{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,10]],"date-time":"2026-04-10T09:55:50Z","timestamp":1775814950996,"version":"3.50.1"},"reference-count":47,"publisher":"MDPI AG","issue":"4","license":[{"start":{"date-parts":[[2026,4,9]],"date-time":"2026-04-09T00:00:00Z","timestamp":1775692800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Patients undergoing hemodialysis often experience reduced quality of life, with psychological symptoms and nutritional risk representing important determinants of patient functioning. This study aimed to examine the relationships between depression, anxiety, stress, nutritional risk, mental health, and physical functioning in patients undergoing hemodialysis, with particular emphasis on the mediating role of mental health. A cross-sectional study was conducted among 199 patients receiving hemodialysis in five Croatian hospitals. Depression, anxiety, and stress were assessed using the DASS-42, quality of life using the SF-36, and nutritional risk using the NRS-2002. Associations between variables were examined using Spearman\u2019s correlation coefficient, while structural equation modeling was used to analyze direct and indirect relationships among psychological symptoms, nutritional risk, mental health, and physical functioning. Depression and stress showed significant negative effects on mental health, while mental health showed a significant positive effect on physical functioning. Nutritional risk had a significant direct negative effect on physical functioning. Mental health significantly mediated the relationship between depression and stress and physical functioning. These findings indicate that psychological symptoms and nutritional risk are important determinants of functioning and quality of life in hemodialysis patients and support the need for an integrated care approach that includes regular psychological and nutritional screening.<\/jats:p>","DOI":"10.3390\/ijerph23040475","type":"journal-article","created":{"date-parts":[[2026,4,10]],"date-time":"2026-04-10T09:08:12Z","timestamp":1775812092000},"page":"475","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Psychological Symptoms, Nutritional Risk, and Quality of Life in Hemodialysis Patients: A Structural Equation Modeling Study"],"prefix":"10.3390","volume":"23","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9862-6946","authenticated-orcid":false,"given":"Tihomir","family":"Jovanovi\u0107","sequence":"first","affiliation":[{"name":"General Hospital Pakrac and Hospital of Croatian Veterans, Bolni\u010dka Ulica 74, 34550 Pakrac, Croatia"},{"name":"Faculty of Dental Medicine and Health Osijek, Josip Juraj Strossmayer University of Osijek, Crkvena 21, 31000 Osijek, Croatia"},{"name":"Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0893-7805","authenticated-orcid":false,"given":"Marin","family":"Mami\u0107","sequence":"additional","affiliation":[{"name":"Faculty of Dental Medicine and Health Osijek, Josip Juraj Strossmayer University of Osijek, Crkvena 21, 31000 Osijek, Croatia"},{"name":"General County Hospital Po\u017eega, Osje\u010dka 107, 34000 Po\u017eega, Croatia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1199-3768","authenticated-orcid":false,"given":"\u0160tefica","family":"Mik\u0161i\u0107","sequence":"additional","affiliation":[{"name":"Faculty of Dental Medicine and Health Osijek, Josip Juraj Strossmayer University of Osijek, Crkvena 21, 31000 Osijek, Croatia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4397-0560","authenticated-orcid":false,"given":"An\u0111ela","family":"Grgi\u0107","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia"},{"name":"Department of Physical Medicine and Rehabilitation, University Hospital Centre Osijek, Josipa Huttlera 4, 31000 Osijek, Croatia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jelena Tomac","family":"Jovanovi\u0107","sequence":"additional","affiliation":[{"name":"General Hospital Pakrac and Hospital of Croatian Veterans, Bolni\u010dka Ulica 74, 34550 Pakrac, Croatia"},{"name":"Faculty of Dental Medicine and