Post-donation health-related quality of life, mood and life satisfaction in living-kidney donors; an explorative study from kidney transplant centre, Lahore Pakistan

Objective: To explore post-donation life satisfaction, quality of life and mood status among kidney donors. Method: The cross-sectional study was conducted from February 5 to July 10, 2021, at the Department of Kidney Transplant Surgery, Pakistan Kidney and Liver Institute and Research Centre, Lahore, Pakistan, and comprised living kidney donors who had donated a kidney at least 6 months before the interview date. Data was collected through telephonic interviews, and, in addition to demographics, the questionnaire comprised the World Health Organisation Quality of Life Brief Version scale, the Satisfaction with Life Scale, and the Patient Health Questionnaire and General Anxiety Disorder. Data was analysed using SPSS 20. Results: Of the 41 subjects, 22(53.7%) were females and 19(46.3%) were males. The overall mean age was 41.10±9.648 years (range: 19-62 years). The most common donor-recipient relationship was brother-sister 10(34.1%) and wife-husband 10(24.4%). Among the donors, there was a significant positive correlation between quality of life and satisfaction with life (r=0.381, p=0.014). Quality of life had a negative correlation with anxiety (r=-0.429, p=0.005), and a negative but non-significant association with depression (r=-0.283, p=0.073). Anxiety and depression were highly positively correlated (r=0.681, p=0.000). Quality of life was significantly associated with donor age (p=0.029) with a negative effect (Beta=-0.588), while satisfaction with life had a positive relationship with age (Beta=0.147). Conclusion: Higher life satisfaction among living kidney donors was associated with an improved quality of life, while increased anxiety levels were linked to a lower quality of life. Age was a critical determinant, with older donors reporting a lower quality of life.


Introduction
Kidney transplantation is one of the most commonly performed transplant surgeries globally, known to significantly enhance both patient survival and quality of life (QOL) compared to long-term dialysis.Altruism has emerged as the primary motivation for kidney donation, but in Pakistan, the shadows of illicit transplant procedures still persist, raising concerns within the healthcare and legal communities.The closely-knit familial dynamics in this region sometimes exert immense pressure on individuals to donate kidneys, making it essential to explore the multifaceted impact of kidney donation on the physical and mental wellbeing of donors.In Pakistan, an organ transplantation ordinance was passed in 2007, and since then the organ trade has markedly reduced, which was preliminary considered an incentive for donors.A study in Pakistan suggested that 88% of the donors had no improvement in their socioeconomic status (SES) post-donation 1 Studies have reported that donors suffered from psychological issues if the donation had been made as an act of trade compared to those having done it for altruistic reasons.Literature suggests that life satisfaction (LS) was more pronounced in kidney donors than in non-donors, but mood symptoms were slightly more prevalent in donors than non-donors [2][3][4] .In recent years, there has been a growing concern regarding the long-term health outcomes and QOL of living kidney donors (LKDs).Studies have shown that kidney donation (KD) does not increase mortality risk 5 .While deceased donors provide most organs, there is a growing need for LKDs due to the shortage of available organs 6 .Living KD involves major surgery and potential risks, but many donors are motivated by the desire to help others and improve their own health related QOL 7 .Research on the effects of KD on donors has produced mixed results.Some studies have suggested that donors experience significant improvements in their QOL post-donation, while others have reported negative effects, such as fatigue, pain and anxiety 8,9 .While the benefits of KD for the recipient are well-documented, the effects of donation on the donor's mood and LS are still not fully understood.
Physical health, psychological wellbeing, social interactions and environmental factors are all evaluated as part of the World Health Organisation Quality of Life Brief Version (WHOQOL-BREF) scale 10 .It describes how people perceive their place in life concerning their objectives, expectations, standards and concerns as well as the culture and value systems in which they live.The QOL in 4 domains can be impacted by a variety of variables, including age, gender, rural or urban settings, 11,12 as well as health and disease status 13 .There is a need to comprehensively investigate the mental and emotional wellbeing of kidney donors in Pakistan.The current study was planned to explore post-donation life satisfaction, QOL and mood status among LKDs.

