Careful donor selection with appropriate pretransplantation psychiatric consulting allows those with normal life quality to donate without consequence to their physical or psychological status [5]. A mental health specialist should evaluate all prospective donors. Psychosocial evaluation aims in assessing competency, cognitive status, and capacity to comprehend information. The assessment is aimed at removing the risk for exploitation of donors by others for monetary or other gain. It provides knowledge and understanding about donation risks and benefits of surgery, psychological functioning, motivations and expectations, the donor-recipient relationship, social support, and financial stability [6–11]. Majority of transplant programs consider active substance abuse/dependence or active mental health problems or instability to be absolute contraindications to the living donor surgery. Amsterdam Protocol recommends that donors with an alcohol abuse history stop drinking at least 1 month prior to surgery [12]. This should be considered minimum abstinence period, given heavy alcohol abuse can increase postoperative morbidity [13] and risk of acute renal failure [14]. All programs should advise potential donors to quit smoking and chewing tobacco and inform them of their increased risks of cardiovascular disease, cancer, and possible kidney disease [15, 16]. Relative contraindications are history of poor adherence to health care recommendations [6], such donors should be counseled for regular follow-up post donation to monitor health status.

When the patient is told about the diagnosis of end-stage chronic renal failure, many patients due to lack of education are unaware about the intricacies of the procedure. The patient and the family members are explained about his present medical condition and treatment alternatives. The patient and the family members need to have discussions and counseling sessions with the treating doctor and the social worker. If the patient decides to undergo kidney transplantation, then the search for a donor within the family begins. The social worker calls a family meeting of the patient, potential donors, and other decision-making individuals within the family and their spouses. All family members are explained about kidney function and kidney donor selection and rejection criteria. The kidney donors are explained about (i) short-term surgical risks, especially the scar, catheter, and hospitalization; (ii) long-term risk of impaired renal function and hypertension; (iii) loss of time and money; (iv) availability of other treatment alternatives, like maintenance dialysis for the recipient; and (v) the risks and success and failure rates of the transplantation. After understanding these risks, all donors who are deemed suitable are medical worked up.

It’s the responsibility of the transplant team to know about the decision of kidney donation that it is taken voluntarily and without coercion and pressure from recipient or any other individual. Minz et al. have reported that 4 (5.3%) donors out of 75 donors were under pressure from family or recipient to donate. Two out of them perceived negative impact on health, and one had loss of sleep, and the other was worried about having single kidney [4]. Some transplant programs exercise a “cooling off period” [6] or reflection period to ensure that they have adequate time to consider the information gathered during evaluation process. The allowance of time ensures that the potential donor does not take the decision of donating kidney in haste and has well thought over about the kidney donation. In a study of pediatric transplantations, donors and partners reported an independent decision-making process with no significant influences of partners, relatives, or hospital staff. There was high degree of decision-making process in a live donor kidney transplant (LRKT). Majority of donors did not report negative medical or psychological consequences. The relationship between donor, partners, and recipient child improved after LRKT [17]. A positive psychosocial outcome is encouraged by the following factors: to safeguard against unwarranted coercion, information about realistic expectations to avoid depressive breakdowns, high stability and balanced mutual autonomy in the donor recipient relationship. In addition, information about possible medical and psychological problems helps to prepare for their actual occurrence, awareness of coping strategies and available social support helps to alleviate critical periods after transplantation [18].

It is noted that strong motivation helps the donor to endure the risk of donation process and plays important role in preventing adverse psychological effect. It is also important to know the motivation for offering to donate out of altruism, love, and affection, as a duty or for any secondary gain. Smith et al. found that 97% of donors reaffirmed their decision about donating kidney, and <15% felt they were pressured to donate [19]. The weight of current evidence indicates that kidney donation has a favorable outcome for both the donor and the recipient, and the participation of living-related donors in kidney transplantation is widely accepted [20].

Based on a narrative review, it is known that those individuals who are ambivalent about kidney donation are at risk for poor psychosocial outcomes after donation. Intervention is targeted to reduce this risk. Intervention structure and content draw on motivational interviewing principles in order to assist prospective donors to resolve ambivalence. Participants’ comments indicated that the intervention addressed their thoughts and concerns about the decisions to donate [21].

