Symptom Networks in Patients Receiving Dialysis: A Systematic Review of Node Centrality, Bridge Centrality, and Methodological Quality

Background/Objectives: Patients receiving dialysis experience multiple interacting physical and psychological symptoms. Network analysis can identify symptoms occupying central or bridging positions, but findings across dialysis studies have not been systematically synthesized. This review aimed to synthesize central and bridge symptoms in adults receiving dialysis and evaluate the methodological quality of symptom network studies. Methods: Following PRISMA 2020 and a prospectively registered protocol (PROSPERO CRD420261410561), PubMed, Scopus, Web of Science, CINAHL, China National Knowledge Infrastructure, and Wanfang Data were searched from inception to 9 May 2026. Two reviewers independently screened studies and assessed methodological quality. Centrality rankings from studies using the Dialysis Symptom Index or modified versions were min-max normalized and synthesized. Results: Sixteen cross-sectional studies involving 7691 participants were included; 15 were conducted in mainland China and one in Singapore, while 14 involved hemodialysis populations and two involved peritoneal dialysis populations. Nine network models contributed to the centrality-ranking synthesis. Anxiety ranked first (median normalized rank 0.0690), followed by difficulty falling asleep (0.2353) and sadness (0.2400). Fatigue and irritability were most frequently identified as bridge or connecting symptoms. Thirteen studies reported strength correlation-stability coefficients of at least 0.50. Seven studies were rated low quality, eight moderate quality, and one high quality, with recurrent deficiencies in model-selection reporting, subgroup comparisons, raw centrality values, and uncertainty assessment. Conclusions: Psychological and sleep-related symptoms occupied prominent positions in the analyzed networks, while fatigue frequently connected symptom communities. The evidence predominantly reflects hemodialysis samples from mainland China. The applicability to peritoneal dialysis populations and to other healthcare systems and cultural settings remains uncertain. These cross-sectional findings are hypothesis-generating and require validation in more diverse populations.