detailed care of post kidney transplantation .

1. 3
Dr. Mohammad kassem
Nephrology specialist .
Saudi – German hospital
Dubai
26-04-2019 .
‫الرحيم‬‫الرحمن‬‫هللا‬ ‫بسم‬

2. Why early post kidney
transplant .
 Erarly post transplant care means the first 3
months post kidney transplant (KTR) .
 The care of patient start since the preparation for
transplant .
 The most exciting and anxious time for pts .
 The time when the acute event happiend like :
 The rejection ,
 The high dose of medication and its side effect
The infections .
 Surgical complication
 Some pateint needs readmission .

3. Prior to admission for
transplantation .
1- Physical examination
Pericardial effusion
was discovered upon
admission to
transplant unite .

4. Pre- transplant evaluation :
 Repeat the blood grouping and cross matching
 The crossmathe = in vitro transplant .
 Repeat the viral marker in case the patient on dialysis
already .
 Routine tests (Lft , rft , cbc , urine test ….)
 Medicine reconciliation ( blood thinner …)
 Make sure No active infection .
 Some elective cases need preparation by TPE , rituximab .

5. in the transplant unite :
 Admission in transplant unites before few days
 Physical examination , repaet lab test , CXR , ECG ,
arrange radiated blood and cryociptate .
 Dialysis treatment prior to the operation with
Avoidance for excessive fluid removal .
 Start with immunosuppressant as per protocol
Two days prior to the operation .
 prepare the area ( shieving- desinfection )
 Continue Blood pressure medicine except ARBS/ACEI .

6. In the OT :
 Anesthesia should be expert in this kind of procedure .
 CVP line insertion , continue the infusion
immunosuppressant .
 Monitor vital signs and ECG , Avoid the hypotension
 Monitor the hemodynamic status /feel up the CVP 10 to 15
mmhg .
 Record the medication and the dosage .
 The cold and warm time .
 The blood loss and the fluid and blood products replacement ,
 Record and replace The urine output .
 Give challenge of diurtics complet the anastomosis .
 Rare need for arterial line .

7. Donor nephrectomy protective
strategy ?
only useful protective approach against renal
damage is to:
 ensure adequate circulatory volume and
optimal renal blood flow.173
 The aim should be to keep intra-abdominal
pressure low(<12 mm Hg) .
 ensure a positive fluid balance,
 and to maintain an adequate urinary output
with mannitol and furosemide as needed.

8. Upon receive the patient from the OT :
 Patient could be in general transplant care unite if stable .
 The patient should be evaluated immediately .
 A-B-C .
 Monitor urine out put and start replacement .
 Pain management .
 Endorsement from anesthesia team regarding :
 The blood pressure stability during the procedure
 The blood loss
 Intraoperative fluid and blood replacement .
 The cold and warm time for the organ .
 The given medications and its dose including the immunosuppressant .
 Frequent physical examination include check the peripheral pulse in
the feet .
 a systolic blood pressure of <180 mm Hg is acceptable
 systolic blood pressure should be kept over 100 mm Hg and mean
arterial pressure over 70 mm Hg

10. Hemodynamic evaluation and
fluid management .
 Prior to transplant :
Keep the patient 1 kg over the dry weight .
 In OT :
 maintain the systolic blood pressure close to the patient’s
normal blood pressure
 central venous pressure of 10 to 15 mm Hg in patients with
good left ventricular function .
 Radiated Blood is given to maintain a hemoglobin
concentration of approximately 10 g/dL if there is CVD .
 In transplant ward :
 Monitor the vitals , monitor the urine out put and make the
replacement :

11. The roles of replacement :
Depends on many factors and clinical examination as well as the
start of urination after the anastomosis .
Urine out put should be replaced hourly with half slain 100% up to
200 ml if the urine volume is grater than more than 200/hour give
200 ml+1/2 of each ml above 200 ml )
Ex: the urine volume for last hour is 1000 ml
The replacement volume is : 200 +1/2(800) = 600 ml .
Some expert will give 100 % for the urine out put in first day .
All fluid should be replaced by IV until the patient is not NPO .
Electrolytes and fluid replacement individually based on clinical
and volume starts and the blood result .
Some patent may excretes up to 40 liter .

12. Post operative nursing order :
 Expert nurse is a corner stone for success transplant .
1- Vital signs checked every hour for 12 hours, then every 2 hours for 8 hours, then every 4
hours for stable patients .
2- Intake and output every hour for 24 hours, then every 4 hours
3- Intravenous fluid per physician
4- Daily weight
5- Turn, cough, deep breath every hour, encourage incentive spirometry every hour while
awake
6- Out of bed on postoperative day 1, ambulate daily thereafter
7- Head of bed at 30 degrees
8- Dressing changes daily as needed
9- Check dialysis access for function every 4 hours
10- No blood pressure, venipuncture in extremity with fistula or shunt .
11- Foley catheter to bedside drainage, irrigate gently with 30 mL normal saline as needed
for clots 12- Catheter care every 8 hours .
13- Notify physicians if urine output drops to less than 60 mL/h for 2 consecutive hours or
greater than 300 mL/h for 4 hours or greater than 500 mL/h for 2 consecutive hours .
14- Notify physicians if systolic blood pressure > 180 mm Hg or < 110 mm Hg .
15- NPO until changed by surgical team .
16- Chest radiograph immediately postoperatively Postoperative Laboratory Orders
Complete

13. Postoperative laboratory orders
:
 CBC , electrolytes, creatinin, glucose, and
blood urea nitrogen every 6 hours for 24
hours, then every morning.
 Calcineurin inhibitor level every morning
Chemistry panel including liver function
tests, urine culture, and sensitivity twice
weekly .

14. 1- oliguria :
Algorithmic approach to postoperative fluid management in an oliguria
patient

15. Allograft function:
 Immediate Graft Function
 There is relation between the creatinine drop and the graft
function in the first year .
 Slow Recovery of Graft Function:
nonoliguric and experience a slow decline in serum creatinine level
which does not normalize within the first postoperative week
 Delayed Graft Function :
describe marginally functioning grafts that recover function after
several days to weeks , the patient may need dialysis in the first
week .
! it is deferent than :
primary nonfunctioning , where the kidney allografts never function
and graft nephrectomy is usually indicated

16. DGF
Medicine :
NSAID
,
ACEI
,
Renal artery
stenosis.

17. Intra renal DGF:
 ATN
 Rejection
 Nephrotoxicity
 TMA
 Pyelonephritis
 Interstitial nephritis .
 Recurrence of original disease .

