Objectives: Living kidney donation provides substantial therapeutic benefit to recipients but may have lasting psychosocial consequences for donors. Sleep quality, which is closely linked to psychological well-being, remains insufficiently studied in North African populations. This study aimed to evaluate quality of life, self-esteem, body image, and sleep quality among living kidney donors in Tunisia.
Materials and Methods: We conducted a cross-sectional, monocentric descriptive study at the Nephrology Department of Sahloul University Teaching Hospital, Sousse, Tunisia, for the period 2007-2024. Data were collected from medical records and standardized interviews. Quality of life was assessed via the 12-Item Short Form Health Survey, self-esteem via the Rosenberg Self-Esteem Scale, body image via the Body Image Scale, and sleep quality via the Pittsburgh Sleep Quality Index. The study remains ongoing.
Results: Preliminary data from 15 living kidney donors were analyzed. The mean age was 55 years, and the female-to-male ratio was 2. The mean time since donation was 7.9 years. The mean physical and mental component scores of the 12-Item Short Form Health Survey were 48.5 and 33.7, respectively, with approximately 30% of donors demonstrating clinically relevant psychological distress. Self-esteem was low in 25%, moderate in 50%, and high in 25% of participants. Body image impairment was moderate to severe in 70% of donors. The mean Pittsburgh Sleep Quality Index score was 4.6; however, 27% of participants had scores >5, indicating poor sleep quality. High follow-up dropout was observed, largely due to limited access to structured health care resources
Conclusions: Living kidney donation may be associated with persistent psychosocial vulnerability and sleep disturbances in a subset of donors. These findings highlight the importance of structured long-term psychosocial and sleep monitoring programs in resource-constrained settings. Key words: Body image, Living kidney donation, Quality of life, Self-esteem, Sleep quality

Introduction
Living kidney donation remains the optimal treatment option for many patients with end-stage kidney disease, offering superior graft survival and reduced time on the wait list. Although recipient outcomes are well documented, donor-centered outcomes, particularly psychosocial well-being, are less extensively studied in North African settings. Previous studies consistently indicate that, although most living kidney donors report satisfactory overall health after donation, significant subsets of donors experience persistent psychological distress, altered self-perception, and impaired quality of life. Sleep quality, a highly sensitive and reliable marker of psychological health, has received scant attention in donor populations, especially in underrepresented North African contexts. Given the pronounced socioeconomic constraints that impede comprehensive follow-up care in Tunisia, rigorous evaluation of these outcomes is critically relevant. This study therefore provides preliminary insights into the multidimensional health-related quality of life among Tunisian living kidney donors and addresses a critical knowledge gap in this specific population.¹ Specifically, our study explored the prevalence of reduced physical and mental health scores, compromised self-esteem, negative body image perceptions, and prevalent sleep disturbances among these donors.^2,3 Our findings are particularly salient given that psychological factors, such as younger age, lack of social support, and specific coping styles, have been linked to poorer mental health outcomes after donation.⁴ This study aimed to assess psychosocial outcomes and sleep quality among living kidney donors at a single tertiary center in Tunisia.

Materials and Methods

Study design and population
This cross-sectional, monocentric descriptive study was conducted at the Nephrology Department of Sahloul University Teaching Hospital in Sousse, Tunisia, on data from patients seen from 2007 through 2024. Living kidney donors who agreed to participate were included. The study remains ongoing.

Data collection
Clinical data were obtained from medical records. Standardized interviews were conducted to assess psychosocial and sleep parameters.

Assessment tools
We used the following assessment tools. Quality of life was evaluated via the 12-Item Short Form Health Survey (SF-12). Self-esteem was evaluated via the Rosenberg Self-Esteem Scale. Body image was evaluated via the Body Image Scale. Sleep quality was evaluated via the Pittsburgh Sleep Quality Index (PSQI). Poor sleep quality was defined as a global PSQI score greater than 5.

Ethical considerations
The study protocol was approved by the institutional ethics committee and conducted in accordance with the 1975 Declaration of Helsinki and its later amendments. Written informed consent was obtained from all participants.

Results
Fifteen living kidney donors were included. Mean age was 55 years, and 66.7% were female participants. The mean interval since donation was 7.9 years (Table 1).

Quality of life
The mean SF-12 physical component score (48.5) was comparable with normative population values, suggesting preserved physical functioning. In contrast, the SF-12 mean mental component score (33.7) was substantially lower, with approximately 30% of donor scores in a range consistent with clinically relevant psychological distress.

Self-esteem and body image
Low self-esteem was observed in 25% of donors, whereas 50% of donors reported moderate levels and 25% high levels. Body image disturbance was frequent, and 70% of donors reported moderate to severe impairment.

