Decreased Incidence of Clotted AV Access in Hemodialysis Patients after the Implementation of Follow up Program

Background and Objectives: Access monitoring and pre-emptive angioplasty is known to decrease the incidence of AVF/AVG thrombosis. The effect on increase the longevity and functionality of Arterial-Venous access (AV access) in end-stage renal disease (ESRD) patients is not settled. Thrombosis is the leading cause of vascular access complications and is almost always associated with the presence of stenosis. Percutaneous transluminal angioplasty (PTA) is an accepted treatment of stenotic lesions in AV access (NKF 2001). The purpose of this study is to assess the effect of follow up of ESRD patients in the dialysis access center with preemptive angioplasty on access thrombosis.Design, Setting, Participants, & Measurements: This is a single center observational interventional study extended over 9 years (Jan 1, 2006 to Dec 31, 2014) at the Dialysis Access Center of Pittsburgh, PA. The study is divided into 2 periods, period A (from Jan 2006 to December 2009), where follow up program was not in place. Period B extends from (January 1, 2011 to December 31, 2014). In this period, a follow up of patients with preemptive angioplasty of AV access has been implemented. We decided not to include 2010 as the program is implemented at the end of that year and including this year might skewed the data. All patients with ESRD on HD are seen in the Dialysis access center of Pittsburgh for access monitoring and interventional PTA if deemed necessary. Patients’ data were abstracted from the electronic medical records. The study is approved by the IRB of Lifeline corp.Results: During period A; a total of 4139 encounters with a mean of 1034, (1653 angioplasties with mean of 413/year, 375 angiogram, mean 94/year, and 303 thrombectomies of AVF/AVG with a mean 76/year) were carried out. Thrombectomies constituted (7.3%) of the total procedures performed.Table 1 showed the mean distributions of AVG, AVF, and tunneled dialysis catheters (TDC) frequencies compared to national average in periods A & B.In period B, a total of 6229 encounters with mean of 1557 encounter/year were performed, (3202 angioplasties, mean 801/year, 950 angiograms, mean 238/year, and 196 thrombectomies, mean 42/year) were done. Thrombectomies were decreased almost 2 folds in this period (7.3% to 3.15%).The percentage of patients being dialyzed via TDC decreased in period B from 31.895% to 17.38%. The numbers of thrombectomies have also been decreased from average 76 to 42 /year (7.3% to 3.15%).After implementing the program, as illustrated in period B, compared to the national average, the frequency of thrombectomies (3.15% vs. 9.6%) and TDC use (17.38% vs. 18%), have showed significant improvement. Meanwhile, the number of PTA has doubled from an average of (413 to 801/year) between the 2 periods. Our fistula rate has gone up from 48.7% to 66.2% between the 2 periods. Mild increase of the AVG use (12.07% to 18.07%) has also been observed. However, the use of TDC has decreased from (31.42% to 17.38%). These results are consistent with the motto of (fistula first and catheter last). The growth of PTA may explain the positive impact of this program on the number of thrombectomies as well as maintenance of access functionality in ESRD patients. The rate of PTA has gone up from (39.85% to 51.25%). This trade off may be acceptable if access patency and functionality have to be maintained. It is not clear whether the follow up program with preemptive angioplasty would have a positive effect on the access expenditure and access longevity in this group of patients.Conclusion: Follow up of ESRD patients in the dialysis access center and preemptive angioplasty if need be is an acceptable means to decrease the number of failed accesses, thrombectomies, as well as the use of TDC in ESRD patients.

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Endovascular mechanical thrombectomy and stenting in a case of central vein thrombosis

BMJ Case Reports ◽

10.1136/bcr-2020-236508 ◽

2021 ◽

Vol 14 (2) ◽

pp. e236508

Author(s):

Rajesh Vijayvergiya ◽

Navjyot Kaur ◽

Saroj K Sahoo ◽

Ashish Sharma

Keyword(s):

Mechanical Thrombectomy ◽

Transluminal Angioplasty ◽

Brachiocephalic Vein ◽

Central Vein ◽

Vein Thrombosis ◽

Catheter Directed Thrombolysis ◽

Stage Renal Disease ◽

End Stage ◽

Vein Stenosis

Central vein stenosis and thrombosis are frequent in patients on haemodialysis for end-stage renal disease. Its management includes anticoagulation, systemic or catheter-directed thrombolysis, mechanical thrombectomy and percutaneous transluminal angioplasty (PTA). Use of mechanical thrombectomy in central vein thrombosis has been scarcely reported. We hereby report a case of right brachiocephalic vein thrombosis with underlying stenosis, which was successfully treated by mechanical thrombectomy followed by PTA and stenting. The patient had a favourable 10 months of follow-up.

