**3. Impact of dyspepsia on quality of life and nutritional condition**

It is well-known that dyspepsia can lower QOL in the general population [7]. In the context of ESRD, quality of life deserves special attention. Compared to the most frequent chronic diseases, like heart failure, angina, diabetes, chronic lung disease, arthritis and cancer, ESRD impairs quality of life the most [27]. Furthermore, high mortality among ESRD patients is stationary despite the recent technical advances in dialysis therapy and the availability of several updated guidelines and recommendations for ESRD treatment. Indeed, in recent years, QOL has become the main outcome of dialysis treatment, either as a self-perceived outcome by the patient or as an objective quality parameter of the dialysis procedure. Unfortunately, many factors associated with low QOL in HD patients are non-modifiable. Consequently, both physical and mental aspects of QOL among HD patients have not been improving during the last decade [12].

My main research line is self-perceived outcomes among HD patients. Since 2006 my research group has been producing studies in this area [8-10, 28-36]. Our sample consists of ESRD patients treated in the only two dialysis units in an area of 34.560 km2 (37.3 inhabitants/ km2 ) in the northern region of Ceará state, northeast Brazil. There we found, as others, a very low level of QOL in HD patients, mainly related to physical aspects. Recently, we presented our results about QOL in dyspeptic patients at the Paulista Congress of Nephrology, in Atibaia, São Paulo, Brazil [37]. We used the SF-36 instrument to evaluate QOL. SF-36 gives results on a scale from 0 (worst result) to 100 (best result) related to eight dimensions of QOL: physical functioning, role-physical, bodily pain, general health, vitality, social functioning, roleemotional and mental health. We used the Functional Dyspepsia Module of Rome III Diag‐ nostic Questionnaires to search for dyspeptic symptoms. Our results showed that physical (bodily pain, general health and vitality) and also mental (role-emotional and mental health) aspects are lower in dyspeptic compared to non-dyspeptic HD patients. Notably, general health and role-emotional are the two dimensions rated below 50 according to the SF-36 scale among dyspeptics. It is exciting to think about FD as a modifiable factor associated with QOL. We urgently need randomized, controlled studies to test the effect of FD treatment on QOL among HD patients.

Another crucial impact of dyspepsia is related to nutritional condition. In the general popu‐ lation, weight loss is taken as an alarm symptom that raises suspicion of organic disease. However, weight loss also occurs in FD [38]. In nephrology, there are many studies on nutrition among HD patients. The most well-known factors associated with malnutrition in ESRD are anorexia and chronic inflammation [39]. FD is not well studied as a factor linked to malnutri‐ tion among ESRD patients. We exposed our preliminary data on this question at the Third Conference on Nephrology, held in Valencia, Spain [40]. In our experience, dyspeptic HD patients have a lower calorie and protein intake compared to non-dyspeptics. Like in the case of QOL, it is encouraging to think about FD as a modifiable factor associated with malnutrition, particularly because to same extent FD is easier to treat than anorexia and chronic inflamma‐ tion. Again, as happens in the context of FD and QOL, clinical trials about the beneficial effects of treating FD on caloric and protein intake are necessary.
