INFORMED CONSENT FORM FOR KIDNEY TRANSPLANTATION

Patient’s Name: Date:

Patient’s Gender: □ F □M
Passport No:
Patient Protocol No:
Date of Birth:
Birth Place:

Dear patients, please read this form carefully

1. INFORMATION RELATED TO KIDNEY TRANSPLANTATION:
1.1. Procedure: Kidneys filter the blood and eliminate metabolic by-products from the body via urine. The urine is
stored in the urinary bladder and then, excreted from the body. Many different conditions may interfere with the
function of our kidneys and it may not be always possible to determine the cause of your liver failure. If your
kidneys are not functioning properly, metabolic by-products will not be removed from the blood. If this problem
persists, you may feel very sick and even die. Kidney transplantation is the surgical management for renal failure,
also known as end-stage kidney disease.
1.1.1. During kidney transplant surgery, you will first be put to sleep (anesthesia) and then, the skin and
muscles in the lower abdominal region are dissected. The new kidney is connected to the blood vessels around
the urinary bladder. To promote the healing of this connection, the urether is usually connected to the urinary
bladder via a small plastic tube. At a later date, this plastic tube, also referred to as a stent, is removed from the
bladder by inserting a device called cystoscope. Another tube called a drain is usually placed around the kidney
to remove any fluid that may accumulate in the space that forms after the surgery.
1.1.2. The transplanted kidney may come either from a healthy individual or a deceased donor. Most of time,
it is not necessary to take out the non-functional original kidney. Nevertheless, if your original kidney has
enlarged, is infected, or stands in the way when connecting the new kidney to blood vessels, one of your
kidneys may be taken out during transplant procedure. If the blood vessels are diseased, a reconstruction of the
blood vessels may be required.
1.1.3. The surgeon may perform additional procedures to manage potential complications that may interfere
with the success of the surgery or jeopardize the postoperative healing including inguinal repair, dissecting the
spermatic cord, or removing the intestines. A central venous line is inserted to most patients to facilitate drug
administration and to monitor the amount of fluid in the body.
1.2. Benefits: The benefits of a kidney transplant are listed below:
1.2.1. A successful kidney transplant eliminates the need for dialysis. Many patients who had a successful
kidney transplant report an improvement in their quality of live. There is evidence to support that compared to
patients who undergo dialysis, a functioning transplanted kidney extends the life-expectancy of patients with
end-stage kidney disease.
1.2.2. A successful kidney transplant may improve your blood counts and energy levels. The strength of your
bones, your growth, and appetite may also improve. You may enjoy a less restricted diet.

2. POTENTİAL RİSKS OF THE SURGERY: It is essential to understand the risks involved before the start of the
procedure. The following risks are well-known. There may be, however, additional risks that are hard to predict

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 by the physician or so infrequent they are not included in this list.

2.1. You have need a blood transfusion. You will be asked to sign a consent form to authorize the doctors to use
blood if needed. As it is a living tissue, blood can only be stored for a limited period of time. Risks of blood
transfusion include infection, allergic reactions, and certain side effects induced by substances used to preserve
blood.
You may experience problems related to wound healing. Many patients experience a transient fluid leak from the
surgical site that can be controlled with bandages. Around 5% of the patients experience bleeding, infections, urine
leaks, or hernias that require additional surgical procedures. Most patients feel some pain at the surgical site, which
usually improves over a couple of weeks. Sometimes, the pain may persist and pain killers may be needed. Some
patients may feel numbness around the surgical region.

2.2. All patients who had a kidney transplant must use drugs to avoid rejection of the transplanted organ by the
body (to suppress the immune system). You will need to use these drugs as long as the transplanted organ remains
in your body (i.e. for the rest of your life). These drugs may sometimes cause serious and life-threatening
complications (problems). The most serious complications include infection, increased predisposition to certain
types of cancer, kidney failure, and nervous system injury. Therefore, your immunosuppressive regimen will be
closely monitored. These drugs may interfere with your blood pressure, elevate your cholesterol levels, weaken
your bones, affect your bone marrow, and may cause cosmetic problems such as swelling of your face, acne,
excessive hair growth or hair loss.

2.3. More serious complications are seen in less than 10% of our patients. These include, but are not limited to the
following:
 Pneumonia,
 Blood clot in major blood vessels,
 Transmission of an infection from the organ donor,
 Recurrence of the disease in the transplanted organ,
 Failure of the transplanted organ to function,
 İnjury to nerves, blood vessels, intestines, or reproductive organs,
 Multi-organ failure,
 Heart attack,
 Stroke,
 İnfections that invade tissues,
 Cancer and death.

2.4. The donor may have an infection or cancer, which may not be identified before the transplantation procedure.
Such incidences are reported quite infrequently. It is important to note that any donor organ, even if it comes from
a living donor, may potentially transmit infections such as human immunodeficiency virus (HIV), hepatitis B virus
(HBV), or hepatitis C virus (HCV). Potential donors are extensively screened for these conditions and the health
history of donors is reviewed before they are deemed eligible to minimize the risk of transmission. Nevertheless, in
spite of all these precautions, there is still a risk of transmission of serious infections or an unknown type of cancer.
Such risks apply to all organ recipients.

