Patient Name:

Age:

Date:

Procedure: Donor Nephrectomy

Indications:

Patient has normal renal function and desires to donate his/her kidney to another patient of a transplant. The patient was evaluated by the nephrology team and transplant surgeons and they feel that there is a high likelihood of successful transfer. The patient is aware that this procedure offers him/her no benefit and may be injurious.

Alternatives:

Alternatives include laparoscopic procedure in experienced surgeons hands.

Risks/Complications:

The risks and complications of the procedure where extensively discussed with the patient. The general risks of this procedure include, but are not limited to bleeding, transfusion, infection, wound infection/dehiscence, pain, scaring of tissues, failure of the procedure, potential injury to other surrounding structures, deep venous thrombosis, pulmonary embolus, myocardial infarction, heart failure, stroke, death or a long-term stay in the Intensive Care Unit (ICU). Additionally, mentioned were the possible serious complications of the anesthesia to include cracked teeth, airway damage, aspiration, pneumonia, spinal head-ache, nerve damage, spinal canal bleeding and malignant hyperthermia. Your anesthesiologist will discuss the risks and complications in more depth separately. Additional procedures may be necessary.

The specific risks of this procedure include, but are not limited to: chronic hypertension, damage to surround organs and their sequellae (lung, liver, spleen, colon, small bowel, great vessels, pancreas, gonadal artery injury leading to loss of ovary or testicle), pleural effusion, pneumothorax requiring chest tube placement post-operatively, partial loss of a rib, the graft may not take and failure of graft to benefit the recipient.

You understand the procedure, general and specific risks as discussed and agree to proceed with the procedure. You also understand that not every possible complication can be listed in this counseling note and additional risks are possible, although unlikely.

Physician's Signature: ________________________________ Date: __________________

Patient Signature: __________________________________ Date: __________________