Chronic kidney disease (CKD) is a worldwide public health concern, affecting approximately 13.4% of the global population (1). Patients with chronic kidney disease face a threefold higher risk of heart failure and an increased susceptibility to urinary tract infections, gastrointestinal bleeding, hip fractures, and other related comorbidities (2). These complications significantly diminish patients’ quality of life. Progressive deterioration of kidney function ultimately leads to the development of end-stage renal disease (ESRD), necessitating renal replacement therapy for survival. Research indicates a projected increase in the number of patients requiring renal replacement therapy, expected to rise from 2,455,000 in 2016 to 5,439,000 by 2030 (3).

Peritoneal dialysis, as a modality of renal replacement therapy, has gained acceptance among patients and is utilized in various countries and regions due to its attributes, including the preservation of residual renal function, the option for home-based administration, and cost-effectiveness (4). Globally, 10–20% of patients are currently undergoing peritoneal dialysis treatment (5). Continuous Ambulatory Peritoneal Dialysis (CAPD) refers to patients exchanging dialysate 3–5 times per day, with each exchange volume of 1.5–2 L. Dialysate is left in the peritoneal cavity for 4–6 h/time during the daytime, and 10–12 h during the night. CAPD is the most dominant peritoneal dialysis modality, accounting for 90% of PD patients (6).

Regrettably, Dialysis fluid exchange at specific times and places restricts patients’ travel and the irreversible aggravation of their psychological burden by their kidneys, leading to the prominence of the phenomenon of “social alienation” (SA), such as peritoneal dialysis patients’ active avoidance of social interaction and the feeling of being alienated by others (7). SA is an objective phenomenon in which an individual is detached from social relationships, accompanied by emotional experiences such as loneliness and indifference, as well as avoidance and rejection of social activities (8). Qing-Er et al. (9) conducted a questionnaire survey involving 300 peritoneal dialysis patients, revealing that 70% of them exhibited deficits in social functioning. Tao Weiwei et al. (10) discovered that, following dialysis, 36.3% of patients experienced reduced interaction with family and community members, rarely engaging in group activities. Moreover, 14.6% of patients remained entirely homebound, with this figure escalating to 84.93% in rural regions. Cuevas-Budhart et al. (11) conducted in-depth interviews with 29 peritoneal dialysis patients across 13 hospitals in Mexico. Their findings indicated that patients’ experiences of family isolation and socioeconomic difficulties led to somatization of emotions, resulting in manifestations of sadness, anxiety, loneliness, and social abandonment.

The SA threatens peritoneal dialysis patients’ physical and mental health. Research has demonstrated that SA induces hypofunction of the hypothalamic–pituitary–adrenal (HPA) axis, subjecting patients to a pro-inflammatory milieu, thus exacerbating the inflammatory aspects of diseases like atherosclerosis, thereby becoming a significant risk factor for cardiovascular disease (11, 12). Furthermore, severe SA exhibits a substantial association with rapid renal failure in patients, serving as a prognostic indicator for the deterioration of renal function and the acceleration of disease progression (13).

Emotional intelligence (EI) is the ability of an individual to recognize and control his or her own emotions and those of others, and to be able to use emotions correctly to deal with and solve problems (14). Previous studies have found a correlation between EI and SA (15), enhancing emotional intelligence and promoting positive emotional expression in patients can help expand social networks and restore social functioning (16). However, how EI affects SA remains a black box that needs to be explored in further research. Understanding the mechanisms of influence will help healthcare professionals to develop targeted interventions to alleviate social alienation in peritoneal dialysis patients.

According to the Cascading Model, the association between EI and behavioral performance is not straightforward; instead, it is influenced by intervening variables (17). Consequently, it is reasonable to hypothesize the presence of mediating variables rather than direct mediators linking EI to SA. The Neurocognitive Processing Model of Emotional Intelligence suggests that emotional intelligence affects social relationships in a way that requires individuals to re-identify and increase their confidence, and that the effectiveness of emotional intelligence relies heavily on reliable feedback from the surrounding environment (18).

Personal mastery is the degree to which an individual perceives control over his or her life and surroundings, and reflects the patient’s self-confidence in life and disease management (19). Furthermore, mentioning the level of EI has been shown to enhance patient self-confidence and elevate self-efficacy, a pivotal factor influencing the personal master (20, 21). It was found that patients with a high personal mastery were more inclined to respond to changes in things with an open and inclusive mindset, actively engage in social interactions, and feel less SA during stressful situations (22, 23). Therefore, this study proposes the hypothesis that EI may improve SA by enhancing patients’ personal mastery.