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Distribution and association of cancer with mortality in end-stage renal disease patients receiving dialysis

Journal of Nephrology ◽

10.1007/s40620-019-00649-4 ◽

2019 ◽

Vol 32 (6) ◽

pp. 1003-1009

Author(s):

Rajkumar Chinnadurai ◽

Emma Flanagan ◽

Philip A. Kalra

Keyword(s):

Cox Regression ◽

Matched Sample ◽

Cancer History ◽

Cancer Group ◽

All Cause Mortality ◽

History Of ◽

Stage Renal Disease ◽

End Stage ◽

Esrd Patients

Abstract Background and aims Cancer in end-stage renal disease (ESRD) patients is an important comorbidity to be taken into consideration while planning for renal replacement therapy (RRT) options due to its associated increased mortality. This study aims to investigate the natural history and association of cancer with all-cause mortality in an ESRD population receiving dialysis. Method The study was conducted on 1271 ESRD patients receiving dialysis between January 2012 and December 2017. A comparative analysis was carried out between 119 patients with and 1152 without cancer history at entry into this study (baseline). A 1:2 (119 cancer: 238 no cancer) propensity score matched sample of 357 patients was also used for analysis. Cox-regression analysis was used to study the strength of the association between cancer and all-cause mortality. Kaplan–Meier (KM) analysis was used to demonstrate the difference in cumulative survival between the groups. A competing risk analysis was also carried out to calculate the probability of competing events (death, transplant and incident cancer). Results At baseline, 10.1% of the cohort had a history of cancer (current and past) with the annual incident rate being 1.3%. Urological cancers were the leading site of cancer. The median age of our cohort was 63 years with a predominance of males (63%) and Caucasians (79%). The majority (69%) of the cohort were receiving haemodialysis. 47% had a history of diabetes with 88% being hypertensive. During a median follow-up of 28 months, the proportion of deaths observed was similar between the groups in the matched sample (cancer 49.6 versus no-cancer 52.1%, p value 0.77). In a univariable Cox-regression model, there was no significant association between cancer and all-cause mortality (HR 1.28; 95% CI 0.97–1.67; p = 0.07). The KM estimates showed similar observations in the cumulative survival between the groups (matched sample log-rank, p value 0.85). In competing risk analysis, the cumulative probability of death at 5 years was non-significantly higher in the cancer group (cancer group 64% vs no cancer group 51%, p value 0.16). Conclusions In our real-world multi-morbid dialysis cohort of 119 cancer patients, baseline cancer history did not prove to be an independent risk factor for all-cause mortality in the first 5 years of follow-up, suggesting the need for a case-by-case approach in provision of RRT options, including transplantation.

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MO641IMPACT OF MAGNESIUM AND L-CARNITINE ADMINISTRATION ON 3-YEAR SURVIVAL IN DIABETIC PATIENTS WITH END-STAGE RENAL DISEASE

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfab094.009 ◽

2021 ◽

Vol 36 (Supplement_1) ◽

Author(s):

Oleksandr Susla ◽

Zoriana Litovkina ◽

Olha Bushtynska

Keyword(s):

