Donor Nephrectomy Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Donor Nephrectomy

1. Patient Identification

I, ______________________________ (patient/next of kin/legal guardian), aged ____ years, in my full senses, voluntarily authorize and give my complete consent for performance of the following procedure(s)/operation(s)/treatment(s):

Procedure: _______________________________
Diagnosis: ________________________________
Major illness & comorbidities: ________________________________

2. Authorization for Procedure

I authorize Dr. __________________ to perform the above procedure, along with such assistants and associates as may be selected by him/her.

I understand that members of the surgical team, including residents or trainees under appropriate supervision, may perform parts of the procedure according to their training and competence.

3. Nature of Procedure

A donor nephrectomy involves surgical removal of my kidney for the purpose of living kidney donation.

The procedure is usually performed laparoscopically/minimally invasively, although conversion to open surgery may sometimes be necessary.

4. Benefits and Indications

The intended benefits include:

  • Voluntary donation of a kidney for transplantation.
  • Potential improvement in the recipient’s survival and quality of life.
  • Contribution to definitive renal replacement therapy.

I understand that the surgery is performed for the benefit of the recipient and not to treat a disease in me, and that I am accepting surgery despite being otherwise healthy.

I understand that no guarantee can be given regarding:

  • The outcome of transplantation in the recipient.
  • The long-term health of the recipient.
  • The absence of surgical or medical complications in me.

5. Risks and Complications

  • Intra-operative
    • Bleeding: 2–10%
    • Blood transfusion: 1–5%
    • Major vascular injury involving renal vessels, aorta, vena cava or iliac vessels: 1–3%
    • Injury to bowel, spleen, pancreas, liver, ureter or diaphragm: 1–5%
    • Difficulty due to adhesions or abnormal anatomy.
    • Prolonged surgery.
    • Conversion to open surgery: 2–10%
    • Anaesthesia-related complications: <1–2%
    • DVT/PE: <1–2%
    • ICU care: 1–5%
    • Rare risk of death: approximately 0.02–0.05%, or approximately 1 in 2,000–5,000 donors.
  • Post-operative
    • Pain at incision/port sites.
    • Wound infection: 2–5%
    • Bleeding/haematoma: 1–5%
    • Chest complications, including atelectasis, pleural injury or pneumonia: 1–5%
    • Ileus: 2–10%
    • Urinary tract infection: 1–3%
    • Incisional/port-site hernia: 1–3%
    • Readmission/reoperation: 1–5%
    • Prolonged fatigue/delayed recovery.
    • Scarring/cosmetic concerns.
    • Rare chronic pain/numbness: 1–5%.
  • Long-term Donor-specific Risks
    • I will have only one kidney.
    • Most donors live a normal, healthy life.
    • There may nevertheless be a small long-term risk of reduced kidney function.
    • High blood pressure may occur.
    • Protein may appear in the urine.
    • Pregnancy-related complications may occur in women of childbearing age.
    • Rare future kidney disease may occur.
    • There is a small but real possibility of future kidney disease or need for dialysis/transplant, although this is uncommon in carefully selected donors

6. Postoperative Course

I understand that lifelong follow-up is required, including:

  • Blood-pressure monitoring.
  • Kidney-function testing.
  • Urine testing.
  • General health surveillance.

I may also receive advice regarding diet, hydration, medications and avoidance of kidney injury.

I understand that:

  • The surgical plan may be changed if there are concerns about my safety or the donor kidney’s safety or quality.
  • In rare circumstances, the kidney may be unsuitable for transplantation because of unexpected findings or surgical problems.
  • The removed kidney will be handed over for transplantation to the intended recipient/transplant team.
  • I may require a urinary catheter, IV lines, pain management, blood tests and routine postoperative monitoring.
  • Blood transfusion may be required if significant bleeding occurs.
  • Follow-up after surgery is essential for my health and safety.

7. Alternatives to Procedure

The recipient’s alternative treatment options may include:

  • Deceased-donor kidney transplantation.
  • Another suitable living donor.
  • Continued dialysis.

The decision regarding donation depends on my medical fitness and my free and informed willingness to donate.

8. Anaesthesia and Pain Management

I understand the risks associated with local, regional, or general anaesthesia.

Pain management options have been explained.

9. Photography / Data Use

I consent to:

☐ Medical photography/video for academic purposes

☐ Use of anonymized clinical data

10. Intraoperative Decision Consent

I authorize the surgeon to perform additional procedures considered necessary if unexpected findings arise during surgery.

11. Team-Based Care

I understand that supervised residents, fellows, or assistants may participate.

12. Patient Statement

I confirm that:

  • The nature of surgery has been explained.
  • Risks, benefits, and alternatives have been explained.
  • My questions have been answered satisfactorily.
  • I voluntarily consent.

Patient to write in own handwriting:

“I have understood the procedure, risks, benefits and alternatives explained to me in a language I understand.”

13. Donor Declaration

I confirm that:

  • Donation has been explained to me.
  • I understand that donation is voluntary.
  • I understand that I may withdraw consent before surgery.
  • I understand the risks to my own health.
  • I understand that I will live with one kidney after donation.
  • I understand that the procedure is being performed for the recipient’s benefit.
  • I have had adequate opportunity to ask questions.
  • I give my consent voluntarily and without coercion.

Signatures

Patient Name & Signature: ______________________________________

Date: ____________________ Time: ____________________

Doctor Name & Signature: ______________________________________

Date: ____________________ Time: ____________________

Witness Name & Signature: ____________________________________

Contact No.: ______________________________

ATTENDANT CONSENT (If applicable)

Reason patient unable to consent:

Attendant Name: __________________________________________

Relationship: _____________________________________________

Signature: ________________________________________________

Contact No.: ______________________________________________

INTERPRETER STATEMENT (If applicable)

I confirm an accurate explanation in understandable language.

Name: _________________________________________________

Signature: ______________________________________________

Contact: ________________________________________________

HIGH-RISK CONSENT (If applicable)

High-risk factors explained due to:

Patient Signature: ________________________________________

Doctor Signature: _________________________________________

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