It began with her toe. It was 1979, and Casey Caswell Williams '81, a 20-year-old junior sociology major at UNH, thought she had broken it somehow. When she couldn't walk on it -- couldn't even stand a bed sheet touching it -- she limped to an emergency room. It could be gout, the doctor told her. But when the pain and swelling disappeared, Williams forgot all about it. Until two years later when it happened again.

This time a doctor not only diagnosed gout but chronic kidney failure, a disease, she would later discover, that ran in her family. In chronic kidney failure, the kidneys gradually stop filtering toxins from the body. In the early years, the disease can be asymptomatic, but as the kidneys begin to fail, wide-ranging symptoms appear, such as excessive thirst, weight loss, fatigue, anemia, lethargy, seizures and coma. Ultimately, its victims can die.

Once Williams recovered from the gout, she felt fine. But she worried about what lay ahead, and family and friends tried to offer comfort and advice. Brenda Reagan Ramsdell '81, her best friend and UNH roommate, could sense her unspoken anxiety. Things will work out, Ramsdell told her. Nearly 25 years later, Ramsdell would reassure Williams again. But this time she would do more than offer words of comfort.

The girls had much in common -- they both came from blended families, their mothers were both bankers, they had similar tastes in music and books, and their senses of humor clicked. They became inseparable friends throughout school (Williams even pierced Ramsdell's ears for her when they were 17), and, in 1977, they ended up going to UNH together. "At first, we decided not to be roommates," recalls Ramsdell. "We wanted to meet new people and have lots of new experiences. But we lived across the Quad from each other -- I lived in Hitchcock, Casey lived in Randolph -- and we ended up seeing each other almost every day anyway."

During sophomore year, Ramsdell took some time off and went to Europe. When she came back, she and Williams became roommates in an apartment in Dover, N.H. It was Ramsdell who gave Williams the nickname "K.C." from her birth name Katherine Caswell. Eventually the name stuck and became Casey. "Now everybody calls me that, and they have since college," says Williams.

While they were living in Dover, Williams broke her leg in a car accident; Ramsdell took care of her until she was back on her feet again. For most of their 20s and 30s, the two women lived far apart -- Williams with her husband in Florida and Ramsdell with her husband, Gary, in New England -- but kept in close contact with frequent phone calls and visits to each other's homes. Ramsdell became a schoolteacher, operating her own kindergarten in Barrington, N.H., for 10 years, and eventually teaching in elementary schools in Loudon, Boscawen and Penacook, N.H., while writing a children's book and stories. Williams joined the corporate world as a leadership trainer in Florida and eventually all over New England. In 1998, Williams and her family -- which included her husband, Tom, her son, Beau, now 16, and daughter SunMi, now 13 -- moved back to New Hampshire.

"Over all the years of our friendship we've never had a single serious argument," says Ramsdell. "Our friendship is unconditional; we just know that we can always count on each other."

About the time Williams moved back to New Hampshire, her health, which had been declining slowly and steadily over the years, took a bad turn. She began to feel numbness in her hands and feet, nausea and headaches. Trying to live a normal lifestyle, she had to force herself to eat. But every day was harder than the last.

For most victims of chronic kidney failure, the disease cannot be cured, and inexorably, the kidneys begin to fail. By the time Stage 5 (kidney failure) is reached, there are two ways to stay alive: dialysis, or a kidney transplant. In the United States, about 20 million adults -- one in nine -- have some degree of chronic kidney disease, according to the National Kidney Foundation, and more than 56,000 people are waiting for a kidney transplant. Williams started peritoneal dialysis, a process that flushes impurities out of the blood. "I never wanted to be a patient; I didn't want that to define me; I wanted to have as normal a life as possible," she says, so she chose continuous ambulatory peritoneal dialysis, which can be performed by the patient without a machine.

As the first step, her doctor surgically inserted a plastic catheter into her abdomen. Then, four or five times a day, Williams would attach a two-quart bag of saline solution called dialysate to the catheter and drain the fluid into her abdominal cavity. After several hours, the solution, which had absorbed impurities that her kidneys could not, would be drained out again and thrown away.

"Although it wasn't really painful, it was inconvenient because I had to travel all through New England and New York for my job," says Williams. "I had to cart around a 30-pound box of stuff wherever I traveled, but I learned to do the dialysis myself in the car."

