Fill in the patient's details, print, explain the form in the patient's own language, and take the signatures on paper.
Fill in, then print
What a renal biopsy is
A renal biopsy is a procedure to remove small pieces of kidney tissue that can be examined under a microscope for signs of damage or disease. Though it is a valuable tool to diagnose kidney diseases, it is associated with certain complications.
Complications of renal biopsy
| Complication | How often |
|---|---|
| Microscopic haematuria (blood in the urine, seen only under a microscope) | 100% |
| Gross haematuria (blood in the urine that can be seen) | 5 to 9% |
| Perinephric haematoma (a collection of blood around the kidney) | 5.0% |
| Need of blood transfusion | 0.1 to 3.0% |
| Need of angiography or angioembolisation (a scan of the kidney's blood vessels, and a procedure to close the bleeding vessel) | Less than 1% |
| Need of nephrectomy (removal of the kidney) | Less than 1 in 1,000 |
| Death of the patient | Less than 1 in 10,000 |
Consent
I have been explained regarding the procedure and complications of renal biopsy in my own vernacular language, and I hereby give consent for renal biopsy after understanding the pros and cons of it.
Patient's name and signature
Relative's name and signature
Relation to the patient
Doctor's signature
Date and time