Subjects and Methods
The cross-sectional study was conducted from February 5 to July 10, 2021, at the Department of Kidney Transplant Surgery, Pakistan Kidney and Liver Institute and Research Centre (PKLI&RC), Lahore, Pakistan, which is a purposebuilt transplant centre that provides pre-transplant evaluation and post-transplant care, and caters to patients from across the country.
After approval from the institutional ethics review board, sample size justification was ensured based on the specific aims of the study, inclusion and exclusion criteria 14 , careful psychological assessment of participants, use of validated instruments, and the statistical methods employed.
The sample was raised using convenience purposive sampling technique from among LKDs with a minimum post-donation period of 6 months.At PKLI&RC, LKD nephrectomy is done either through hand-assisted retroperitoneoscopic (HARS), hand-assisted laparoscopic (HALS), or open surgeries.The usual hospital stay is 3 days.Psychological evaluation of potential donors is done as part of the standard pre-transplant procedure.Only those individuals who are deemed psychologically fit by the institutional psychologists were included in the current study.The pre-transplant evaluation process was thorough, and any hint of external pressure or coercion during the assessment resulted in the rejection of those individuals as potential donors.Only those who met all elements of the inclusion criteria were included, while the rest were excluded.
After taking informed consent, data was collected through telephonic interviews, and, in addition to demographics, the questionnaire comprised the WHOQOL-BREF, Satisfaction with Life Scale (SWLS), 9-item Patient Health Questionnaire (PHQ-9) and the General Anxiety Disorder (GAD) questionnaire.Telephone interviews were done to avoid unnecessary travel of the participants, and to ensure the observance of standard operating procedures (SOPs) related to the coronavirus deisease-2019.
The reliability of the questionnaires was assessed through a test-retest reliability check.All items exhibited Cronbach's alpha values ranging from 0.50 to 1.00, or intraclass correlation coefficient (ICC) values ranging from 0.55 to 1.00, indicating fair to excellent reliability (Table 1).
Data was analysed using SPSS 20.Data was analysed as frequencies and percentages, mean ± standard deviation, as appropriate.Quantitative data was analysed using bivariate correlation.Linear regression was applied to examine the relationships between independent and dependent variables.P<0.05 was considered significant.
Bivariate correlation analysis indicated a significant positive correlation between QOL and satisfaction with life (r=0.381,p=0.014).No significant correlation was found between satisfaction with life and anxiety (r=-0.181,p=0.257) or depression (r=-0.159,p=0.320).Quality of life had a negative correlation with anxiety (r=-0.429,p=0.005), and a negative but non-significant association with depression (r=-0.283,p=0.073) (Table 4).There was a highly significant positive correlation between anxiety and depression (r=0.681,p=0.0001).
Linear regression analysis showed QOL was significantly associated with donor age (p=0.029) with a negative effect (Beta=-0.588),while satisfaction with life had a positive relationship with age (Beta=0.147)(Table 5).

Discussion
The current findings indicated that most donors experienced little change in their health-related QOL, mood or LS over time post-donation.Mean value of QOL domains showed that most of the respondents had good QOL in terms of physical health, moderately good QOL in terms of psychological health, good social relationships and moderately good QOL in terms of the environment 17 .Among other factors, most   respondents had non-minimal severity of depression 18 , mild anxiety 19 and satisfaction with life [3] post-donation.
A small proportion of donors reported poorer healthrelated QOL, mood, or LS. the results are in line with earlier studies 25,26 .The findings further support earlier results 27,28 that most respondents are likely to experience psychological advantages from donating a kidney, including feelings of fulfilment and compassion.The small proportion of donors who reported poorer outcomes may represent a group of donors who were particularly vulnerable to the demands of donation, such as those with pre-existing conditions.The finding that younger donors may be at greater risk of poorer outcomes was consistent with previous research 29 and underscores the need for careful donor selection and predonation counselling.
Between QOL and LS there was a positive relationship.LS in LKD improves after KD due to which QOL improves 26 .
Whereas QOL with anxiety showed that anxiety levels increased and that decreased the QOL in respondents with poor results, indicating that anxiety has a negative impact on QOL.Finally, QOL with depression showed no correlation.One study found that donors reported high levels of satisfaction with their decision to donate, and experienced improved mental health and wellbeing 15 , but among the respondents, good QOL and satisfactory LS was noted.However, not all studies have found positive effects of donation on the donor's mood and LS.
Age is one factor that can have an impact on QOL across the 4 domains 11,12 , which was consistent with the current findings.
The current study has several limitations.First, the small sample size may have hindered the ability to identify substantial variations in donor outcomes.The lack of a particular statistical technique may be viewed as a constraint, affecting statistical power, even though we based our sample size on particular objectives and criteria.We acknowledge that there may have been an impact on precision even though we adhered to accepted protocols for cross-sectional studies 14 .To maintain openness and guide future studies, this is described in more detail.Second, self-report metrics were used, which could be biased or inaccurate.Finally, it was a singlecentre study with limited generalisability of the findings.

Conclusion
Higher LS was associated with improved QOL, while elevated anxiety levels were linked to low QOL.Age played a pivotal role, with older donors experiencing a lower QOL.

in sexual life post-donation
SD: Standard deviation.

Table - 4
: Correlations between quality of life (QOL) and psychological factors.