Sleep quality
The mean PSQI score was 4.6, which indicated overall satisfactory sleep at the group level. However, 27% of donors met criteria for poor sleep quality (PSQI >5), and among these individuals prolonged sleep latency and reduced subjective sleep quality were the most affected domains. Exploratory analysis suggested a trend toward association between lower mental component scores and higher PSQI scores, although statistical power was insufficient for definitive conclusions.

Follow-up adherence
High follow-up attrition was observed, which was primarily attributed to socioeconomic barriers and limited access to structured health care resources.

Discussion
Although many donors maintain acceptable physical health for many years after donation, our preliminary analysis suggests that a substantial proportion of donors experience psychological vulnerability and impaired sleep quality. Specifically, our findings align with previous observations in broader living donor populations for whom multidimensional health-related quality of life has been shown to vary significantly after donation, emphasizing the need for targeted interventions to optimize donor outcomes.¹ Moreover, the observed high rates of psychological distress, low self-esteem, and body image impairment corroborate existing literature on the complex psychosocial sequelae of organ donation, and such negative effects can be further exacerbated by inadequate postdonation support structures.⁵ The discrepancy between preserved physical scores and lower mental health scores highlights the importance of addressing psychosocial domains independently from somatic outcomes. Body image disturbances and self-esteem variations may reflect long-term adaptation to physical surgical scars and lifestyle changes. Our findings regarding sleep quality further emphasize the persistent psychosocial challenges experienced by living kidney donors, even for many years after donation. This is particularly relevant given that the long-term negative effects of kidney disease often extend to mental health domains for recipients and, as suggested here, for donors.⁶ The prevalence of poor sleep quality in a substantial subset of donors, as indicated by PSQI scores, necessitates further investigation into the long-term health implications of poor sleep quality and its potential associations with other psychological distress markers.⁷ Furthermore, the observed high rates of follow-up dropout emphasize the systemic challenges for provision of sustained postdonation care, which may exacerbate these psychosocial vulnerabilities and hinder comprehensive long-term health monitoring. The challenges in follow-up retention highlight a critical need for enhanced supportive frameworks, including robust social support systems and comprehensive postdonation follow-up protocols, to mitigate psychosocial risks and improve donor well-being.⁸ Sleep impairment in nearly one-third of donors suggests that subtle psychological distress may persist even when global scores appear satisfactory. Sleep disturbances may serve as an early marker of psychosocial strain. This is particularly pertinent in the context of chronic kidney disease, in which sleep disturbances, anxiety, and depression often exhibit an intricate interplay, considerably affecting overall mental well-being.⁹ In recognition of this complex interrelationship, future research should explore the specific mechanisms through which living kidney donation might contribute to sleep disturbances and other psychological morbidities, to distinguish between direct physiological effects and secondary psychosocial stressors.¹⁰ Such future investigations could inform the development of comprehensive predonation and postdonation care strategies aimed to mitigate these adverse outcomes and improve the overall health trajectory of living kidney donors.¹¹ Our study contributes to the growing number of studies that emphasize the critical need for long-term psychosocial support for living kidney donors, particularly in regions where such support is nascent or inadequate. Furthermore, the high prevalence of sleep disturbances in this cohort aligns with broader findings in chronic kidney disease populations and indicates a need for tailored interventions to improve sleep quality.¹² Our findings emphasize the necessity for standardized psychosocial assessments and interventions within postdonation care protocols, particularly given that presently established practices often rely on retrospective data, small sample sizes, and professional opinions rather than standardized questionnaires.¹³ Socioeconomic barriers and limited postdonation access to structured health care resources. in Tunisia likely contribute to insufficient long-term monitoring, emphasizing the need for structured follow-up systems. Implementation of national registries and integrated electronic medical records could substantially enhance the tracking of long-term donor outcomes and facilitate the provision of continuous support and monitoring.¹⁴ Moreover, future prospective studies with rigorous follow-up protocols will be crucial to comprehensively evaluate the evolving psychosocial landscape of living kidney donors over time, thereby informing evidence-based guidelines for their holistic care.¹⁵

Conclusions
Living kidney donation in this North African cohort was associated with persistent psychosocial vulnerability and sleep disturbances in a subset of donors. These findings support the integration of systematic psychosocial and sleep assessments into routine donor follow-up, particularly in resource-limited settings. Longitudinal studies are crucial to better understand the long-term effects of psychosocial factors on living kidney donors and to improve postdonation outcomes, because this field of research is presently often limited by lack of comparison groups and by reliance on self-reported data.