2.5. After the transplant procedure, you may experience depression, post-traumatic stress syndrome (PTSS),

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 anxiety related to dependency to others, and guilt. Such problems may affect your relationship with family or
friends and you may need medical therapy.

2.6. If you are a Turkish citizen and covered by public insurance (SGK - Social Security Institution), all
healthcare-related expenses that incur during the preparation for the kidney transplantation procedure and at
admission to the hospital for surgery will be covered by SGK. After your discharge, the hospital may charge you
for the legally permissible amount. If you are not a Turkish citizen, the hospital will charge you the established fee
for the follow-up process after the kidney transplantation procedure.

2.7. Alternative Options: The alternative option for kidney transplant is dialysis. This procedure involves filtering
your blood outside your body in a machine (hemodialysis) or injecting a solution to your abdominal cavity that
cleans the blood in your intestines (peritoneal dialysis). These options, in turn, are associated with serious risks
along with their benefits.

3. Donor options
3.1. Based on our past experience and literature evidence, the best outcome is achieved when the kidney is
harvested from a living donor. Patients who are eligible for kidney transplant are included in a national waiting list
for cadaver kidneys. The National Organ and Tissue Transplantation Center established under the Turkish MoH is
responsible for managing the cadaver kidney distribution nationwide. The criteria used to select a recipient of a
donor organ include tissue-match between donor and recipient, waiting time on the list, and recipient’s age among
others. It may take several years for a suitable organ to be found.
3.2. Many people who are brain dead and became cadaver kidney donors have had conditions and diseases such as
smoking, high blood pressure, infection, diabetes, or advanced age that interfere with the quality of the donated
organ. Thus, their kidneys may be damaged. Some kidneys may have structural problems involving the blood
vessels or tissues. Information on the additional risks associated with the use of such organs will be provided in due
time. Please inform your physician if you don’t accept the kidney transplantation based on this information. This
may, however, mean a significantly longer waiting time for a suitable kidney to be transplanted. The kidney
transplant team of may ask for periodic tests to determine continued eligibility of the potential kidney recipient.
3.3. The type of the donor organ may have significant effet on the outcome of the transplantation procedure. Based
on the information provided on the risks and benefits of the proposed procedure, I consent to the transplantation
from the following type of donor:

3.3.1. Kidney from a living donor:

The kidney transplant doctors have informed me that the potential donor has no evidence of a kidney disease
and has two healthy kidneys. I was, however, informed that some kidneys may have medical conditions,
including multiple blood vessels, problematic urine collection system, or other conditions that may increase the
risks associated with the transplantation procedure.

3.3.2. Kidney from a cadaver donor:

The kidney transplant doctors have informed me that I am eligible to get the kidney harvested from the person
who is brain dead. I was explained that compared to living donors, kidneys from cadavers have poorer long-
term outcomes and there is higher risk of the kidney not working. I was also informed that I have the right to
refuse an organ proposed for transplant with no adverse consequences for my status/position on the waiting list.
I was assured that I will remain a candidate recipient on the kidney transplant waiting list even if I refuse the

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 proposed kidney.

4. RECOMMENDED TREATMENT/INTERVENTION CONSENT FORM

4.1. I have been informed about the diagnosis and treatment of my condition as well as the required anesthetic
procedure / medical-surgical treatment and intervention.

4.2. I hereby acknowledge and agree that any additional intervention to those specified herein will be performed
solely to prevent significant harm to my health and to save my life.

4.3. I have been informed about possible complications and risks

4.4. I have been informed about other life-threatening risks that may emerge if I refuse these diagnostic and
therapeutic procedures, if any, that can replace this form of treatment

4.5. I have been informed that other interventions/medical treatments may be needed in case complications listed
above develop (Section II) and that in some cases the process may not lead to full recovery.

5. Kidney transplantation from a living donor/cadaver is carried out within the scope of the facilities provided by
Ankara University Faculty of Medicine and the patient's health insurance (Social Security Institution, Pension Fund
and Social Security Organization for Artisans and the Self-employed) and their own financial means. Drugs and
medical materials that are not available at the pharmacy of the hospital must be covered by the health insurance, the
patient and his/her family within the valid protocols.

Patient’s Name and Surname Republic of Turkey Identity No/ Date/Hour Signature
Passport No

Address:

Phone No:
FOR PATIENTS WITHOUT LEGAL CAPACITY: This section shall be filled out by the Patient’s Natural / Legal
Guardian
Legal Representative Republic of Turkey Identity No/ Date/Hour Signature
Name and Surname Passport No

Address:

Phone No:

PHYSICIAN PROVIDING THE INFORMATION:

Institution Doctor Name and Surname: Diploma No Date/Hour Signature

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