18. ATN(Acute tubular necrosis) :
 ATN is uncommon in living donor kidney transplants
 (ATN) is the most common cause of DGF
 It is a consequence of ischemia and reperfusion injury (IRI)
 Clinically, patients may develop oliguria after having an initial good urine output.
 Renal blood flow is generally well preserved, leading to dissociation between flow
and excretory function. Doppler ultrasound may show an elevated resistive index
(RI) of greater than 80%
Studies suggest that endothelial injury upregulates and exposes donor
histocompatibility antigens, adhesion molecules, and costimulatory molecules,
heightening the risk for acute rejection that occurs at a rate of approximately 50%
greater than in kidneys that function immediately.

19. Prevention :
 Avoidance of intraoperative and perioperative volume contraction, or
use of CNI-sparing protocols to avoid their vasoconstrictive effect.
 aggressive lowering of blood pressure may increase the risk for ATN
and DGF
 For high risk patient a protocol consisting of induction therapy with anti-
thymocyte globulin daily for 4 doses and delayed introduction of CNI
until day 3 may be employed ( also may decrease the IRI) .
 Avoid mTOR in the acute phase .
 ?Low-dose dopamine infusions of 1 to 5 μg/kg/min
 ?(CCB) to the donor or recipient, at the time of vasculature
anastomosis
 ?Could DGF (independent of other factors) affect long-term graft
survival,
 DGF has financial and programmatic significance.

20. TREATMENT :
 maintaining adequate immunosuppression and of repeating
biopsies every 7 to 10 days to assess for covert acute
rejection.
 Fluid balance and Control the electrolytes disturbance .
 In case need for hemodialysis , Avoid the hypotension
episode .
 Sodium polystyrene sulfonate (Kayexalate) should not be
administered in the early post-transplant period because it
may induce colonic dilatation and predispose to perforation.

21. ACUTE REJECTION:
 There are three main
patterns diagnosed on
the basis of time of
onset, pathogenetic
mechanisms (humoral
or cellular immunity),
and clinical and
histologic features:

22.  Accelerated Acute Rejection:
 donor-specific antibodies present in the serum of the
recipient at the time of transplantation (ABO
incompatible )
 it is very rare nowadays because flow cytometry
crossmatchis technique
 DD :
 ATN , thrombosis ,
 Renogram , renal Doppler , kidney biopsy and repeat the cross match .
 Prevent :
 Desensitization protocol :
plasma exchange /IVIG/ Rituximab .

23. Acute Cell-Mediated Rejection
 occur between the first week and the first few months
after transplantation .
 Signs :
 asymptomatic rise in serum creatinine or failure of the
serum creatinine to decrease below an elevated level
 less frequently : fever, malaise, graft tenderness, and
oliguria are seen
 mediated primarily by T lymphocytes ,monocytes and
plasma cells
 Presence of neutrophile may indicate the acute bacterial
infection while the presnece of eosinophile
drug-induced interstitial nephritis

24. (Banff 2007 type 2A)

25. • No acute rejection. Absence of tubulitis or intimal arteritis, with or without interstitial inflammation.
• Borderline (suspicious) changes. Mononuclear cell infiltrate involving 10% or more of the nonscarred
cortical interstitium, but not meeting the threshold for diagnosis of type 1 acute rejection due to:
• Insufficient tubulitis (<5 lymphocytes in most severely involved tubular cross-section)
Insufficient inflammation (<25% of nonscarred cortex inflamed)
• Type 1 Acute Rejection : Interstitial inflammation in ≥25% of nonscarred cortical tissue with:
• 1A. Moderate tubulitis (5–10 lymphocytes in most severely involved tubular cross-section or
group of 10 tubular epithelial cells, excluding atrophic tubules)
• 1B. Severe tubulitis (>10 lymphocytes in most severely involved tubular cross-section or group
of 10 tubular epithelial cells, excluding atrophic tubules)
•
• Type 2 Acute Rejection :
• Intimal arteritis, with or without interstitial inflammation and/or tubulitis, with:
• 2A. Less than 25% luminal occlusion in the most severely involved artery (mild to moderate
intimal arteritis)
• 2B. ≥25% luminal occlusion in the most severely involved artery (severe intimal arteritis)
• Type 3 Acute Rejection:
• Transmural arterial inflammation and/or arterial fibrinoid change and necrosis of medial smooth muscle
cells with accompanying lymphocytic inflammation
• (Adapted from Solez K, Colvin RB, Racusen LC, et al. Banff 07 classification of renal allograft pathology:
updates and future directions. Am J Transplant 2008;8:753–760.)
Banff 2007 Diagnostic Criteria for Acute Cell-
Mediated Rejection

26. Acute Antibody-Mediated
Rejection
 It usually occurs early after transplantation,
usually it develops in the setting of preexisting
sensitization and the presence of donor specific
antibodies .
The hallmark micro vascular inflammation and injury
involving the glomerular and peritubular capillaries .as
glomerulitis and peritubular capillaritis
Less frequently seen morphologic lesions TMA & acute
tubular injury . See the classification .
It is mandatory to do PRA for all patient including the low
risk patient .

27. * C4d staining in peritubular capillaries. Indirect immunofluorescence using a mouse monoclonal antibody against C4d
followed by fluorescein-conjugated anti-mouse IgG shows strong linear staining in the walls of peritubular capillaries.
Tubular basement membranes are recognized by weak, nonspecific staining (×400).
C4 staining * Peritubular capillaritis