Health Osijek, Josip Juraj Strossmayer University of Osijek, Crkvena 21, 31000 Osijek, Croatia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ivana","family":"Mami\u0107","sequence":"additional","affiliation":[{"name":"Faculty of Dental Medicine and Health Osijek, Josip Juraj Strossmayer University of Osijek, Crkvena 21, 31000 Osijek, Croatia"},{"name":"General County Hospital Po\u017eega, Osje\u010dka 107, 34000 Po\u017eega, Croatia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0818-8488","authenticated-orcid":false,"given":"Ivana","family":"Jelin\u010di\u0107","sequence":"additional","affiliation":[{"name":"Faculty of Dental Medicine and Health Osijek, Josip Juraj Strossmayer University of Osijek, Crkvena 21, 31000 Osijek, Croatia"},{"name":"Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia"},{"name":"Department of Psychiatry, University Hospital Centre Osijek, Josipa Huttlera 4, 31000 Osijek, Croatia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hrvoje","family":"Vidi\u0107","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia"},{"name":"General County Hospital Po\u017eega, Osje\u010dka 107, 34000 Po\u017eega, Croatia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mirela","family":"Fran\u010dina","sequence":"additional","affiliation":[{"name":"General County Hospital Po\u017eega, Osje\u010dka 107, 34000 Po\u017eega, Croatia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3544-2071","authenticated-orcid":false,"given":"Harolt","family":"Placento","sequence":"additional","affiliation":[{"name":"Faculty of Dental Medicine and Health Osijek, Josip Juraj Strossmayer University of Osijek, Crkvena 21, 31000 Osijek, Croatia"},{"name":"General Hospital Na\u0161ice, Bana Jela\u010di\u0107a 10, 31500 Na\u0161ice, Croatia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ivan","family":"Vukoja","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia"},{"name":"General County Hospital Po\u017eega, Osje\u010dka 107, 34000 Po\u017eega, Croatia"},{"name":"Faculty of Medicine, University of Rijeka, Bra\u0107e Branchetta 20, 51000 Rijeka, Croatia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Bo\u017eica","family":"Lovri\u0107","sequence":"additional","affiliation":[{"name":"Faculty of Dental Medicine and Health Osijek, Josip Juraj Strossmayer University of Osijek, Crkvena 21, 31000 Osijek, Croatia"},{"name":"General County Hospital Po\u017eega, Osje\u010dka 107, 34000 Po\u017eega, Croatia"},{"name":"Department of Nursing, University of Applied Sciences Ivani\u0107-Grad, Moslava\u010dka 13, 10310 Ivani\u0107-Grad, Croatia"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2026,4,9]]},"reference":[{"key":"ref_1","unstructured":"Daugirdas, J.T., Blake, P.G., and Ing, T.S. (2015). Handbook of Dialysis, Wolters Kluwer Health. [5th ed.]."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"605","DOI":"10.2215\/CJN.06970810","article-title":"Satisfaction with Renal Replacement Therapy and Education The American Association of Kidney Patients Survey","volume":"6","author":"Fadem","year":"2011","journal-title":"Clin. J. Am. Soc. Nephrol."},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Jelakovi\u0107, A., Radunovi\u0107, D., Josipovi\u0107, J., \u017deljkovi\u0107 Vrki\u0107, T., Gellineo, L., Domislovi\u0107, M., Prelevi\u0107, V., \u017divko, M., Fu\u010dek, M., and Marinovi\u0107 Glavi\u0107, M. (2024). Prevalence, Characteristics, and Awareness of Chronic Kidney Disease in Croatia: The EH-UH 2 Study. J. Clin. Med., 13.","DOI":"10.20944\/preprints202408.2081.v1"},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Su\u0142kowski, L., Matyja, A., and Matyja, M. (2025). The impact of dialysis duration on multidimensional health outcomes: A cross-sectional study. J. Clin. Med., 14.","DOI":"10.3390\/jcm14020376"},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Luca, A.-L., Militaru, F., Mu\u0219at, M.I., Udri\u0219toiu, I., and Mo\u021ba, E. (2026). Longitudinal changes in depression, anxiety and stress symptoms among hemodialysis patients. Clin. Pract., 16.","DOI":"10.3390\/clinpract16020037"},{"key":"ref_6","doi-asserted-by":"crossref","unstructured":"Luca, A.