Perceived social support is an individual perceives or appreciates material or emotional support from the outside world, which reflects the emotional response of the surrounding environment to the patient.

Emotional intelligence was positively correlated with perceived social support, with individuals with high EI subjectively perceiving more social support and utilizing it (24). According to the WHITE heuristic cognitive model of the cognitive theory of emotion, patients in a state of somatic vulnerability tend to actively detach themselves from social activities and persist in negative emotions if the perceived level of social support is low (25). Above all, this study again hypothesizes that EI influences the SA process in which perceived social support plays an important role.

To date, despite some studies examining the connections among EI, personal mastery, perceived social support, and SA, the precise nature of their interrelationships remains ambiguous. Consequently, this study seeks to explore the mediating functions of personal mastery and perceived social support in the relationship between EI and SA among peritoneal dialysis patients.

This endeavor aims to establish a theoretical foundation for intervention strategies aimed at mitigating social alienation within this patient population. Therefore, we developed a mediation model (see Figure 1) to explore the effects and mediating mechanisms of EI on SA in peritoneal dialysis patients, which outlines the hypotheses that (1) EI may affect SA in peritoneal dialysis patients (2) personal mastery and perceived social support mediate EI and SA in peritoneal dialysis patients.

Social alienation (SA) represents an inescapable challenge faced by peritoneal dialysis patients, profoundly impacting their mental well-being. Consequently, it is imperative to scrutinize the determinants of SA and to formulate tailored intervention strategies. In this investigation, the SA score among peritoneal dialysis patients averaged 42.01 ± 3.15, indicating a notably elevated level compared to the scale’s median total score of 37.50. These findings align closely with the scores reported by Xiaofang et al. (37) for lung cancer patients, though they slightly surpass scores observed in stroke patients (38). Several factors contribute to this discrepancy. Firstly, Zhao Cuicui (38) study encompassed a substantial proportion of older adult patients, the cognitive and physical functions of the older adult population are in a stage of decline, which, with increasing age, causes them to be socially inactive and thus aggravates SA. While this study predominantly enrolled young and middle-aged individuals who shoulder diverse family and occupational responsibilities, thus experiencing heightened demands for social engagement (39). Furthermore, the social role of supporting the older adult and caring for children compounds the burdens borne by these patients. Additionally, influenced by traditional Chinese cultural norms, individuals frequently refrain from sharing the impact of their illness with others, believing that such vulnerability does not align with societal expectations. This restraint fosters heightened anxiety, feelings of powerlessness, and a sense of detachment.

Simultaneously, our findings underscore the significance of age and duration on dialysis as pivotal determinants of SA in peritoneal dialysis patients. Surprisingly, our study revealed elevated SA scores among younger patients, a trend contrary to the findings of several previous investigations (40, 41). Notably, dialysis-related complications manifest as discernible alterations in patients’ physical appearance, encompassing generalized edema (42), melanosis (43) and characteristic hyperparathyroidism (44), etc. These conspicuous disease-related attributes are prone to create unfavorable impressions on others, further exacerbated by societal misconceptions and potential instances of social discrimination, thereby inducing psychological distress among patients (44, 45). Younger patients, in particular, grapple with the pronounced impact of these appearance-related changes, which can lead to challenges in pursuing marriage, forming new social connections, and realizing their socialization aspirations (46). Moreover, younger patients often exhibit reticence in sharing their emotions and experiences, ultimately isolating themselves from active engagement in social activities, thus fostering SA (47).

Furthermore, the study results indicate that peritoneal dialysis patients with a dialysis vintage of less than 1 year exhibited higher scores on social alienation, aligning with the findings of Xiaofang et al. (37). Peritoneal dialysis necessitates multiple daily fluid exchanges, meticulous monitoring of fluid balance, and the endurance of complications like pruritus and sleep disturbances (48, 49). For patients with a short dialysis history, striking a swift equilibrium between demanding self-care regimens and their pre-existing work commitments poses a formidable challenge. For patients who have been on peritoneal dialysis for a longer period of time, they have had a rich experience with nephrological care, better adapted to dialysis treatments, and have found the right place in their lives for dialysis, and therefore are less concerned about feeling alienated (50). Consequently, confronted with the stressors of dialysis, these patients often struggle to adapt to and redefine their roles, harboring numerous anxieties and reservations about their treatment. The amplification of psychological symptoms exacerbates their inclination toward social avoidance and SA (51). As a result, healthcare practitioners should direct their attention toward younger patients with shorter dialysis histories, proactively monitoring their emotional shifts. Collaborative interventions, such as patient support associations, can be instrumental in fostering positive emotional experiences, thereby establishing stable social bonds and mitigating their degree of social alienation.

