Palliative care for patients with advanced chronic kidney disease

Over the past three decades there has been a dramatic rise in the number of patients with advanced chronic kidney disease. The fastest expanding group receiving dialysis has been the elderly. However, for those patients who are very elderly with co-morbidity, dialysis may not offer a survival advantage. Therefore, active conservative management is a growing service offered by many renal units in the UK and focuses on non-dialytic correction of fluid and electrolyes, management of renal anaemia, and assessment and management of symptoms.

Methadone replacement therapy: tried, tested, effective?

Methadone prescription is a controversial topic. While many believe that it is an effective treatment for opiate dependency, others argue that it is not successful in reducing either the addiction or even injecting behaviour. In this debate, Dr Robertson makes the case that methadone has been well tested, is cheap and acceptable to the patient and results in visible improvement. Dr Daniels argues that methadone treatment is philosophically ill-conceived, ethically dubious, and costly.

Chronic opioid use: a risk factor for central sleep apnoea and successful therapy with adaptive pressure support servo-ventilation

Sleep apnoea is a global health problem with significant morbidity. Obesity is a well-known risk factor for this condition, however chronic intake of opioids as a risk factor for central sleep apnoea is under-recognised. We report a case of a 47-year-old man who developed significant sleep-disordered breathing secondary to opioid use for chronic pain. A sleep study  demonstrated a picture of complex sleep apnoea with a prominent central sleep apnoea component. He had no significant improvement with conventional continuous positive airway pressure therapy.