Kidney Transplant

Kidney Transplant Referral

Submit a kidney transplant referral to Aga Khan University Hospital, Pakistan.

Referring Physician

Referring physician *

Physician contact number

Physician email *

Specialty

Select specialty

Patient Information

Patient name *

Patient contact number *

Date of birth

Country

Select country

Province / State

Select country first

City *

Select country first

Area / locality *

Diagnosis *

Current weight (kg) *

Current height (cm)

eGFR *

eGFR done date

Patient on dialysis?

Yes

Patient has access problems?

Yes

Clinical Details

Patient has living donor? *

Yes

Hepatitis B status

Hepatitis B vaccination date

Hepatitis C status

Cause of renal failure

Current medication list *

Comorbid & Associated Conditions

Important past history and assessments *

Cancer (date and type) *

Oncologist

Cardiovascular disease *

Cardiologist

Pulmonary disease *

Pulmonologist

HIV status *

Surgical history *

Psychiatric history *

Others

Previous transplant? *

Yes

Attachment

Attach relevant documents (chest x-rays, ECG, labs, discharge summary, etc.)

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