28. Banff 2013 Classification of Antibody-Mediated Rejection (ABMR)
in Renal Allografts
 Acute/Active ABMR :
 All Three Features Must be Present for Diagnosis:
 1. Histologic evidence of acute tissue injury, including one or more of the following: Microvascular inflammation (glomerulitis and/or
peritubular capillaritis) Intimal or transmural arteritis Acute thrombotic microangiopathy, in the absence of any other cause Acute tubular
injury, in the absence of any other apparent cause
 2. Evidence of current/recent antibody interaction with vascular endothelium, including at least one of the following: Linear C4d staining in
per tubular capillaries (in at least 10% of capillaries by immunofluorescence on frozen sections, or in any capillaries by
immunohistochemistry on paraffin sections) At least moderate microvascular inflammation (mild glomerulitis AND peritubular capillaritis, at
least moderate glomerulitis OR peritubular capillaritis; at least mild glomerulitis must be present when there is acute cell-mediated
rejection) Molecular markers, such as increased expression of endothelial-associated transcripts
 3. Serologic evidence of Donor-Specific Antibodies (HLA or other antigens)
 Chronic, Active ABMR;
 All Three Features Must be Present for Diagnosis
 1. Morphologic evidence of chronic tissue injury, including one or more of the following: Transplant glomerulopathy by light microscopy
and/or EM, if no evidence of chronic thrombotic microangiopathy Severe peritubular capillary basement membrane multilayering (requires
EM) Arterial intimal fibrosis of new onset, excluding other causes
 2. Evidence of current/recent antibody interaction with vascular endothelium, including at least one of the following: Linear C4d staining
in peritubular capillaries (as with acute/active ABMR, above) At least moderate microvascular inflammation (as with acute/active ABMR,
above) Molecular markers, such as increased expression of endothelial-associated transcripts
 3. Serologic evidence of Donor-Specific Antibodies (HLA or other antigens)
 C4d Staining without Evidence of Rejection;
 All Three Features Must be Present for Diagnosis :
 1. Linear C4d staining in peritubular capillaries (as with acute/active ABMR, above)
 2. No glomerulitis, peritubular capillaritis, transplant glomerulopathy, thrombotic microangiopathy, peritubular capillary basement
membrane multilayering, or acute tubular injury (in the absence of another apparent cause for this)
 3. No acute cell-mediated rejection (Banff 2007 type 1A or greater) or borderline changes
 (Adapted from Haas M, Sis B, Racusen LC, et al. Banff 2013 meeting report: inclusion of C4d-negative antibody-mediated rejection and
antibody-associated arterial lesions. Am J Transplant 2014;14:272–283.)

29. ACUTE AMR
ACR
>3 days
>5 days
CLINICAL ONSET
present
Usually absent
DONOR Ab in serum
Present
Absent
Neutrophile in Glomerular and
peri tubular capillaries
present
Absent
C4d staining
Plasma
pheresis.ivig.steroids
Pulse steroids
Primary therapy
ACR vs. AMR ....

31. Treatment of acute rejection
 High-dose steroids :
 prevent the release of IL-1 by macrophages, block
IL-2-mediated synthesis by
 T helper cells, and inhibit tumor necrosis factor-α
(TNFα) methylprednisolone (MP) 0.5 g for 3–5
days)
 About 75% of primary acute rejection episodes are
reversible after treatment with MP .
 Complications :
 seizures, anaphylaxis, and even sudden death ,
ventricular arrhythmias,
 others complain of flushing, tremor, or nausea.
Hyperglycemia is frequent after MP infusion, and

32. ATG :
 Indicated in ACR not responding to MP and vascular
inovolvemnt .
 mode of action :
 lyse circulating T cells and perhaps favor the production of T
suppressor cells.
 obtained by the immunization of rabbits with human
thymocytes.
 ATG have been claimed to be more effective than MP in
reversing rejection and in preventing a second episode of
acute rejection
 Rabbit ATG proved to be superior to horse ATG in reversing
acute rejection and in preventing recurrent rejection (Gaber et
al., 1998).
 ATG is expensive, may require hospitalization (ATG should
be administered in a central vein, needs premedication with
MP, and should be infused in at least 4–6 h)

33. OKT3 :
 The monoclonal antibody OKT3 blocks the
antigen receptor complex CD3 and prevents
antigen recognition.
 It is administered intravenously, usually at a
dose of 5 mg/day for 7–14 days .
 IVIG : 0.5 g/KG daily for seven days usually in
AMR .
(high dose protocol 2g/kg every 2-3 weeks )
 Plasma exchange : ( replacement is the 4 %
albumin ).
 rituximab (2doses 375mg/m2) .
 Bortezomib : 1.3mg/m2/dose X 4 (3days
interval) borteasome inhibitors )

35. AMR ,Prognostic
OKT3 IVIG PP/IVIG Ritux/PP PP/IVIG
Ritux
patients 43 21 16 8 12
Patients
survival
100% 84% 100% 100%
Graft
survival
57% 70% 81% 75% 91.3%
authors Feucht 1993 Lefeucheur
2007
Rocha 2003 Faguer 2007 Lefaucheur
2009

36. ‫الدوائية‬ ‫السمية‬
:

‫ثبطات‬‫م‬ ‫سها‬‫أ‬‫ر‬ ‫عىل‬
‫سينورين‬‫ل‬‫الاك‬
CNI
‫خالل‬ ‫من‬ ‫اللكية‬ ‫عىل‬ ‫ثر‬‫ؤ‬‫ي‬ ‫حيث‬
:

‫نقص‬
‫بيب‬‫لص‬‫ا‬
‫الشعرايت‬ ‫ضغط‬ ‫نقص‬‫و‬ ‫الشديد‬ ‫ارد‬‫و‬‫ال‬ ‫رشاين‬‫ل‬‫ا‬ ‫تقبض‬ ‫سبب‬‫ب‬ ‫اللكوي‬
‫ا‬
‫لكيب‬

‫مبارشة‬ ‫بية‬‫و‬‫نب‬‫أ‬ ‫ذية‬‫أ‬ ‫حدوث‬

‫الشديد‬ ‫الرجفان‬ ‫حدوث‬ ‫ية‬‫ر‬‫ي‬‫رس‬ ‫عالمات‬
‫نزول‬ ‫لعدم‬ ‫شائع‬ ‫سبب‬ ‫يعد‬‫و‬
‫ينني‬‫ت‬‫الكراي‬
‫بعد‬ ‫اته‬‫ري‬‫ث‬‫تأ‬ ‫اجع‬‫رت‬‫ت‬‫و‬
48
‫ب‬ ‫فض‬‫ر‬‫ال‬ ‫عن‬ ‫متزي‬‫ي‬‫و‬ ‫اجلرعة‬ ‫تعديل‬ ‫من‬ ‫ساعة‬
‫عدة‬
‫تفاع‬‫ر‬‫ا‬ ‫منه‬ ‫ات‬‫زي‬‫م‬
‫ينني‬‫ت‬‫الكراي‬
‫بطئ‬ ‫بشلك‬
‫عيار‬ ‫نطلب‬
‫ميوس‬‫ل‬‫التاكرو‬
‫ابلساعة‬
(
0
)
‫وعيار‬
‫بوؤين‬‫يلكوس‬‫الس‬
‫ابلساعة‬
(
2
( )
‫للزرع‬ ‫ابع‬‫ر‬‫ال‬ ‫اليوم‬ ‫يف‬
)