Availability of social support of spouse or other significant family member, friends, and employer is essential to proceed with the kidney donation process. In the event of negative outcome or complication, emotional support from family and friends helps in coping. Whenever there is a search for a kidney donor within the family, it is said that there exists some amount of psychological pressure in some subtle form. In a study by Smith et al. 14.2% of the kidney donors did mention family pressure as one of the reasons for agreeing to donate their kidneys [19]. Among the family members, motivation to donate follows costs and gains factor. The greatest reward is said to be the feeling that you have helped somebody who has been critically ill to restore his life and health. It is noted that in most cases, the donors received a great deal of family praise and gratitude, both before and after for their humanitarian act [22].

The psychological benefit like increase in self-esteem seems to persist even after the allograft (transplanted kidney) has failed. The kidney donation is also reported to improve the relationship with the donor during 12 years period after nephrectomy [19]. The studies of kidney donors have generally shown that they experience long-lasting positive feelings about their decision to donate regardless of the success of transplantation. Many donors are found to report an increased self-esteem and sense of worth. In addition, some donors report an indirect benefit from the improved health of the recipient. Long-term involving follow-up of 20–30 years after kidney donation showed that most donors have high quality of life with a boost in self-esteem and increased sense of well-being.

Living-related kidney donation is associated with generally positive donor-recipient relationship. It is also noted that living-related donors usually demonstrate sustained improved self-esteem and lowered levels of depressive mood posttransplant [23]. In the study of 536 kidney donors done by Smith et al., the relationship between the donor and recipient was described as somewhat or substantially improved after surgery by 13.9% and 28.0% of the donors. If provided an opportunity to reconsider, a majority of the donors stated that they would donate. Their responses were 91.5% definitely, 5.3% probably, 2.9% equivocal, and 0.4% unlikely to donate. These decisions were not related to the success of the graft or the extent of financial hardship created by donation [19].

Open surgery was accompanied by long-term complications like mild to moderate incision pain and incisional hernia and a very visible scar leading to diminished body image. In a study, all donors experienced pain, anxiety, and inconvenience during open donor surgery [24]. However, in a study comparing donors who had different operations, the mean body image and cosmetic scores of both laparoscopic and open donors were high and similar [25].

Recently, donor surgery using laparoendoscopic single-site (LESS) donor nephrectomy has been developed for donor comfort and better cosmetics. A randomized comparative study performed at our institute compared postoperative patient pain score and quality of life (QOL) of standard laparoscopic donor nephrectomy (LDN) versus laparoendoscopic single-site (LESS) donor nephrectomy. This study showed that on a select group of donors, LESS patients show early relief of pain with shorter hospital stay with similar complications rate and equivalent graft outcome [26]. Comparative studies with open donor nephrectomy have shown that laparoscopic donor nephrectomy removes some of the disincentives to live donation with shorter hospital stay and faster return to work, without compromising the outcome of the recipient graft function [26].

The strength of marriage is the mutual trust and understanding between the spouses. It is believed that illness in the family may cause stress on partners which may have an adverse effect on marriage. Kidney donation may add additional stress to already troubled marriages (especially if the donor’s spouse is opposed to the donation) [23]. Smith et al. (1986) have noted that out of 371 donors, 27 (7.1%) were divorced or separated at the time of follow-up, and 12 (44.4%) of these reported a failed marriage within 1 year of donation. It is noted that a failed marriage occurred among the donors who were pressurized to donate by other family members [19]. The donors who were married and older than 51 years old had higher scores for posttraumatic growth (PTG) than donors who were not married or younger [27]. In my opinion based on counseling kidney donor families both pre- and postoperatively in over 2,500 cases, I did not find any major marital discord postoperatively. This is probably a result of sociocultural factors, extensive preoperative counseling and taking informed consent of the donor’s spouse.

Kidney donation may impact on employment; an important concern is whether the employer will grant leave from work till the donor is completely recovered. Will the donor receive pay during investigations, operation, and post donation recovery period? It is important that the employer has knowledge and understanding about kidney donation. More significant factor being under what circumstances he/she is donating kidney. The employer’s positive attitude will help during the convalescence and periodic check-ups lifelong. The support of employer is crucial in lessening financial burden if any. Laparoscopic donor nephrectomy gives kidney donor added advantage of less hospitalisations resuming normal activities and start of work sooner.