve permanenza in DP We know that …… So a question araises…. In other words….

44 HAZARD RISK FOR DEATH HD PD time on dialysis 1.9 1,86** 1.8 1,68** 1.7
1,63** PD 1.6 1,5* 1,61 1.5 1.4 1,48 1,31° HR 1.3 1,32 1.2 1,27 1.1 The study of Goldfarb is a good answer to our question. He analyzed the effect of the dialysis duration on patient survival and found that in HD there is a progressive and significant increase of the hazard risk ofor death, higher than that, not significant, observed in PD patients. 1,08 1 0.9 1-2 yrs 2-3 yrs 3-5 yrs >5 yrs time on dialysis Reference: days ° p<0.05; * p<0.005; ** p<=.0001 (drawn from data by: Goldfarb-Rumyantzev A, et al. Nephrol Dial Transplant 2005; 20: 167–175)

45 HAZARD RISK FOR GRAFT FAILURE
1,8 1,7 1,61** 1,6** 1,54** HD 1,6 1,49** 1,5 1,37* PD 1,4 1,46 1,4 1,42 1,39 1,22° 1,3 HR 1,2 1,22 1,1 1,12 1 Similar results were obtained when the end point was the graft survival. That can potentially be explained by the fact that predictors of the graft survival (e.g. oxidative stress, loss of residual renal function, aberrant T, B cell and cytokine production [20]) might be peaking at 1 year. Additional factors affecting recipient survival (e.g. cardiovascular calcification) continue to accumulate after 1 year of dialysis therapy. Since dialysis for up to 6 months does not appear to affect graft survival adversely, these results suggest that patients who have uraemic symptoms should not defer dialysis while waiting for kidney transplant. While the time on the waiting list is still associated with the graft and recipient outcome, duration of pretransplant ESRD is a better predictor of the graft and recipient survival. 0,9 0,92 0,8 1-2 yrs 2-3 yrs 3-5 yrs >5 yrs time on dialysis (drawn from data by: Goldfarb-Rumyantzev A, et al. Nephrol Dial Transplant 2005; 20: 167–175) Reference: days ° p<0.05; * p<0.005; ** p<=.0001

46 PD vs. HD PRE-CONCLUSIONI
I RISULTATI DEL TRAPIANTO DI RENE IN PAZIENTI IN DP SONO PARAGONABILI A QUELLI DELL’EMODIALISI. E’ FONDAMENTALE, IN AMBEDUE LE METODICHE, RIDURRE IL PIU’ POSSIBILE IL TEMPO TRA INIZIO-DIALISI ED INSERIMENTO IN LISTA. IDEALE: GIA’ IN LISTA ALL’INIZIO DEL TRATTAMENTO

47 Brescia: Ambulatorio Ma.Re.A. (CKD5)
DP HD TX Pre-emptive: - Da vivente - Doppio Tx (anziani) Da cadavere