‫مع‬ ‫املشاركة‬ ‫عند‬ ‫يته‬‫مس‬ ‫تزداد‬

CIDOFOVIR. FOSCARNET .SULFONAMIDES .AMPH B

‫امخلرية‬ ‫ثبطات‬‫م‬‫و‬ ‫غليكوزيدات‬ ‫ينو‬‫م‬‫ال‬ ‫مثل‬ ‫سمية‬‫ل‬‫ا‬ ‫سبب‬‫ت‬ ‫خرى‬‫أ‬ ‫ية‬‫و‬‫د‬‫أ‬
(
‫تخ‬‫اس‬ ‫يؤجل‬ ‫ذلكل‬
‫بعد‬ ‫ما‬ ‫ىل‬‫ا‬ ‫داهما‬
‫الضغط‬ ‫لعالج‬ ‫اول‬ ‫خيار‬ ‫تصبح‬‫ل‬ ‫الزرع‬ ‫من‬ ‫ول‬‫ال‬ ‫شهر‬‫ل‬‫ا‬
)
‫تريوئي‬‫الالس‬ ‫الالهتاب‬ ‫ومضادات‬
‫دية‬

‫مس‬ ‫دليه‬ ‫يض‬‫ر‬‫م‬ ‫جند‬ ‫قد‬ ‫ابلتايل‬ ‫و‬ ‫فض‬‫ر‬‫ال‬ ‫و‬‫أ‬ ‫سمية‬‫ل‬‫ا‬ ‫من‬ ‫لك‬ ‫و‬ ‫اء‬‫و‬‫ادل‬ ‫تركزي‬ ‫بني‬ ‫تداخل‬ ‫هناك‬
‫مع‬ ‫ائية‬‫و‬‫د‬ ‫ية‬
‫اء‬‫و‬‫ادل‬ ‫من‬ ‫عال‬ ‫تركزي‬ ‫وجود‬ ‫رمغ‬ ‫فض‬‫ر‬ ‫دليه‬ ‫خر‬‫أ‬ ‫و‬ ‫منخفض‬ ‫تركزي‬

37. CNI toxicity :
 cause renal and systemic vasoconstriction
 may induce ischemia, with consequent tubular atrophy and
interstitial fibrosis
 Clinically :
 slowly progressive graft dysfunction, hypertension, and mild
to moderate proteinuria.
 Prevention :
 Monitor the level , CCB . Free CNI in low risk PATEINT ?

38. Pathology :
 Isometric vacuolization of
proximal tubular epithelium,
and vascular injury with loss of
smooth muscles, myocyte
cytoplasmic vacuolization, and
dropout from necrosis or
apoptosis, injured myocytes
are replaced by focal nodular
hyalinosis , Chronic CNI
toxicity shows a striped
pattern interstitial fibrosis with
proportional tubular atrophy
 Can cause (TMA)

41. Creatinin still elevated
Rapid raise
Slow- non
oligouric
High
sensitized
Empirical
steroid
pulse
biopsy
‫المناسب‬ ‫العالج‬
CNI
High
No
improvment
in 1-2 days
Reduce dose
Low risk
pateint
No response
in 3-5 days
TPE / IVIG
Solumedrol

42. Vascular Causes of DGF
Renal Artery Stenosis
 may occur as early as the first week, but it is
usually a later complication
 Signs :
 accelerated or refractory hypertension and
peripheral edema in the absence of proteinuria
 elevated ratio (greater than 3) of PSV in the renal
artery compared to that in the external iliac artery is
more reliable than the various proposed threshold
values of PSV ranging from 100 to 300 cm/sec.
 CTA or MRA can also be used to confirm RAS

43. Case .
 20 years old female patient .
 On follow up she has hypertension
and increase in the creatinin level 1.5
mg/dl
 Us doppler and Msct showed sever
stenosis .
 Angioplasty with stent was implanted ,
 The creatinine improved to i mg/dl .

44. Before

45. Ballon dilatation
After dialtation

46. Case :
 30 years old
 Living donation
 In the 3th days there is sever pain over the graft .
 Us and ct scan showed hematoma over the graft
 Start creatinine to raised
 Repeat the us showed no flow in the vein
 Reexploration .

48. Graft Thrombosis
 occurs within the first 2 to 3
postoperative days
 Mostly due to technical surgical
complications
 Signs and symptoms :
 Hematuria / pain/
 The diagnosis is usually made by
Doppler ultrasound or isotope flow
scan

49. Risk factors for vascular
thrombosis
 arteriosclerotic involvement of the donor or
recipient vessels;
 intimal injury of graft vessels;
 kidney with multiple arteries;
 history of recurrent thrombosis;
 thrombocytosis;
 younger recipients or donor age;
 antiphospholipid antibody (anticardiolipin antibody
or lupus anticoagulant).
 perioperative or postoperative prophylactic
anticoagulation should be considered
 Treatment : remove the graft .

50. Postoperative Bleeding
 riad of hypotension, precipitous drop
in hemoglobin/hematocrit levels, and
pain
 the perinephric drain may fill with
blood,
 Hematoma
 Treatemnt :
 Conservative treatment ,
 Surgical intervention if there is
pressure on the ureter or surrounding

51. ‫األصلي‬ ‫المرض‬ ‫نكس‬

‫ابكر‬ ‫طعم‬ ‫فشل‬ ‫عادة‬ ‫سبب‬‫ي‬‫ال‬

‫منط‬ ‫البديئ‬ ‫الوز‬‫ز‬‫وك‬‫ال‬ ‫مثل‬ ‫تثناءات‬‫س‬‫الا‬ ‫بعض‬ ‫هناك‬
1
‫توض‬ ‫بسب‬ ‫يع‬‫رس‬ ‫تطور‬ ‫خطورة‬ ‫مع‬ ‫طفال‬‫ال‬ ‫عند‬
‫ع‬
‫بول‬ ‫حش‬ ‫بوجود‬ ‫خاصة‬ ‫و‬ ‫اللكية‬ ‫يف‬ ‫الوز‬‫ز‬‫وك‬‫ال‬