The study’s findings reveal a negative association between higher levels of EI and lower levels of SA among peritoneal dialysis patients. These results align with previous research and contribute to a deeper understanding of the underlying mechanisms (52). Individuals with elevated EI exhibit a propensity to mitigate the impact of stress within their social environment through positive coping strategies, such as cognitive reappraisal. This serves as a protective factor against SA, in accordance with the stress buffer model (53). During this process, individuals tend to refrain from negative emotional expressions (self-containment and avoidance), increase positive emotional experiences, bolster resource development when facing stressful circumstances, and fulfill the prerequisites for social participation. These dynamics align with the extended construction theory (54). It was found that one feature of EI - affective differentiation – neutralizes neural responses to social rejection (i.e., dACC and forebrain insulae) (55), and from this perspective, EI creates conditions for patients to initiate social interactions. These findings lay the groundwork for further exploration of the interplay between personal mastery, perceived social support, EI, and SA among peritoneal dialysis patients.

Our study reveals that personal mastery acts as a complete mediator between EI and SA in peritoneal dialysis patients. According to the theory of limited self-control, self-control resources are finite, allowing individuals only short-term exertion of self-control. Externally stressful situations deplete these resources, diminishing self-control, and potentially resulting in emotional regulation failures (56). Peritoneal dialysis patients, grappling with the enduring burden of lifelong dialysis, job transitions, and life adjustments, often experience a significant erosion of self-worth, which profoundly affects their personal mastery. Moreover, personal mastery is cultivated through continuous social interactions. EI emerges from the amalgamation of self-cognitive processes and emotional management (57). In the realm of emotion regulation and control, patients employ self-beneficial coping strategies, facilitating the transformation of negative emotions into positive ones through cognitive reappraisal. The sustenance of positive emotions fosters self-management confidence, life optimism, and an ensuing personal mastery. Patients possessing high personal mastery exhibit superior disease-related stress coping mechanisms, and through positive outlooks, they confront adverse events related to their condition, thereby fostering improved societal engagement and lower levels of SA (23, 58).

Additionally, our study reveals that perceived social support fully mediates the relationship between EI and SA in peritoneal dialysis patients. Individuals with high EI excel at perceiving and effectively regulating emotions, fostering positive emotional states during social interactions. These positive emotions often extend to family members and friends, fostering positive social interactions, aligning with the concept of emotional contagion (59, 60). Moreover, high EI equips patients to harness valuable social resources effectively. Perceived social support enhances patients’ sense of belonging and identity, compensating for social roles lost due to illness and encouraging proactive engagement in social interactions, ultimately reducing SA (61).

Our study further demonstrates that personal mastery and perceived social support partially mediate the relationship between EI and SA in peritoneal dialysis patients. Notably, navigational social support plays a more substantial mediating role than personal mastery, suggesting that perceived social support may be a stronger predictor of SA. However, additional research is required to validate this hypothesis. This study offers a mechanistic examination of the EI-SA relationship, addressing a gap in previous research. Nevertheless, relevant studies remain limited, and the precise mechanisms require further validation through additional research. Several limitations should be acknowledged. Firstly, this study is cross-sectional, precluding the establishment of causal relationships among variables. Subsequent longitudinal investigations are warranted to validate these findings. Secondly, the study sample was drawn from a single province in China, limiting its generalizability to all peritoneal dialysis patients.

To delve deeper into these intricate connections, future research could explore them through longitudinal surveys and mixed-method studies, incorporating qualitative research components.

In summary, our study has revealed a pronounced level of SA in peritoneal dialysis patients, with a robust association with EI. Personal mastery and perceived social support emerge as crucial mediators in this relationship. Specifically, implementing an emotional intelligence management program has the potential to enhance patients’ personal mastery and perceived social support, resulting in a subsequent reduction in SA levels. These findings offer a substantive theoretical foundation for addressing SA among peritoneal dialysis patients, suggesting that future clinical practice should consider tailoring interventions, such as the development of an emotional intelligence management program, to augment patients’ personal mastery and perceived social support, ultimately mitigating SA.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving humans were approved by Zhengzhou University Life Science Ethics Committee. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

KD: Conceptualization, Methodology, Writing – original draft. JW: Methodology, Writing – review & editing. YZ: Data curation, Methodology, Writing – original draft. YH: Data curation, Investigation, Writing – original draft. YS: Funding acquisition, Resources, Supervision, Writing – review & editing.