Two years into her dialysis, Williams came down with a potentially deadly infection called peritonitis. To recover, she switched to hemodialysis, a process that uses a machine the size of a medicine cabinet to cleanse the blood. Williams' doctor inserted a catheter into a vein below her collarbone that led directly to her heart. Three or four times each week, Williams would return to the hospital and lie on a gurney for four to five hours while her blood circulated through the hemodialyzer. The procedure was excruciating. Her kidneys continued to deteriorate, their function dropping to about 3 percent of normal. The disease began to affect every part of her body. "I was exhausted and in pain a lot," she recalls. "My fingers and feet often felt numb and tingly. I had restless leg syndrome, and I never slept well."

Although kidney dialysis has been in existence for more than 50 years -- a young Dutch physician named Willem Kolff invented the first dialyzer in 1943 -- researchers do not know how long people can live while undergoing dialysis. Some patients tolerate the procedure well and live for decades. Others develop complications, including fever, vomiting, cramps, infections and seizures. More than 3,000 people on the waiting list die each year before receiving a transplant.

Williams' family, well aware of the risks of chronic kidney failure from her brother and sister's struggles with the disease, knew her best chance of survival was to receive a new kidney from a living donor. All her family members with healthy kidneys were tested as potential matches. Although some came close, no one was close enough.

The first successful living-donor kidney transplant was performed in 1954 between 23-year-old identical twins. Since then, thousands of kidney transplants between living donors and patients have been performed, making it the most common type of living-donor organ transplant. In 2002, there were 14,770 kidney transplants performed, 6,613 of them from living donors. Of those donors, about 29 percent were unrelated either by marriage or blood to the recipient.

To qualify as a donor, an individual must be healthy, physically fit and free from serious disease. Those who pass that first hurdle are tested for blood-type compatibility. Additional testing includes tissue typing for white blood cells, crossmatching for organ rejection, an antibody screen and an arteriogram, where a dye injected into the kidneys is viewed with X-rays. Perhaps most important, donors and recipients are both encouraged to undergo a psychiatric or psychological evaluation. For the donor, the procedure involves some risk, including damage to the remaining kidney as well as the kind of risks associated with any surgery-- blood clotting, collapsed lung, allergy to anesthesia and death (three out of every 10,000 kidney transplants). The donor does not normally suffer diminished kidney function since the remaining kidney grows to take on the job of two.

When Ramsdell heard that Williams' family members had all been rejected as possible donors, she made a decision. She could see that Williams' condition was deteriorating, even though Williams never complained. "I had to force information out of her," says Ramsdell. Calling her friend on the phone, she told her, "'"I'm going to be tested, and I just know I'm going to be a match.'"

When the results of her tests arrived, Ramsdell was given the option of changing her mind. Someone from the hopsital would make the call, and Williams would never know that she could have been the donor. Ramsdell didn't hesitate. "I called her and said, 'Guess what? I'm going to give you a kidney!'"

Williams' reaction was one of guarded optimism. "I think, in a way, she felt bad -- how could she possibly accept this from me?" Ramsdell recalls. "She gave me every opportunity not to do it."

"I did feel guilty, and worried," says Williams. "My thoughts were about her. I was hoping that there wouldn't be any complications; it's hard to know someone is going to go through that for you."

But for Ramsdell, there was never any doubt. "I was never scared. Because I had had surgery in the past, in a way I knew what to expect," says Ramsdell. "And the risks of serious complications are low. I thought, 'Oh my God, this could be the one big thing I do in my life to help someone; this could be the whole reason I'm here."

For years, Williams had ridden an emotional rollercoaster of rising hopes that a match would be found, followed by sinking disappointment. The months leading up to the surgery would prove to be no different. Williams came down with an infection, so the surgery had to be postponed. Then a test revealed that Ramsdell had been exposed to hepatitis B, a potentially fatal liver disease. But a further test showed that while Ramsdell had been exposed, she did not have hepatitis and nor was she a carrier.