HUS
‫متمة‬‫مل‬‫ا‬ ‫عامل‬ ‫عوز‬ ‫عند‬ ‫خاصة‬ ‫و‬ ‫يع‬‫رس‬ ‫عضو‬ ‫فشل‬ ‫مع‬ ‫الزرع‬ ‫بعد‬ ‫مبارشة‬ ‫يشاهد‬ ‫ممكن‬
H
‫يف‬ ‫و‬‫أ‬
‫العائلية‬ ‫شاكل‬‫ال‬

‫من‬ ‫طفال‬‫ال‬ ‫عند‬ ‫احلاالت‬ ‫بعض‬
FSGS
‫اللكية‬ ‫و‬ ‫يضة‬‫و‬‫احل‬ ‫الهتاب‬
:
‫يه‬ ‫اخلطر‬ ‫امل‬‫و‬‫ع‬ ‫و‬ ‫الزرع‬ ‫بعد‬ ً ‫ا‬‫ر‬‫ابك‬ ‫يشاهد‬ ‫ما‬ ‫اندر‬
:
‫لية‬‫و‬‫ب‬ ‫قثطرة‬ ‫وجود‬
-
DJ
-
‫اضه‬‫ر‬‫ع‬‫أ‬
:
‫ابلطعم‬ ‫مل‬‫أ‬ ‫و‬ ‫محى‬
–
‫بيض‬‫ل‬‫ا‬ ‫الكرايت‬ ‫عدد‬ ‫تفاع‬‫ر‬‫ا‬
–
‫اب‬ ‫العالج‬ ‫و‬
‫لصادات‬
(
‫الزرع‬ ‫مرىض‬ ‫عند‬ ‫القثطرة‬ ‫كيب‬‫ر‬‫ت‬ ‫عند‬ ‫الوقايئ‬ ‫العالج‬ ‫عطاء‬‫ا‬ ‫تطب‬‫يس‬
. )
‫احلاد‬ ‫اخلاليل‬ ‫اللكية‬ ‫الهتاب‬
:
‫ملهتمة‬‫ا‬ ‫ية‬‫و‬‫د‬‫ال‬ ‫توقف‬ ‫و‬ ً ‫احياان‬ ‫يصادف‬
(
‫الباكرتمي‬
)
‫تري‬‫الس‬ ‫جرعة‬ ‫فع‬‫ر‬ ‫من‬ ‫مذكورة‬ ‫الفائدة‬
‫وئيدات‬
(
‫ابخلزعة‬ ‫شخيص‬‫ت‬
)

52. MICROANGIOPATHIC SMERSM

‫تظهر‬
‫الكريات‬
‫المجزأة‬
‫بشكل‬
‫الخوذة‬
(
‫السهم‬
‫األسود‬
‫القصير‬
)
‫كريات‬
‫حمر‬
‫مجزأة‬
‫أخرى‬
(
‫السهم‬
‫األسود‬
‫الطويل‬
)
‫الكريات‬
‫الصغيرة‬
‫المدورة‬
(
‫السهم‬
‫األزرق‬
)
‫نقص‬
‫عدد‬
‫الصفيحات‬
‫الصفيحات‬
‫الكبيرة‬
‫ف‬
‫ي‬
‫المركز‬
‫توحي‬
‫بأن‬
‫نقص‬
‫الصفيحات‬
‫ناتج‬
‫عن‬
‫زيادة‬
‫استهالكها‬
‫وبالت‬
‫الي‬
‫زيادة‬
‫التصنيع‬

53. TMA
 DUE TO : antibody-mediated rejection .
 immunosuppressive drug-induced (CNI and mTOR inhibitors);
 recurrence of atypical HUS;
 TMA associated with ADAMTS-13 deficiency or the presence of
inhibitory antibodies,
 and the presence of lupus anticoagulant or anticardiolipin;
 CMV infection, and less frequently systemic viral infection with
parvovirus B 19 or influenza A virus.
 hepatitis C infection and anticardiolipin antibody positivity.
 Treatment should be directed against the underlying cause.
 Belatacept is a therapeutic option in patients with
immunosuppressant-associated TMA along with plasma exchange .
 Some studies on IVIG .

54. ‫اليوريميائية‬ ‫االنحاللية‬ ‫المتالزمة‬
‫الناكسة‬
‫الزرع‬ ‫بعد‬
‫الــ‬ ‫نكس‬ ‫معدالت‬ ‫إن‬
HUS
‫بين‬ ‫تتراوح‬ ‫الزرع‬ ‫بعد‬
25
%
‫حتى‬
50
%
‫الحاالت‬ ‫من‬
‫ور‬ ‫لسبب‬ ‫أو‬ ‫مجهول‬ ‫المتالزمة‬ ‫سبب‬ ‫لديهم‬ ‫يكون‬ ‫الذين‬ ‫المرضى‬ ‫لدى‬ ً‫ا‬‫خصوص‬
‫اثي‬
‫الــ‬ ‫أن‬ ‫حين‬ ‫في‬
HUS
‫ينكس‬ ‫ال‬ ‫الشغيال‬ ‫لذيفان‬ ‫التالية‬
‫نكس‬ ‫خطورة‬ ‫عوامل‬
‫الــ‬
HUS
‫الزرع‬ ‫بعد‬
‫المتالزمة‬ ‫حدوث‬ ‫عند‬ ‫المتقدمة‬ ‫األعمار‬
‫إلى‬ ‫والوصول‬ ‫المتالزمة‬ ‫بدء‬ ‫بين‬ ‫القصيرة‬ ‫الفترة‬
ESRD
‫حي‬ ‫متبرع‬ ‫من‬ ‫الزرع‬
‫ضياع‬ ‫مع‬ ‫وتترافق‬ ‫المعالجة‬ ‫من‬ ‫شكل‬ ‫ألي‬ ً‫ة‬‫عاد‬ ‫تستجيب‬ ‫ال‬ ‫الناكسة‬ ‫األشكال‬
‫الكلية‬
‫الحاالت‬ ‫معظم‬ ‫في‬ ‫المزروعة‬
(
‫للزرع‬ ‫استطباب‬ ‫مضاد‬
)
‫ن‬ ‫بسبب‬ ‫المزروعة‬ ‫كليتهم‬ ‫يفقدون‬ ‫الذين‬ ‫المرضى‬ ‫بأن‬ ‫أفادت‬ ‫تمهيدية‬ ‫معطيات‬
‫كس‬
‫الــ‬
HUS
‫مثبطات‬ ‫استخدام‬ ‫ودون‬ ‫بنجاح‬ ً‫ثانية‬ ‫لهم‬ ‫يزرع‬ ‫قد‬
‫الكالسينيورين‬

