Kidney transplantation is the standard treatment for patients with chronic end-stage renal disease. Although it has long been known that the quality of life of a transplant patient is better than that of a dialysis patient, it has taken longer to demonstrate that transplantation also provides a better life experience. It was a study taken from the United States Renal Data System (USRDS) registry which made it possible for the first time to demonstrate this advantage conferred by transplantation [1] . In France, 16% of kidney transplants were carried out from living donors in 2021 [2] , compared to 14% in 2020 [3] . In a review of studies conducted with the Medical Outcome Survey Short Form 36-items (MOS SF-36) as well as a recently published study, the quality of life of donors is as good as the quality of life of the general population, again higher than that of healthy subjects [2] [4] . However, other studies highlight a deterioration in the quality of life of donors after donation. Our study aims toreassess the psychosocial experience and quality of life of living kidney donors at Grenoble University Hospital.

The present study took place in the nephrology, hemodialysis, apheresis, kidney transplantation department of the Grenoble Alpes University Hospital in France. These were living kidney donors between January 2016 and April 2019 at Grenoble Alpes University Hospital. During the defined period, living kidney donors aged at least 18 years, residing in France and having given their consent for the study were included. Donors whose medical records were unusable were not included. This was a retrospective cross-sectional study. This survey was carried out by self-administered questionnaires using standardized instruments. The survey is transversal for measurements of health status and quality of life, collected at the time of measurement, it is retrospective for reconstructions of the donation process.

The data was collected using pre-established survey forms bearing anonymity numbers which noted:

A standardized questionnaire was used:

It is also possible to calculate a physical summary score and a mental summary score from the eight dimensions. Donor and recipient medical data at the time of harvest and transplantation, after transplantation and at one year were extracted from the CRISTAL registry. The donor-recipient relationship, the date of birth and the sex of the donor as well as all medical monitoring data, collected in CRISTAL, were extracted for the study. These included donor height and weight, blood pressure and renal assessment, date and type of surgery, major intraoperative complications, postoperative complications, discharge date, and the first hospitalization.

The SF36 quality of life score:

The entry and processing of Data collected on a survey form were entered into EXCEL software and analyzed using SPSS version 21. Quantitative variables were expressed as mean ± standard deviation and qualitative variables as frequency or proportions. Quantitative variables were compared using the reduced deviation test for large samples (N ≥ 30) and Student for small samples (N < 30) on an independent sample and to qualitative variables using the Chi² test. A p value less than 0.05 was considered statistically significant.

During the study period, 447 patients received a kidney transplant, including 87 from living donors. A total of 70 people responded to our questionnaires, representing a participation rate of 80%. The mean age of living donors was 55.6 ± 13 years, with extremes of 18 and 80 years at the time of donation. The age group of 50 to 60 years represented 32.40% of living donors ( Table 1 ).

In our series, 43 were women (61%) with a sex ratio of 0.63. Living donors with an education level equivalent to elementary level represented 79.3% of cases ( Table 2 )

In our study, spouses represented 40% among living donors. The duration of donation was 3 to 4 years in 25 donors or 36%. In the series, post-donation follow-up was good in the majority (97.28%). The donors all benefited from laparoscopy as a surgical technique.

Mean blood pressure was normal in 96% of donors. Overweight was noted in 40 donors or 60%.

There was a slight increase in post-donation renal function with serum creatinine above 100 micromoles/l in 42 patients, or 60%. The glomerular filtration rate was greater than 60 ml/min in 63% of donors with normal proteinuria in 83% of donors.

In our study, health status was poor in only 8.6% of cases. In total, 97% of donors would recommend donating to another person. The donation experience was bad for 03% of donors. Self-esteem or enthusiasm for donating was found in 88.6% of donors. In our work, social relationships with those around us or family were understandable in 85.72%. Donors’ loved ones perceive the donation as an act of heroism in 44% of cases. No vocational rehabilitation was observed in 87.1% of donors. Post-donation anxiety is found in 55.7% of donors.

Quality of life was poor in the physical role domain in men with no significant difference (p > 0.05). In our series, 97% of donors had a quality of life score greater than 50%. Overall quality of life was good in 97.10% of donors.

The quality of life of living kidney donors remains better in general and there is an age-related prevalence.