Renal Disease ◽

End Stage Renal Disease ◽

Cardiovascular Complications ◽

Diabetic Patients ◽

Carnitine Supplementation ◽

Basic Therapy ◽

Stage Renal Disease ◽

End Stage ◽

Esrd Patients

Abstract Background and Aims According to population registries, the survival of diabetic patients with end-stage-renal disease (ESRD) remains low today. In this context, it is reasonable to develop new therapeutic strategies based on advances in science of the important role of magnesium (Mg) and L-carnitine deficiency (via inflammation and endothelial dysfunction) in mechanisms of cardiovascular remodeling, high morbidity and mortality rates. Thus, the purpose of the present study was to evaluate the effect of Mg and L-carnitine supplementation on 3-year survival and development of the cardiovascular complications in diabetic hemodialysis (HD) patients. Method 48 type 2 diabetic ESRD patients were included in this prospective cohort study (male/female, 29/19; age, 59.9±0.6 years; HD duration, 34.8±4.8 month; diabetes mellitus duration, 174.7±7.1 month). The study was performed in accordance with the provisions of the Declaration of Helsinki last revision. Depending on the treatment programme, patients were divided into two groups: the 1st (main) group (n=24) in addition to basic treatment (hypoglycemic, antihypertensive therapy, according to indications - correction of anemia, hyperparathyroidism, hyperphosphatemia) was treated by combination of magnesium aspartate (0.5 g/day orally) and L-carnitine (1 g/day parenterally after each HD session (three times weekly); the 2nd (comparison) group (n=24) was only on the basic therapy. Complex treatment lasted 12-months; administration of L-carnitine was performed continuously throughout the year, while magnesium aspartate – by three 2-months’ courses/year. The follow up period in both groups was 36 months. Quantitative data are expressed as means±SEM, qualitative ones – as %. Kaplan-Meier method and Log-rank test were used to estimate survival of HD patients, χ2-test – to compare the frequency values. Results The cumulative proportion of survivors at the end of follow-up was 60.4%; however, after 36 months, the survival rate of diabetic HD patients who received a combination of magnesium aspartate and L-carnitine as part of their modified treatment was significantly higher (75 vs. 45.8%; Log-rank=2.07, p=0.038) compared to patients who were on basic therapy (Figure). Survival time in main and comparison groups was 31.9±1.7 and 26.4±2.2 months respectively. It is noteworthy, that throughout the year (from 10 to 22 months), no completed events were recorded in subjects who underwent Mg and L-carnitine supplementation. Conclusion (1) The combined use of magnesium aspartate and L-carnitine in addition to the basic 12-month treatment provides an effective reduction of cardiovascular complications and promotes 3-year survival of diabetic HD patients. (2) The results obtained substantiate the advisability of using repeated courses of Mg and L-carnitine administration 1 years after the end of the primary modified treatment to improve the prognosis in these ESRD patients.

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Cell-free DNA as a marker for the outcome of end-stage renal disease patients on haemodialysis

Clinical Kidney Journal ◽

10.1093/ckj/sfaa115 ◽

2020 ◽

Author(s):

Susana Coimbra ◽

Susana Rocha ◽

Henrique Nascimento ◽

Maria João Valente ◽

Cristina Catarino ◽

...

Keyword(s):

Oxidative Stress ◽

End Stage Renal Disease ◽

Stress Markers ◽

Free Dna ◽

All Cause Mortality ◽

Stage Renal Disease ◽

End Stage ◽

Esrd Patients ◽

And Oxidative Stress

Abstract Background DNA damage and inflammation are common in end-stage renal disease (ESRD). Our aim was to evaluate the levels of circulating cell-free DNA (cfDNA) and the relationship with inflammation, anaemia, oxidative stress and haemostatic disturbances in ESRD patients on dialysis. By performing a 1-year follow-up study, we also aimed to evaluate the predictive value of cfDNA for the outcome of ESRD patients. Methods A total of 289 ESRD patients on dialysis were enrolled in the study: we evaluated cfDNA, haemogram, serum iron, hepcidin, inflammatory and oxidative stress markers, and haemostasis. Events and causes of deaths were recorded throughout the follow-up period. Results ESRD patients, as compared with controls, presented significantly higher levels of cfDNA, hepcidin, and inflammatory and oxidative stress markers, and significantly lower values of iron and anaemia-related haemogram parameters. The all-cause mortality rate was 9.7%; compared with alive patients, deceased patients (n = 28) were older and presented significantly higher values of inflammatory markers and of cfDNA, which was almost 2-fold higher. Furthermore, cfDNA was the best predictor of all-cause mortality and cardiovascular mortality in ESRD patients, in both unadjusted and adjusted models for basic confounding factors in dialysis. Conclusions Our data show cfDNA to be a valuable predictive marker of prognosis in ESRD patients on dialysis treatment; high levels of cfDNA were associated with a poor outcome.

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Hemodialysis Decreases the Etiologically-Related Early Vascular Aging Observed in End-Stage Renal Disease: A 5-Year Follow-Up Study

Blood Purification ◽

10.1159/000448986 ◽

2016 ◽

Vol 43 (1-3) ◽

pp. 18-30 ◽

Cited By ~ 1

Author(s):

Daniel Bia ◽

Cintia Galli ◽

Yanina Zócalo ◽

Rodolfo Valtuille ◽

Sandra Wray ◽

...