55. MICROANGIOPATHIC SMERSM

‫تظهر‬
‫الكريات‬
‫المجزأة‬
‫بشكل‬
‫الخوذة‬
(
‫السهم‬
‫األسود‬
‫القصير‬
)
‫كريات‬
‫حمر‬
‫مجزأة‬
‫أخرى‬
(
‫السهم‬
‫األسود‬
‫الطويل‬
)
‫الكريات‬
‫الصغيرة‬
‫المدورة‬
(
‫السهم‬
‫األزرق‬
)
‫نقص‬
‫عدد‬
‫الصفيحات‬
‫الصفيحات‬
‫الكبيرة‬
‫ف‬
‫ي‬
‫المركز‬
‫توحي‬
‫بأن‬
‫نقص‬
‫الصفيحات‬
‫ناتج‬
‫عن‬
‫زيادة‬
‫استهالكها‬
‫وبالت‬
‫الي‬
‫زيادة‬
‫التصنيع‬

56. ‫القاعدي‬ ‫الغشاء‬ ‫أضداد‬ ‫أدواء‬
(
ANTI-GBM
: )

‫نك‬ ‫لعدم‬ ‫حرة‬ ‫فرتة‬ ‫ناك‬‫ه‬ ‫يكون‬ ‫ن‬‫أ‬ ‫يطة‬‫رش‬ ‫اجلديد‬ ‫الطعم‬ ‫يف‬ ‫تصادف‬ ‫ما‬ ‫اندر‬
‫مع‬ ‫املرض‬ ‫س‬
‫ية‬‫ب‬‫سل‬ ‫ضداد‬‫أ‬

‫ذية‬‫أ‬ ‫مع‬ ‫بورت‬‫ل‬‫أ‬ ‫داء‬ ‫دلهيم‬ ‫اذلين‬ ‫املرىض‬ ‫ند‬‫ع‬
GBM
‫شاء‬‫لغ‬‫ا‬ ‫ضداد‬‫أ‬ ‫داء‬ ‫ا‬‫و‬‫يطور‬ ‫ان‬ ‫ممكن‬
‫القاعدي‬ ‫شاء‬‫للغ‬ ‫ناعي‬‫مل‬‫ا‬ ‫اجلهاز‬ ‫تعرض‬ ‫ند‬‫ع‬ ‫ذكل‬ ‫و‬ ‫الزرع‬ ‫بعد‬ ً ‫ا‬‫ر‬‫ابك‬ ‫القاعدي‬
‫يف‬ ‫يعي‬‫ب‬‫لط‬‫ا‬
‫ول‬‫ال‬ ‫بوع‬‫س‬‫ال‬

‫العالج‬
:

ً ‫ا‬‫ر‬‫ابك‬ ‫سان‬‫ك‬‫و‬‫ند‬‫أ‬ ‫بدون‬ ‫و‬‫أ‬ ‫مع‬ ‫بالزما‬ ‫فصادة‬
.

58. Case :
 50 years old male patient ,
 ESRD for unknown cause /good urine output
before transplantation
 Underwent Living donation KTR .creatinine upon
discharge is 1.3 mg/dl
 3 months later came with serum creatinine of 8
mg/dl .
 Us hydronephrosis .
 Nephrostomy done with kidney function
improvment , creatinine became 1.1 mg/dl
 Reexporation for ureter reimplantation , d/c
creatinine 1.1 mg/dl . a

59. ‫الكلوي‬ ‫مابعد‬ ‫القصور‬
 Catheter obstruction
Per nephric fluid collection (lymphocyte,
urine leak, hematoma)
 Ureteral obstruction
 Intrinsic (blood clots, poor re-
implantation, ureteral slough)
 Extrinsic (ureteral kinking)

60. Urine leakage :
 Due to the ureter ischemia or the short ureter during the first week of
transplantation .
 Symptoms : abdomen distension , abdominal pain , high volume from
the drain , high creatinine in the drainage fluid .
 Conservative tx :
 Stent / nephrostomy ...
 In case of persistant leakage the reexploration is indicated . .

61. MEDICAL MANAGEMENT IN THE FIRST :
WEEK
 Hypertension :
lack of conclusive evidence that one class of antihypertensive
agent is superior to another in the transplant setting and
treatment should be individualized .
β blockers are generally used in the perioperative period
because they have been shown to reduce cardiovascular events
in high-risk candidates
ACEIs and ARBs should be avoided in early post transplat ,
later we may use if no RAS .
First choise : dihydropyridine ( amlodipine- nifedipine ,
lecardipine...)
Nondihydropyridine calcium channel blockers such as diltiazem
may permit CNI dose reduction ( carfull monitroing for CNI level
) .

62. Surgical Incision, Drains, and
Stents
 ! Sirolimus may delay wound healing
and increase the incidence of
lymphocele formation .
 Foley removal on day 3 or 4
 perinephric drainin the following if
drain is less than 100 mL/day and
After graft Doppler .
 2 weeks remove the Surgical staples .
 4- 5 weeks double-J stent removal .

63. DD :
Infections ( baceial 80%- viral( cmv ) – fungal
Rejection
Cytokines release due to medications ( eg : ATG )
Allergy
SIRS ( pancreatitis , PE , )

65. Diarrhea
 Very common
 13% of ktr within first 2 weeks
 41% of cases due to C-DIFF .
 34 % due to SI of medication .
 Tx :
 Metronidazol , oral vancomycin in sever case , anti motalty if c- diff is negative .

66. Hyperglycemia
 In the immediate post transplant the
hyperglycemia should be controlled with
an intravenous infusion of insulin ange
150-180 mg/dl .
 then after transitioned from intravenous
insulin to a subcutaneous regime
 In case the risk of NODAT, and type 2 DM
, consideration to use cyclosporine
 steroid exposure should be minimized,
 d/c prednisone within the first few days in
low immunologic risk pts .

67. (NODAT)
 serious complication of transplantation that is associated
with : dyslipidemia,
 chronic allograft dysfunction,
 cardiovascular morbidity,
 death.
 Risk factors :
obesity, weight gain, hepatitis C, steroids, tacrolimus, and
restoration of insulin metabolism by the kidney allograft.
(ADPKD) ?