At the end of our study, the average age was 55.6 years. The majority of donors were women (61%). Our results corroborate those of Franquet who found an average age of 50 years and a female predominance of 64% [6] . The Garcia and Menjivar series respectively find an average age of 41.02 and 50.18 years [7] [8] . According to a meta-analysis, the average age of living kidney donors in 2017 is 51.3 years with an increase from 2 years to 10 years. Nearly 21% of donors are aged 60 and over in France [9] . This female predominance in our series and elsewhere could be explained by the fact that women perceive donation as a family obligation and it is the woman who gives life. However, some authors found no difference in gender distribution [10] . In our series, the living kidney donors were respectively the spouses followed by collaterals then ascendants as well as descendants all having family or emotional ties. These results are similar in the literature according to a meta-analysis carried out in 2017 in France; of the 611 transplants, the donors and recipients were genetically related [11] . In our study population, all our donors benefited from better medical monitoring and the only technique used was laparoscopy. According to the literature, differences in surgical techniques appear to have little relationship to quality of life outcomes [12] . In our work, rare complications such as urinary infections and pneumothorax were found (1.3%). Pain immediately after collection was noted in all donors to varying degrees, as with any surgical procedure. Unlike Garcia’s study which found a prevalence of 8%, the presence of a perioperative complication was associated with lower quality of life related to mental health and higher symptoms of depression 3 months after donation; none of these differences persisted at 12 months [13] . Furthermore, for other authors, perioperative complications were not associated with quality of life related to physical health or anxiety 3 months after donation [14] . Donation is medically considered to be a practice with minimal morbidity and mortality for the donor and therefore acceptable, provided that contraindications to donation have been eliminated by appropriate medical evaluation. The majority of donors did not perceive a significant change in their appearance and were not embarrassed or considered their nephrectomy scar unattractive. And that they had no impact on their state of health and their quality of life. The average BMI of the donor population was 28.85 kg/m² with extremes of 17.06 and 41.93. In our series, 47% of donors were overweight with a body mass index (BMI) of 25 kg/m², among them 13% were obese with a BMI of 30 kg/m². Our results agree with those of Franquet in France who found an average BMI of 24.3 kg/m² [7] . After any nephrectomy, there is compensatory hyperfiltration in the remaining kidney which results in a reduction in GFR of approximately 30% [15] . A study conducted in 2002 on predominantly Caucasian living donors followed for up to 20 years in one center did not find a link between the drop in post-donation glomerular filtration rate (GFR) and the risk of developing renal failure [16] . A study of 3956 predominantly Caucasian kidney donors found that 36% of them had a GFR < 60 ml/min per 1.73 m², which corresponds to stage 3 of chronic kidney failure according to the KDIGO classification. a median period of 9.2 years after donation, and 2.6% had a GFR < 30 ml/min per 1.73 m² (at CKD stage 4) at a median of 23.9 years [17] . A meta-analysis found that after an average of 10 years of follow-up, 12% of donors had a GFR between 30 and 59 ml/min, while only 0.2% had a GFR between 30 ml/min [18] . In our study population, we found a GFR of 60 ml/min in 63% of our donors and we also noted higher proteinuria in women (20.93%). Body mass index (BMI) was low with a p-value of 0.4, which was not significant. However, some authors found higher post-donation proteinuria in men and in those with a higher body mass index (BMI) [5] . As in the general population, the risk of developing chronic kidney disease varies depending on certain predisposing factors such as race. Furthermore, a study of 4650 donors in the United States found that 7 years after donation, a greater proportion of melanoderma donors than Caucasian donors had CKD [17] . Almost all donors were in good health, i.e. 90%. They reported that their general health remained unchanged after a greater proportion of melanoderma donors than Caucasian donors had CKD [18] . Almost all donors were in good health, i.e. 90%. Almost all donors were in good health, i.e. 90%. The literature states that the life expectancy of donors is not reduced. It would even be higher than that of the general population, which demonstrates that the state of health of selected donors remains perfect at the time of donation [8] . Renal sampling therefore does not alter the state of health of the donor who is a subject without comorbidity. The majority of donors in our sample are satisfied with having saved a life, do not regret this donation and that their experience was worth it, i.e. 88.6%. Several studies have reported evidence demonstrating that living kidney donation does not compromise the psychological outcome of the donor, and even constitutes an extremely positive experience for the donor [19] . In Kessler’s series, he found persistent feelings of accomplishment, pride, and enhanced self-esteem in the donor [20] . In contrast, Johson EM et al. in a cohort of 524 donors noted