Finally, after a four-year wait, surgery was scheduled for Feb. 4, 2003, at Tufts-New England Medical Center in Boston, a hospital that offered laparoscopic surgery for Ramsdell, which is less invasive. Overseeing the two operations would be Dr. Richard Rohrer, chief of the transplant surgery division. Williams and Ramsdell spent the night before surgery with their husbands and mothers in a hotel across the street from the hospital. Williams' mother gave them each care packages with fresh toiletries, nightgowns and matching slippers.

In living-donor kidney transplant surgery, the two operations take place in adjoining operating rooms. Since a kidney from a living donor increases the five-year success rate to 90 percent, compared to 78 percent from deceased donors, the operations are timed to coincide to maximize the advantage. After Ramsdell's kidney was removed, it would be iced and flushed with a cold preservative, then whisked next door, where it would be implanted below one of Williams' nonfunctioning kidneys and attached to her bladder.

For Ramsdell, the biggest risk was the surgery itself. For Williams, an additional risk was infection due to the immunosuppressant medications she would need to take. The medications could also have side effects, such as high blood pressure and osteoporosis.

But taking immunosuppressant medicine would be important, to help prevent her body from rejecting the new kidney. Research conducted by Robert Woodward, Forrest D. McKerley Professor of Health Economics at UNH, underscores this point. Woodward has found that before 1990, lower-income patients had a 4 to 5 percent higher risk of kidney transplant failure because Medicare, which pays for about 70 percent of kidney transplants, was covering the cost of immunosuppressants only for the first year. But when from July 1993 to July 1995 Medicare gradually extended coverage of these medications to three years, Woodward's data showed the survival rates became equal.

For Williams, there was also the possibility that the donated kidney would fail. After implanting Ramsdell's donated kidney, Williams' medical team would watch to see if it began to function, which they would take as a good sign.

The morning of the surgery, just before they wheeled Ramsdell into her operating room, the women exchanged hugs and I-love-yous.

"Later, the nurses and doctors told me how Brenda had learned each of their names and was talking to them right up until the anesthesia took hold," says Williams. "That's so her--she always makes a point of meeting everybody and remembering everybody's name."

Surgery for both women initially went smoothly. Less than a minute after Ramsdell's kidney had been transplanted into Williams, it began working--the best possible outcome. But when the surgeon began to close Williams' incision, a complication arose. Because Ramsdell's kidney was bigger than Williams', one of her arteries pinched off and the kidney stopped working. The doctors immediately opened her incision, fixed the problem and reclosed the incision.

It would be another day and a half before the two women saw each other. Ramsdell was still nauseated from the anesthesia and was having a lot of abdominal pain. "I hobbled down to Casey's room," recalls Ramsdell, "and there she was eating a big meal. She said to me, 'Wow, I feel great!' and at that moment, I knew it was all worth it."

They spent much of the next few days together in the hospital, "shuffling like old women around the hallways and talking," says Ramsdell. Williams, although in some pain herself, was feeling better than she had in years. The tingling and numbness in her hands and feet were gone, as was the restless leg problem. By the end of the week, they were both home recuperating, a process that would take a couple of weeks before the pain went away, and two to three months before they were both back to work.

Now, a year later, both women are doing well. Williams continues to take her anti-rejection medicine, but side effects have been minimal and tests on her new kidney show that it is working better than average, exceeding everyone's hopes. If all continues to go well, her new kidney should last 10 to 20 years; if she's lucky, she'll never need another transplant. Her blood pressure has been normal, the gout is gone and she may be able to cut back on the immunosuppressant medicine soon.

"I have a lot more energy, I'm thinking clearer and I'm sleeping better, too. People tell me that my color is better," says Williams. "What Brenda did for me was incredible, but that's the person she is. She is so caring. Our friendship has always been strong, but now we have this physical link." Ramsdell likes to ask Williams if she's started craving her favorite foods. Not yet, Williams replies, laughing.

Ramsdell knows that had the roles been reversed, Williams would have done the same for her. "I feel so lucky to have Casey in my life," she says. "She has a gentle spirit and we laugh so hard when we're together. Both of us are amazed that things worked out the way they did, after all those years of being friends."

Ramsdell has become an advocate for organ donation and hopes that her story will inspire others to get tested. On her car is a bumper sticker that reads, "Don't Take Your Organs To Heaven; Heaven Knows We Need Them Here."