69. ‫الدم‬ ‫سكر‬ ‫ارتفاع‬

‫عرب‬ ‫احة‬‫ر‬‫اجل‬ ‫بعد‬ ً ‫ا‬‫ر‬‫ابك‬ ‫يضبط‬ ‫ن‬‫أ‬ ‫جيب‬
‫يب‬‫رس‬‫ت‬
‫ابملضخة‬ ‫يع‬‫رس‬‫ال‬ ‫لني‬‫و‬‫نس‬‫ال‬
(
‫بني‬
150
‫ىل‬‫ا‬
180
)

‫يوض‬ ‫للطعام‬ ‫يض‬‫ر‬‫امل‬ ‫تناول‬ ‫بداية‬ ‫عند‬ ‫و‬
‫عىل‬ ‫ع‬
‫املتوسط‬ ‫لني‬‫و‬‫نس‬‫ال‬ ‫من‬ ‫جرعتني‬
NBH
.
‫مث‬
‫نس‬‫أ‬ ‫من‬ ‫مديدة‬ ‫جرعة‬ ‫عىل‬ ‫يض‬‫ر‬‫امل‬ ‫وضع‬ ‫ممكن‬
‫لني‬‫و‬
‫مديد‬
GLARGINE
‫لني‬‫و‬‫نس‬‫ال‬ ‫حاجة‬ ‫ن‬‫أ‬ ‫مع‬
‫تريوئيدات‬‫الس‬ ‫ختفيض‬ ‫مع‬ ‫ختف‬
.

‫داء‬ ‫ير‬‫و‬‫تط‬ ‫خطورة‬ ‫عىل‬ ‫اذلين‬ ‫املرىض‬ ‫عند‬
‫عىل‬ ‫وضعهم‬ ‫يفضل‬ ‫يون‬‫ر‬‫سك‬ ‫مه‬ ‫و‬‫أ‬ ‫سكري‬
‫تريوئ‬‫س‬ ‫ختفيض‬ ‫مع‬ ‫بورين‬‫سايلكوس‬
‫و‬‫أ‬ ‫يدات‬
‫ف‬‫ر‬‫لل‬ ‫اخلطورة‬ ‫منخيض‬ ‫املرىض‬ ‫عن‬ ‫فطمها‬
‫ض‬

‫السكر‬ ‫ادلاء‬ ‫حول‬ ‫املرىض‬ ‫ثقيف‬‫ت‬ ‫جيب‬
‫و‬ ‫ي‬
‫و‬ ‫لني‬‫و‬‫نس‬‫ال‬ ‫تخدام‬‫اس‬ ‫و‬ ‫يته‬‫و‬‫د‬‫أ‬ ‫و‬ ‫عالجه‬
‫العاديني‬ ‫السكري‬ ‫مكرىض‬ ‫متابعهتم‬

70. hyperlipidemia

71. ‫للزر‬ ‫األولى‬ ‫الفترة‬ ‫في‬ ‫المضطربة‬ ‫التحاليل‬
‫ع‬

ً‫ال‬‫و‬‫أ‬
–
‫البول‬ ‫حتليل‬
:

‫بيب‬‫لط‬‫ا‬ ‫ىل‬‫ا‬ ‫زايرة‬ ‫لك‬ ‫عند‬ ‫الباكرة‬ ‫املرحةل‬ ‫يف‬ ‫روتيين‬ ‫اء‬‫ر‬‫ج‬‫ا‬
,
‫وج‬ ‫عن‬ ‫يعرب‬ ‫بيض‬‫ل‬‫ا‬ ‫الكرايت‬ ‫وجود‬
‫فض‬‫ر‬ ‫و‬‫أ‬ ‫نتان‬‫ا‬ ‫عن‬ ‫ود‬
‫كيب‬‫ر‬‫ت‬ ‫وجود‬ ‫ياق‬‫س‬ ‫يف‬ ‫و‬‫أ‬
DJ
(
‫اض‬‫ر‬‫ع‬‫ال‬ ‫و‬ ‫البول‬ ‫زرع‬ ‫عرب‬ ‫منزي‬
)

‫املفاغرة‬ ‫من‬ ‫ادلم‬ ‫نز‬ ‫سبب‬‫ب‬ ‫الشائعة‬ ‫ية‬‫و‬‫ادلم‬ ‫بيةل‬‫ل‬‫ا‬
(
‫مشوهة‬ ‫غري‬ ‫كرايت‬
)
‫ت‬‫برو‬ ‫بيةل‬ ‫وجود‬ ‫ميل‬ ‫مع‬
‫ينية‬

‫ينية‬‫ت‬‫الربو‬ ‫بيةل‬‫ل‬‫ا‬ ‫متابعة‬ ‫جيب‬
FSGS
‫نكسه‬ ‫ملتابعة‬

ً ‫نيا‬‫اث‬
–
‫يوم‬‫البواتس‬
:

‫اابمايسني‬‫ر‬‫ال‬ ‫تخدام‬‫اس‬ ‫و‬‫أ‬ ‫يوم‬‫زن‬‫املغ‬ ‫نقض‬ ‫او‬ ، ‫نيف‬‫لع‬‫ا‬ ‫ار‬‫ر‬‫د‬‫اال‬ ‫سبب‬‫ب‬ ‫الباكرة‬ ‫املرحةل‬ ‫يف‬ ‫ينخفض‬
‫بيةل‬ ‫ىل‬‫ا‬ ‫يؤدي‬ ‫قد‬ ‫مما‬
ً‫ا‬‫نش‬‫مل‬‫ا‬ ‫ية‬‫و‬‫لك‬ ‫تفهة‬

‫ل‬ ‫نيب‬‫ا‬‫ج‬ ‫ثري‬‫كتأ‬ ‫تفع‬‫ر‬‫ي‬ ‫قد‬
CNI
‫و‬‫أ‬
ACEI
‫ات‬‫رص‬‫حا‬
‫و‬‫أ‬
‫امحلاض‬
.