-L., Militaru, F., V\u0103duva, C.M., Dinu, I.-R., Maria, D.T., Mu\u0219at, M.I., R\u0103dulescu, V.M., Udri\u0219toiu, I., and Mo\u021ba, E. (2026). Depression, anxiety, stress symptoms and health-related quality of life in hemodialysis patients: Cross-sectional findings from a Romanian cohort. Medicina, 62.","DOI":"10.3390\/medicina62020242"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"600","DOI":"10.1097\/MNH.0000000000000741","article-title":"Depression in dialysis","volume":"30","author":"Tian","year":"2021","journal-title":"Curr. Opin. Nephrol. Hypertens."},{"key":"ref_8","first-page":"1095","article-title":"Multiple factors influencing mortality in hemodialysis patients","volume":"27","author":"Yaprak","year":"2023","journal-title":"Eur. Rev. Med. Pharmacol. Sci."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1331","DOI":"10.3390\/nursrep13030112","article-title":"Investigation of perception of quality of life and psychological burden of patients undergoing hemodialysis\u2014Quality of life of hemodialysis patients","volume":"13","author":"Rikos","year":"2023","journal-title":"Nurs. Rep."},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Dembowska, E., Jaro\u0144, A., Gabrysz-Trybek, E., Bladowska, J., Gacek, S., and Trybek, G. (2022). Quality of life in patients with end-stage renal disease undergoing hemodialysis. J. Clin. Med., 11.","DOI":"10.3390\/jcm11061584"},{"key":"ref_11","first-page":"e49408","article-title":"Quality of life in hemodialysis versus peritoneal dialysis patients in Bahrain","volume":"15","author":"Aljenaidi","year":"2023","journal-title":"Cureus"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1215","DOI":"10.3390\/clinpract13050109","article-title":"Quality of life among peritoneal and hemodialysis patients: A cross-sectional study","volume":"13","author":"AlRowaie","year":"2023","journal-title":"Clin. Pract."},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Szu, L.-Y., Chang, C.-H., Hsieh, S.-I., Shih, W.-M., Huang, L.-M., Tsai, M.-C., and Tseng, S.-M. (2023). Factors related to quality of life of hemodialysis patients during the COVID-19 pandemic. Healthcare, 11.","DOI":"10.3390\/healthcare11081155"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"6112","DOI":"10.21037\/apm-20-2211","article-title":"Mental health status and quality of life in patients with end-stage renal disease undergoing maintenance hemodialysis","volume":"10","author":"Ma","year":"2021","journal-title":"Ann. Palliat. Med."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"1026","DOI":"10.12669\/pjms.38.4.5308","article-title":"Analysis of quality of life and risk factors in 122 patients with persistent hemodialysis","volume":"38","author":"Xie","year":"2022","journal-title":"Pak. J. Med. Sci."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"207","DOI":"10.1002\/jcsm.12383","article-title":"GLIM criteria for the diagnosis of malnutrition\u2014A consensus report from the global clinical nutrition community","volume":"10","author":"Cederholm","year":"2019","journal-title":"J. Cachexia Sarcopenia Muscle"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"126","DOI":"10.7762\/cnr.2023.12.2.126","article-title":"Exploring the impact of appetite alteration on self-management and malnutrition in maintenance hemodialysis patients: A mixed methods research using the International Classification of Functioning, Disability and Health framework","volume":"12","author":"Hwang","year":"2023","journal-title":"Clin. Nutr. Res."},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Sahathevan, S., Khor, B.-H., Ng, H.-M., Abdul Ghafor, A.H., Mat Daud, Z.A., Mafra, D., and Karupaiah, T. (2020). Understanding development of malnutrition in hemodialysis patients: A narrative review. Nutrients, 12.","DOI":"10.3390\/nu12103147"},{"key":"ref_19","first-page":"588","article-title":"Prevalence of malnutrition for elderly hemodialysis patients","volume":"97","author":"Mahjoub","year":"2019","journal-title":"Tunis. Med."