**2. How to assess dyspeptic symptoms**

only modest performance of the Rome III criteria, reaching only 60.7% sensitivity and 68.7%

*Postprandial fullness* Unpleasant sensation of prolonged persistence of food in the stomach after a meal

*Epigastric pain* Subjective, intense and unpleasant sensation in the epigastrium, which can lead patients to believe that some tissue damage is occurring

*Epigastric burning* Unpleasant subjective sensation of heat in the epigastrium

**Table 1.** Definition of dyspeptic symptoms as proposed by the Rome III consensus

*Early satiation* Feeling that the stomach is overfilled soon after starting to eat, out of proportion to the size of the meal being eaten, so that the meal cannot be finished

Why do I classify FD as underestimated among end-stage renal disease (ESRD) patients? In my view, dyspepsia really deserves special attention among ESRD patients on hemodialysis

**1.** The most common non-renal complaints in HD patients are gastrointestinal symptoms,

**2.** The negative effect of dyspepsia on quality of life (QOL) is well known [7]. From the perspective of ESRD, the association between dyspepsia and impaired quality of life has

**3.** Dyspepsia is also associated with another important condition: nutritional status [14]. **4.** ESRD allows several lines of investigations about the pathophysiology of FD. The clinical research about the interactions between typical features of ESRD (like neuropathy, uremic toxins, abnormal gut motility and excess of extracellular volume) and FD need to advance [15-23]. Meanwhile, the pathophysiology of FD in ESRD is still not completely understood

**5.** Treatment challenge of FD is specific in HD patients due to the polypharmacy imposed on these patients, the high prevalence of depressive feelings, which can modulate dyspeptic symptoms, and the multi-factorial mechanisms of uremia acting on the

Despite the above, from my observations dyspepsia is not routinely screened in dialysis units as is done for cardiovascular disease, osteodystrophy and nutritional status. There is also a lack of randomized, placebo-controlled studies about treatment of FD among HD patients, and a clear explanation of the physiopathological mechanisms regarding FD in ESRD is missing. In my institution, Federal University of Ceará in Brazil, data have been collected since the 1980s on the relationships between volemic status and gastric motility, especially in animal models, but also among healthy subjects [18-23]. As an attending physician, I have under my care at the dialysis unit of Santa Casa de Sobral Hospital ESRD patients who form an ideal sample for

greater implications due to central role of QOL among HD patients [8-13].

and the clinical therapy of dyspeptic symptoms typically fails.

specificity for diagnosis of FD [5].

94 Updates in Hemodialysis

**Symptom Definition**

(HD) for many reasons:

gastrointestinal tract.

mainly dyspeptic symptoms [6].

Dyspeptic symptoms can be easily assessed by interview. This can be done by applying the Functional Dyspepsia Module [24], one of several diagnostic questionnaires based on the Rome III Consensus [25]. The Functional Dyspepsia Module allows quantitative analysis of dyspeptic symptoms. It contains 18 items. Responses are given according to 4-item and 6-item Likert scales. If a symptom is absent, the respondent skips the questions, so opening the possibility of completing the test without answering all the 18 items. Diagnostic criteria include: one of the symptoms (bothersome postprandial fullness or early satiation or epigastric pain or epigastric burning) with a minimum intensity as assessed by the Likert scale plus a normal endoscopy and a "yes" answer to the "yes-no-questions" about the persistence of a symptom for the past three months, with symptoms' onset at least six months ago.

The Functional Dyspepsia Module is an important and validated diagnostic tool of FD. However, a validated instrument is lacking to specifically detect changes of dyspeptic symptoms over time. This gap could be filled by a kind of patient-reported outcomes questionnaire in line with the Rome III consensus aiming to evaluate the evolution of symptoms. Such a questionnaire would encourage clinicians to routinely check the effects of therapies, and would allow increased studies on treatment of FD. In this sense, it is important to mention a recent pilot study designed to develop a questionnaire to evalu‐ ate the outcomes of PDS [26].