ً ‫اثلثا‬
–
‫الفوسفور‬
:

‫الباكرة‬ ‫افرتة‬ ‫يف‬ ‫اخنفاضه‬ ‫شائع‬

‫يوم‬‫البواتس‬ ‫يفوسفات‬ ‫يض‬‫و‬‫للتع‬ ‫حيتاج‬ ‫قد‬

‫لبان‬‫ل‬ ‫ا‬‫و‬ ‫جبان‬‫اكل‬ ‫ابلفوسفور‬ ‫نية‬‫لغ‬‫ا‬ ‫امحلية‬ ‫تناول‬ ‫عىل‬ ‫املرىض‬ ‫شجيع‬‫ت‬ ‫جيب‬ ‫و‬

‫يوم‬‫الاكلس‬
‫يف‬
40
%
‫ن‬ ‫قد‬ ‫نوي‬‫ا‬‫الث‬ ‫ادلرق‬ ‫ات‬‫ر‬‫جا‬ ‫هرمون‬ ‫فرط‬ ‫سبب‬‫ب‬ ‫يوم‬‫الاكلس‬ ‫يف‬ ‫طفيف‬ ‫تفاع‬‫ر‬‫ا‬ ‫جند‬
‫بعض‬ ‫يف‬ ‫ضطر‬
‫ادلرق‬ ‫ات‬‫ر‬‫جا‬ ‫استئصال‬ ‫ىل‬‫ا‬ ‫احلاالت‬

72. ‫الدموية‬ ‫االضطرابات‬

‫عن‬ ‫حديد‬ ‫عوز‬ ‫دلهيم‬ ‫معظمهم‬ ‫و‬ ‫الزرع‬ ‫شعبة‬ ‫من‬ ‫التخرج‬ ‫عند‬ ‫دم‬ ‫فقر‬ ‫دلهيم‬ ‫املرىض‬ ‫معظم‬
‫و‬ ‫القبول‬ ‫د‬
‫للزرع‬ ‫هلم‬‫و‬‫قب‬ ‫ثناء‬‫أ‬ ً ‫وريداي‬ ‫يعوض‬ ‫ن‬‫أ‬ ‫ممكن‬
.

‫عطاء‬‫ا‬ ‫اما‬
EPO
‫نذاك‬‫أ‬ ‫فعال‬ ‫غري‬ ‫ن‬‫قا‬
.
‫خماز‬ ‫ملء‬ ‫بعد‬ ‫وصفه‬ ‫ممكن‬ ‫العيادة‬ ‫يف‬ ‫عطاء‬‫ا‬ ‫ممكن‬ ‫و‬
‫احلديد‬ ‫ن‬
‫الزنف‬ ‫نفي‬ ‫جيب‬ ‫نزوهل‬ ‫و‬‫أ‬ ‫اخلضاب‬ ‫حتسن‬ ‫عدم‬ ‫حال‬ ‫يف‬
(
‫الهضمي‬ ‫سبيل‬‫ل‬‫ا‬ ‫و‬‫أ‬ ‫اجلرح‬ ‫من‬
)

‫ابل‬ ‫نتان‬‫الا‬ ‫و‬ ‫امخلرية‬ ‫ات‬‫رص‬‫حا‬ ‫تخدام‬‫اس‬ ‫ادلم‬ ‫لفقر‬ ‫باب‬‫س‬‫أ‬
HPV

‫اللكوي‬ ‫رشاين‬‫ل‬‫ا‬ ‫تضيق‬ ‫ادلم‬ ‫ار‬‫ر‬‫امح‬ ‫باب‬‫س‬‫أ‬ ‫من‬

‫زايدة‬ ‫كذكل‬ ‫الثالثة‬ ‫ادلم‬ ‫عنارص‬ ‫نقص‬ ‫سبب‬‫ت‬ ‫ن‬‫أ‬ ‫نقسام‬‫الا‬ ‫ملضادات‬ ‫ممكن‬
MCV

‫ال‬ ‫مضادات‬ ‫و‬ ‫يةل‬‫نس‬‫ل‬‫ا‬ ‫وحيدة‬ ‫و‬ ‫عديدة‬ ‫ضداد‬‫أ‬ ً ‫يضا‬‫أ‬
CMV

‫من‬ ‫اقل‬ ‫تصبح‬ ‫عندما‬ ‫و‬ ‫عدالت‬ ‫نقص‬ ‫سبب‬‫ت‬ ‫ن‬‫أ‬
500
‫نبوجني‬‫ل‬‫ا‬ ‫اء‬‫و‬‫ادل‬ ‫يوقف‬
(
GM-CSF
)

73. THE DAY OF DISCHARGE
 It is imperative that all patients (together with family members or caregivers)
attend the patient education session .
 Explain ALL the medication .
 Encourage fluid intake 3 liter and above if nedded .
 Follw up plan for suture anf jj stent removal .
 Monitor the blood pressure / weight daily / urine out put
 Healthy life style :
 encourage Exercises .
 Advise for stop smoking .
 Dietician consultation with avoid gain weight

74.  Personal hygiene ,
 hand washing , avoid the crowded places .
 Well done cooking and carful about food hygiene .
 Seek advise any symptoms like : fever , low urine output and
diarrhoea ,......
 Back to work after 3 month on average
 no objection for Pregnancy after one year of well functioning
kidney with avoidance for antiprolifrative ( MMF- sirolimus-
evrolimus) .

75. TIMING DRUG NOTE
On empty stomach CNI LIFE LONG
Dose should be adjusted by
physicien
Every 12 hours should be
taken .
Beore brekfast ppi For 2 months
After brekfast Prednesolon LIFE ONG
AFTER THE MEALS for 3
months
NYSTATINE FOR 3 MONTHS
Twicw a day Ciprofloxacin For one week
2 TABLETS CMV PREVENTION (
VALCYTE )
FOR 100 DAYS
2 hours after the food MMF Twice a day Life long
Bedtime Septrin 80/420 For 9 months
With food Mutlivitamines-
magnesium calcium and
vitamin D .
Once daily As directed .

76. Lab test :
• Urea , creatinin , sugar , cbc , CNI level ,
electrolytes panel with every visit .
• May required additional test if required
like iron profile ,,,,
• At the end of 3 months should done lipid
profile .
And Urine test and urine albumine as well
 Renal doppler in 1,3,6 months after
KTR .

77. Follow up plan :
 Twice weekly for first 4 weeks .
 Weekly for the next month .
 Every two weeks after 2 months .

78. ‫اجع‬‫ر‬‫امل‬
REFERENCES
medical complications of kidney
transplantations .
Handbook of kidney transplantations –5th
Edition-.
Pocket companion to Brenner & rector's the
kidney-8th Edition- .
Comprehensive clinical nephrology -3rd
Edition -

79. ”
‫يعلمها‬ ‫إال‬ ‫ورقة‬ ‫من‬ ‫تسقط‬ ‫ما‬ ‫و‬
“