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"759","DOI":"10.1007\/s11136-020-02684-2","article-title":"Examining the relationship between nutrition, quality of life, and depression in hemodialysis patients","volume":"30","author":"Daniel","year":"2021","journal-title":"Qual. Life Res."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"562","DOI":"10.1111\/hdi.13032","article-title":"Screening for malnutrition with malnutrition inflammation score and geriatric nutritional risk index in hemodialysis patients","volume":"26","year":"2022","journal-title":"Hemodial. Int."},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Masi\u00e0-Plana, A., Sitjar-Su\u00f1er, M., Mantas-Jim\u00e9nez, S., and Su\u00f1er-Soler, R. (2024). The influence of emotional intelligence on quality of life in patients undergoing chronic hemodialysis focused on age and gender. Behav. Sci., 14.","DOI":"10.20944\/preprints202401.1193.v1"},{"key":"ref_23","first-page":"1826","article-title":"Malnutrition as a potential predictor of mortality in chronic kidney disease patients on dialysis: A systematic review and meta-analysis","volume":"16","author":"Rashid","year":"2024","journal-title":"Nutrients"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"787","DOI":"10.1016\/j.clnesp.2024.08.011","article-title":"Association between objectively measured protein intake and muscle status, health-related quality of life, and mortality in hemodialysis patients","volume":"63","author":"Salamah","year":"2024","journal-title":"Clin. Nutr. ESPEN"},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"Bellanti, F., Lo Buglio, A., Quiete, S., and Vendemiale, G. (2022). Malnutrition in hospitalized older patients: Screening and diagnosis, clinical outcomes, and management. Nutrients, 14.","DOI":"10.3390\/nu14040910"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"672","DOI":"10.1007\/s12020-022-02982-4","article-title":"Thyroid disorders and cardiovascular manifestations: An update","volume":"75","author":"Paschou","year":"2022","journal-title":"Endocrine"},{"key":"ref_27","first-page":"15","article-title":"Depression, Anxiety and Stress Scale","volume":"Volume 6","year":"2012","journal-title":"Collection of Psychological Scales and Questionnaires"},{"key":"ref_28","doi-asserted-by":"crossref","unstructured":"Lovibond, S.H., and Lovibond, P.F. (1995). Manual for the Depression Anxiety Stress Scales, Psychology Foundation of Australia. [2nd ed.].","DOI":"10.1037\/t01004-000"},{"key":"ref_29","first-page":"95","article-title":"Psychometric evaluation and establishing norms of Croatian SF-36 health survey: Framework for subjective health research","volume":"47","year":"2006","journal-title":"Croat. Med. J."},{"key":"ref_30","unstructured":"Ware, J.E., Kosinski, M., and Gandek, B. (2003). SF-36 Health Survey: Manual and Interpretation Guide, QualityMetric Incorporated."},{"key":"ref_31","first-page":"69","article-title":"The Croatian Health Survey\u2014SF-36: I. General quality of life assessment","volume":"24","author":"Mastilica","year":"2000","journal-title":"Coll. Antropol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"321","DOI":"10.1016\/S0261-5614(02)00214-5","article-title":"Nutritional risk screening (NRS 2002): A new method based on an analysis of controlled clinical trials","volume":"22","author":"Kondrup","year":"2003","journal-title":"Clin. Nutr."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"297","DOI":"10.1002\/ncp.10082","article-title":"Validation of Nutritional Risk Screening-2002 in a hospitalized adult population","volume":"34","author":"Bolayir","year":"2019","journal-title":"Nutr. Clin. Pract."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"e35133","DOI":"10.1097\/MD.0000000000035133","article-title":"Risks of undernutrition and depression in hospitalized patients: A cross-sectional study","volume":"102","author":"Asma","year":"2023","journal-title":"Medicine"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"409","DOI":"10.1016\/j.clnu.2005.11.001","article-title":"Comparison of tools for nutritional assessment and screening at hospital admission: A population study","volume":"25","author":"Kyle","year":"2006","journal-title":"Clin. Nutr."