that living kidney donors whose recipients had died would not advise donation, regretted the decision to donate and were therefore dissatisfied [21] , which is discordant. with our study. The general experience of donating after several studies seems enriching for donors. We saw 12.9% vocational rehabilitation in our work due to some donors being limited by certain strenuous physical activities such as heavy lifting and driving. Some donors reported feeling anxious about the daily activities of life, namely dressing, moving, vacuuming [22] . Residual pain immediately after collection was noted in all donors to varying degrees, as with any surgical procedure. Donation is medically considered to be a practice with minimal morbidity and mortality for the donor and therefore acceptable, provided that contraindications to donation have been eliminated by appropriate medical evaluation. The majority of donors did not perceive a significant change in their appearance and were not embarrassed or considered their nephrectomy scar unattractive. And that they had no impact on their state of health and their quality of life. In our series, almost all of our donors had an improvement in their relationships with those around them as well as with the recipient, i.e. 90%, as has been described in the literature. In particular, the rapprochement of certain spouses who often felt in debt has been described by certain authors [23] . This family support reflects the high degree of brotherhood, the strong warmth of interpersonal relationships which characterize families in Europe and above all social cohesion. No donor has been abandoned by those around them. In our series, some donors reported a post-donation financial loss of 12.9%. Thus, several studies have shown the existence of financial difficulties, particularly in relations with mutual societies for the coverage of costs incurred, in the context of insurance premiums or when applying for a real estate insurance loan [24] . The leave required for recovery resulted in some donors losing their jobs [3] . Indeed, impacts on the mental health status of donors several years after nephrectomy. The authors rarely described concerns related to anxiety and depression. In our series, anxiety was found in 55.7% of donors, this being mainly linked to late recovery after surgery. Like any surgical intervention, this is a non-trivial procedure. Similarly, a new study of 193 living kidney donors in the United States, assessed 1, 6, 12, and 24 months after donation, found that 21% (n = 32) reported the emergence of anxiety due to the progressive onset of renal failure during the post-donation evaluation period, but this anxiety dissipated in 35% (11 of 32) [10] . According to studies, anxiety and depression are significantly related to donation [11] . Furthermore, a systematic review assessing the psychosocial health of living kidney donors found that the majority of donors scored high on health-related quality of life measures [12] . Psychosocial health was generally unchanged after donation, it was similar to that of the general population. A minority of donors experienced negative psychosocial consequences such as depression, anxiety, stress, and lower quality relationships. It is reassuring that most donors did not regret their decision to donate and started the process again, even in the rare circumstances where the recipient experiences a poor outcome [16] . However, Graft loss and recipient death have been associated with an increased risk of post-donation depression treatment in some studies [25] . The use of donor quality of life questionnaires has been shown to be very useful in assessing outcomes. In our series, 7 areas of quality of life remain above 50 out of 8. It appears from our series that the highest score remains in the area of vitality at 88.2% among women and the lowest in the area of physical role at 46.3%. In his series, Padrao MB reports a deterioration in the physical role score, physical functioning, vitality and body pain [5] . Frade IC found negative emotions and perceptions in the physical domain and social functioning in its donors explaining anxiety and depression immediately after donation [17] . Additionally, Sommerer et al. also found a low score for physical functioning and body pain, especially in women [25] . According to a study conducted by Clemens et al., they found that of the 29 studies measuring quality of life after donation, the quality of life score remained statistically higher in living donors than in the general adult population [26] . Our work shows that the different areas of quality of life remain satisfactory after nephrectomy. This is explained by the fact that the selection of different donors is very rigorous, the donors do not present any comorbidity. After the donation, they benefit from medical monitoring and special attention from those around them.

Overall, 97% of living donors were satisfied with their donation and their quality of life after donation was good. This observation reflects the rigor in the selection of donors. The benefits to others far outweigh any difficulties they may have encountered personally. The donor’s decision was made without hesitation or constraint. All the DVA are ready to do it again if it were possible. All they ask is that their act be recognized symbolically for its fair value, which is not always the case. Their testimonies, based on real-life experience, are a sincere and effective plea for the development of transplantation from living donors.