Keyword(s):

Renal Disease ◽

End Stage Renal Disease ◽

Pulse Wave ◽

Vascular Aging ◽

Control Subjects ◽

Potential Association ◽

Stage Renal Disease ◽

End Stage ◽

Esrd Patients

Aims: To analyze the early vascular aging (EVA) in end-stage renal disease (ESRD) patients, attempting to determine a potential association between EVA and the etiology of ESRD, and to investigate the association of hemodialysis and EVA in ESRD patients during a 5-year follow-up period. Methods: Carotid-femoral pulse wave velocity (cfPWV) was obtained in 151 chronically hemodialyzed patients (CHP) and 283 control subjects, and in 25 CHP, who were followed-up after a 5-year lapse. Results: cfPWV increased in ESRD patients compared to control subjects. The cfPWV-age relationship was found to have a steeper increase in ESRD patients. The highest cfPWV and EVA values were observed in patients with diabetic nephropathy. Regression analysis demonstrated a significant reduction of the EVA in HD patients on a 5-year follow-up. Conclusion: Patients in ESRD showed higher levels of EVA. cfPWV and EVA differed in ESRD patients depending on their renal failure etiology. CHP showed an EVA reduction after a 5-year follow-up period.

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Outcomes of Simultaneous Peritoneal Dialysis and Arteriovenous Fistula Placement in End-Stage Renal Disease Patients

Peritoneal Dialysis International ◽

10.3747/pdi.2017.00072 ◽

2017 ◽

Vol 37 (6) ◽

pp. 658-661 ◽

Cited By ~ 5

Author(s):

Nosratollah Nezakatgoo ◽

Albert Ndzengue ◽

Manhunath Ramaiah ◽

Elvira O. Gosmanova

Keyword(s):

Peritoneal Dialysis ◽

Renal Disease ◽

Arteriovenous Fistula ◽

End Stage Renal Disease ◽

Catheter Insertion ◽

The Mean ◽

Stage Renal Disease ◽

End Stage ◽

Esrd Patients

Peritoneal dialysis (PD) interruption requiring hemodialysis (HD) is not uncommon and its frequently abrupt nature prevents timely creation of permanent HD access and avoidance of central venous catheters (CVC). We retrospectively studied a cohort of 24 end-stage renal disease (ESRD) patients (mean age 50.7 years, 83.3% African-Americans, 58.3% females, time on dialysis interquartile range [IQR] 0 - 65 days) who had simultaneous PD catheter insertion and backup arteriovenous fistula (AVF) creation between January 1, 2012, and December 31, 2013. The primary outcome of interest was the percent of patients receiving HD through the backup AVF at the time of PD interruption. A median (IQR) for PD catheter use after its insertion was 10.5 (2 - 20) days. After the mean follow-up of 19.6 months, 12 patients remained on PD, 2 patients received a kidney transplant, and 1 patient died. The overall AVF patency was 66.7%. A total of 9 (37.5%) patients had PD interruption requiring permanent (8 patients) or temporary (1 patient) HD after the mean (standard deviation [SD]) follow-up of 12.3 (8.2) months. Arteriovenous fistula was used as the initial access in 4 patients, and in 3 patients the original AVF was used after additional surgical revision. Forty-four percent of patients with a backup AVF fistula avoided CVC at the time of PD interruption requiring HD. The simultaneous AVF creation at the time of PD catheter insertion reduced but did not fully eliminate CVC at the time of PD interruption. Larger studies are needed to evaluate the utility of a backup AVF in PD patients.

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P1432THE PRE-DIALYSIS CARE TRAJECTORIES OF ESRD PATIENTS: WHAT TYPES AND WHAT FACTORS OF EMERGENCY DIALYSIS START?

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfaa144.p1432 ◽

2020 ◽

Vol 35 (Supplement_3) ◽

Author(s):

Maxime Raffray ◽

Adélaïde Pladys ◽

Fei Gao ◽

Cécile Couchoud ◽

Cécile Vigneau ◽

...