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"3325","DOI":"10.1590\/1413-81232018249.25042017","article-title":"Comparison of NRS-2002 criteria with nutritional risk in hospitalized patients","volume":"24","author":"Barbosa","year":"2019","journal-title":"Cien. Saude Colet."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"e022993","DOI":"10.1136\/bmjopen-2018-022993","article-title":"Comparison of two malnutrition risk screening tools with nutritional biochemical parameters, BMI, and length of hospital stay in Chinese geriatric inpatients: A multicenter, cross-sectional study","volume":"9","author":"Miao","year":"2019","journal-title":"BMJ Open"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1080\/19312458.2020.1718629","article-title":"Use omega rather than Cronbach\u2019s alpha for estimating reliability. But\u2026","volume":"14","author":"Hayes","year":"2020","journal-title":"Commun. Methods Meas."},{"key":"ref_39","unstructured":"JASP Team (JASP, 2026). JASP, Version 0.96.0; Computer Software."},{"key":"ref_40","doi-asserted-by":"crossref","unstructured":"Mohamed, N.A., Eraslan, A., and Kose, S. (2023). The impact of anxiety and depression on the quality of life of hemodialysis patients in a sample from Somalia. BMC Psychiatry, 23.","DOI":"10.1186\/s12888-023-05312-8"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"3029","DOI":"10.1038\/s41598-022-07055-0","article-title":"The impact of nutritional status on health-related quality of life in hemodialysis patients","volume":"12","author":"Visiedo","year":"2022","journal-title":"Sci. Rep."},{"key":"ref_42","doi-asserted-by":"crossref","unstructured":"Yang, Y. (2024). The mediating effects of symptom experiences on the relationship between body image and quality of life among hemodialysis patients in a single center. Healthcare, 12.","DOI":"10.3390\/healthcare12171779"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"e19383","DOI":"10.1016\/j.heliyon.2023.e19383","article-title":"Depression in maintenance hemodialysis patients: What do we need to know?","volume":"9","author":"Li","year":"2023","journal-title":"Heliyon"},{"key":"ref_44","doi-asserted-by":"crossref","unstructured":"Moreira, M.B., Cavalli, N.P., Righi, N.C., Schuch, F.B., Signori, L.U., and Silva, A.M.V.D. (2023). Quality of life and functional capacity in depressive patients on hemodialysis: A systematic review and meta-analysis. Healthcare, 11.","DOI":"10.1590\/1414-431x2023e12850"},{"key":"ref_45","doi-asserted-by":"crossref","unstructured":"Bakhsh, A.M., and Mahallawi, W.H. (2025). Psychological effects of hemodialysis on patients with renal failure: A cross-sectional study. J. Clin. Med., 14.","DOI":"10.3390\/jcm14207136"},{"key":"ref_46","doi-asserted-by":"crossref","unstructured":"Yoshida, N., Tanaka, T., Suzuki, Y., Takahashi, S., Hitaka, M., Ishii, S., Yamazaki, K., and Ohashi, Y. (2025). Clinical significance of phase angle for assessing quality of life and prognosis in hemodialysis patients. Nutrients, 17.","DOI":"10.3390\/nu17233631"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"897","DOI":"10.1007\/s11255-022-03374-3","article-title":"The effect of psychosocial interventions on depression, anxiety, and quality of life in hemodialysis patients: A systematic review and a meta-analysis","volume":"55","author":"Barello","year":"2023","journal-title":"Int. Urol. Nephrol."}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/23\/4\/475\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,10]],"date-time":"2026-04-10T09:11:43Z","timestamp":1775812303000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/23\/4\/475"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4,9]]},"references-count":47,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2026,4]]}},"alternative-id":["ijerph23040475"],"URL":"https:\/\/doi.org\/10.3390\/ijerph23040475","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,9]]}}}