Fear of disease progression as a mediator of the association between symptom clusters and social alienation among hemodialysis patients: A cross-sectional study

Patients undergoing maintenance hemodialysis often experience multiple concurrent symptoms that may affect psychosocial functioning. This study aimed to identify symptom-clusters and examine the associations among symptom-cluster severity, fear of disease progression (FoP), and social alienation, including the statistical mediating role of FoP. This analytical cross-sectional study included 321 patients receiving maintenance hemodialysis at a tertiary hospital in Shenyang, China. Symptoms, social alienation, and FoP were assessed using the Chinese versions of the Dialysis Symptom Index, General Alienation Scale, and Fear of Progression Questionnaire-Short Form, respectively. Principal component analysis with Varimax rotation was used to identify symptom-clusters. Correlation analyses and structural equation modeling were performed, and indirect effects were tested using 5000 bootstrap resamples. Five symptom-clusters were identified: water and electrolyte, sleep disorder, gastrointestinal, skin, and psychological symptom-clusters, collectively explaining 55.50% of the total variance. The severity scores of all 5 symptom-clusters were positively correlated with FoP and social alienation (all P  < .01), with the sleep disorder symptom-cluster showing the strongest correlation with total social alienation (correlation coefficient = 0.703, P  < .01). The partial-mediation model showed better fit than the competing full-mediation model and demonstrated acceptable model-fit ( χ ² /df = 2.604, root mean square error of approximation = 0.072). Symptom-clusters were positively associated with FoP (B = 4.910, β = 0.705, P  < .001), and FoP was positively associated with social alienation (B = 0.112, β = 0.358, P  < .001). The direct association between symptom-clusters and social alienation remained significant after FoP was included in the model (B = 1.610, β = 0.737, P  < .001). The indirect effect through FoP was statistically significant (B = 0.551, β = 0.252, 95% confidence interval: 0.180–1.258), accounting for 25.5% of the total effect. Greater symptom-cluster severity was associated with greater FoP and social alienation, with FoP showing a significant statistical indirect effect. Integrated assessment of symptom-clusters, disease-related fears, and psychosocial needs may help identify patients requiring comprehensive support. Given the cross-sectional design, these findings should not be interpreted as evidence of temporal or causal relationships.