Keyword(s):

Multiple Correspondence Analysis ◽

Healthcare Consumption ◽

Logistic Regression Models ◽

Factors Associated ◽

Qualitative Approaches ◽

Stage Renal Disease ◽

End Stage ◽

Esrd Patients ◽

Rein Registry

Abstract Background and Aims According to the REIN registry, in France in 2017, 30% of incident end-stage renal disease (ESRD) patients started dialysis in emergency. Emergency dialysis start (ES) is associated with higher risks of morbidity and mortality as well as a decreased quality of life for patients. The objectives were to describe groups of patients with similar care trajectories (or “types”) and identify the factors associated with ES. Method Data from the French REIN registry linked with the French national health insurance database (SNDS) were used. Patients aged 18 years old and older who started dialysis in 2015 in France were included. The 2 years pre-dialysis care trajectory was defined using 8 key components of ambulatory and hospital CKD care consumption. Multiple Correspondence Analysis (MCA) on these components was performed before a Hierarchical Clustering on Principal Components (HCPC) in order to identify types of care trajectories. Logistic regression models including both patients’ characteristics and the key CKD healthcare consumption were used to identify factors associated with ES. Results Among the 8856 patients included, 2681 (30.3%) started dialysis in emergency. The HCPC identified 6 types of pre-dialysis care trajectories. ES rate ranged from 11% to 62% depending on the type. Patient’s profiles were also different between types of trajectories, including age and comorbidities (diabetes prevalence ranged from 22% to 56%). For example, the 5th and 6th types of pre-dialysis care trajectories with high ES rates were characterized by low and absent CKD healthcare consumption respectively. They were shared by younger and less comorbid patients (26.7% and 25.7% aged < 45 years old, 66.5% and 59.4% without any cardiovascular diseases respectively). Conversely to the absence of nephrologist follow-up, the absence of general practitioner follow-up was not significantly associated with ES (OR=1.83, CI 95% [1.58-2.13] and OR=0.79, CI 95% [0.61-1.04] respectively). Conclusion Exploiting the strength of the combined use of clinical and healthcare consumption data, our study shows the diversity of pre-dialysis care trajectories of CKD patients. While some of these types of trajectories can be explained by patients’ clinical and demographic characteristics, complementary qualitative approaches are required to fully understand ES. Some types, as well as ES associated factors, highlight the need for earlier CKD screening and nephrologist referral.

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Leptin/Adiponectin Ratio is an Independent Predictor of Mortality in Nondiabetic Peritoneal Dialysis Patients

Peritoneal Dialysis International ◽

10.3747/pdi.2011.00066 ◽

2013 ◽

Vol 33 (1) ◽

pp. 67-74 ◽

Cited By ~ 18

Author(s):

Jung Tak Park ◽

Tae-Hyun Yoo ◽

Jwa-Kyung Kim ◽

Hyung Jung Oh ◽

Seung Jun Kim ◽

...

Keyword(s):

Peritoneal Dialysis ◽

Body Mass ◽

Density Lipoprotein ◽

High Sensitivity ◽

Diabetic Patients ◽

Reactive Protein ◽

Stage Renal Disease ◽

End Stage ◽

Esrd Patients

♦BackgroundThe leptin/adiponectin (L/A) ratio has been suggested to be an atherosclerotic index for diabetic patients and a useful marker of insulin resistance in patients with and without diabetes. Even though end-stage renal disease (ESRD) patients on peritoneal dialysis (PD) are well characterized by abnormal adipocytokine metabolism, the significance of alterations in the L/A ratio is largely unexplored in these patients. In this prospective study, we investigated the associations of leptin, adiponectin, and the L/A ratio with clinical outcomes in nondiabetic PD patients.♦MethodsThe study included 131 stable nondiabetic ESRD patients who had been on PD for more than 3 months. Serum leptin and adiponectin levels were determined at baseline. Mortality was evaluated over a 5-year follow-up period.♦ResultsDuring the follow-up period, 22 patients died (16.8%), including 10 (45.5%) as a result of cardiovascular disease. The L/A ratio showed a significant positive correlation with body mass index [BMI ( r = 0.47, p < 0.001)], high-sensitivity C-reactive protein ( r = 0.32, p < 0.001), and triglycerides ( r = 0.43, p < 0.001). In addition, we observed significant inverse correlations between the L/A ratio and percentage lean body mass ( r = –0.30, p = 0.001) and high-density lipoprotein cholesterol ( r = –0.31, p = 0.001). In contrast to individual leptin and adiponectin levels, the L/A ratio was found to be independently associated with an increased mortality risk (relative risk: 1.15; 95% confidence interval: 1.05 to 1.27; p = 0.003) even after adjustments for age and BMI.♦ConclusionsThe L/A ratio might be better related to patient outcomes than adipocytokines are individually in nondiabetic patients undergoing PD.

