title: Multidimensional symptom clusters: an exploratory factor analysis in advanced chronic kidney disease.
abstract: OBJECTIVE
  To explore the existence of symptom clusters in advanced chronic kidney disease.
  
  
  BACKGROUND
  People with chronic kidney disease commonly report multiple symptoms. However, the complex relationships among these symptoms are still poorly understood.
  
  
  METHODS
  Cross-sectional.
  
  
  METHODS
  A total of 436 people with stage 4 and 5 chronic kidney disease were recruited from three tertiary hospitals during 2013-2014. Participants completed the Chronic Kidney Disease-Symptom Burden Index that assesses four symptom dimensions (occurrence, distress, severity and frequency) of 32 symptoms. Exploratory factor analysis was used to identify symptom clusters across each symptom dimension. Core symptoms in each cluster were determined based on stability across dimensions and clinical plausibility. A high cutoff of 0·50 for factor loading was used for all analyses.
  
  
  RESULTS
  Five symptom clusters were consistently identified across all symptom dimensions: fluid volume symptoms, neuromuscular symptoms, gastrointestinal symptoms, sexual symptoms and psychological symptoms. Overall, clusters ranged from 2-10 symptoms. Several symptoms were also interconnected with multiple clusters. Fatigue cross-loaded on all five clusters, whereas sleep disturbance and restless leg symptoms cross-loaded across three clusters.
  
  
  CONCLUSIONS
  Adopting a symptom cluster approach has the potential to significantly advance symptom assessment and nursing care for people in advanced stages of chronic kidney disease. Routine clinical assessment and management strategies targeted at the cluster level should have synergistic effects in reducing symptoms. Fatigue is a pervasive symptom in advanced chronic kidney disease that is interconnected with global symptom burden, suggesting better management of symptom clusters may also reduce fatigue.
authors.affiliation: School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia.|School of Nursing, King Abdulaziz University, Jeddah, Saudi Arabia.|Chronic Kidney Disease Centre for Research Excellence, University of Queensland, Brisbane, Queensland, Australia.
authors.forename: Hayfa
authors.initials: H
authors.lastname: Almutary
authors.affiliation: School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia.
authors.forename: Clint
authors.initials: C
authors.lastname: Douglas
authors.affiliation: School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia.|Chronic Kidney Disease Centre for Research Excellence, University of Queensland, Brisbane, Queensland, Australia.|Renal Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
authors.forename: Ann
authors.initials: A
authors.lastname: Bonner
mesh_terms: D016000:Cluster Analysis; D015897:Comorbidity; D003430:Cross-Sectional Studies; D005163:Factor Analysis, Statistical; D006801:Humans; D011788:Quality of Life; D051436:Renal Insufficiency, Chronic / Q000150:complications* / Q000523:psychology; D013577:Syndrome
keywords: chronic kidney disease; management; nursing; symptom assessment; symptom clusters