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Frail phenotype might herald bone health worsening among end-stage renal disease patients

PeerJ ◽

10.7717/peerj.3542 ◽

2017 ◽

Vol 5 ◽

pp. e3542 ◽

Cited By ~ 4

Author(s):

Chia-Ter Chao ◽

Jenq-Wen Huang ◽

Ding-Cheng Chan ◽

Keyword(s):

Lumbar Spine ◽

Renal Disease ◽

Bone Health ◽

End Stage Renal Disease ◽

Mineral Density ◽

One Year ◽

Stage Renal Disease ◽

End Stage ◽

Esrd Patients

Background Frailty exhibits a high prevalence in end-stage renal disease (ESRD) patients and is associated with adverse health-related outcomes, including falls and fractures. Available studies do not address whether frailty is associated with temporal changes in BMD. We evaluated this issue by analyzing the follow-up dual energy X-ray absorptiometry (DXA) results in an ESRD cohort. Methods In 2015, we enrolled forty-three ESRD patients, divided into frail, pre-frail, and robust ones based on a validated simple FRAIL scale, all receiving DXA at baseline. After one year of follow-up, survivors received another DXA, and we calculated the absolute and percentage changes in area, bone mineral density (BMD), T-, and Z-scores of lumbar spine and femoral neck (FN) between baseline and follow-up examinations. Results Among all, frail individuals with ESRD had significantly lower average lumbar spine area, lower L4, FN, and total BMD and T-scores, lower FN and total Z-scores than non-frail ones, without differences in gender, body mass index, dialysis duration, and comorbidities. Furthermore, we discovered frail ESRD patients had significantly more prominent decrease in average lumbar spine area, percentage changes in L1 Z-scores and average lumbar spine area, and a trend toward more prominent decrease in L4 area than non-frail ones after one year of follow-up. Conclusions Baseline frailty might be associated with deteriorating bone health, including shrinking L-spine areas and a more rapid decrease in L-spine Z scores, among ESRD patients. This frailty-bone association should be highlighted during our care of frail individuals with ESRD.

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Bioethics & Organ Transplantation in a Muslim Society

American Journal of Islam and Society ◽

10.35632/ajis.v25i2.1473 ◽

2008 ◽

Vol 25 (2) ◽

pp. 108-110

Author(s):

Birgit Krawietz

Keyword(s):

Organ Transplantation ◽

Scientific Progress ◽

Medical Doctor ◽

University Of Virginia ◽

The Gift ◽

Stage Renal Disease ◽

End Stage ◽

The University ◽

Esrd Patients

FarhatMoazam was born in Pakistan and attended medical school there. Formany years, she pursued her surgical and pediatric training in the UnitedStates, witnessing not only scientific progress in organ transplantation butalso the rise of modern secular bioethics, the advocacy of individual rightsand patient autonomy, and feminism(p. 175). Equipped with such privilegedknowledge, she obtained high-ranking positions back in Pakistan, reflectingher competence as both a medical doctor and a medical ethics specialist.While working on this dissertation (she received her doctorate in religiousstudies from the University of Virginia in 2004), however, she employed athird and quite unexpected quality: that of an ethnographer. ButMoazamhasno ambition to contribute to the broader theoretical discussion of MarcelMauss’ The Gift (W.W. Norton & Co., 2000). Rather, she brushes aside theapplicability of reasoning in the tradition of the reception of Mauss (cf. pp.126, 138, 143, and 218). Similarly, she is not concerned with theoretical ethnologicalor sociological debates on globalization and its local appropriations,although, ultimately, this is what the story is about.To conduct her fieldwork, she chose to spend three months at a dialysisand renal transplantation unit in her hometown of Karachi. This vanguardinstitution for end-stage-renal-disease (ESRD) patients, part of her old medicalcollege, is now both the largest and the first institution of its type inPakistan. In addition, the country’s first renal transplant was performed therein 1985. Financed to a lesser degree by the state, about 60 percent of theinstitute’s budget has to be raised by sponsors (p. 46). Such services as dialysis,transplantation, medication, and follow-up are free of charge (p. 37), sothere is a tremendous overflow of people in need.The institute, having started its pioneering work in a traditional societythat is still strongly averse to posthumous donation, has to rely on live ...

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