g. allergies, scabies). Skin moisteners advised. If patient presents with both UP and RLS commence Gabapentin. Main side-effects of Gabapentin are blurred vision and drowsiness. Gabapentin[23, 24] – doses as above. Dopamine agonists – e.g. Ropinirole 0.5 mg nocte.[25, 26] Take careful history to establish whether find more the patient fulfils the international diagnostic criteria (see above). If patient presents with both RLS and UP commence Gabapentin. Metoclopramide 5–10 mg tds before meals. Haloperidol 0.5 bd. Cyclizine 25 mg tds. Often multifactorial

in origin. Metoclopramide acts as both a central anti-emetic and a peripheral pro-kinetic. The latter action is useful with uraemic EPZ6438 or diabetic gastroparesis. Check causative medications. Add fibre to diet

Principal first step is to exclude reversible causes (see accompanying comments). Management Hydromorphone – commence 05 mg qid then increase if tolerated. Benzodiazepine – e.g. Lorazepam 0.5 mg bd sublingually and 0.5–1 mg prn if a severe episode of dyspnoea. Often multifactorial. May include Cardiac disease, Respiratory disease, fluid overload and anaemia. Treat reversible precipitants. Review by Renal Dietician. Supplementary drinks. Treat the reversible cause(s). Reassurance to the patient and family of the ubiquity of this symptom in patients with ESKD. Counselling. Psychologist/Psychiatry review. For panic attacks consider Benzodiazepines – e.g. Lorazepam 0.5 mg–1 mg mafosfamide sublingually stat. The SSRIs that are safe to use without the need for dose adjustment are Citalopram, Fluoxetine, Sertraline. Also consider TCAs ‘in treatment – resistant depression’.[27] May

be difficult to diagnose – the constitutional symptoms of ESKD are identical to several of the diagnostic criteria for Major Depression. When in doubt seek a Psychiatry review. Careful history taking to find a cause. Treat the cause. Temazepam 10 mg 20 mg – nocte. Multifactorial. If suspect sleep apnoea – Formal Sleep Study. For symptom management of the dying patient, see section by Dr Urban, Models of Care – End of Life Pathways. Frank Brennan The palliative approach to patients with end-stage kidney disease (ESKD) includes all aspects of the physical, emotional and spiritual dimensions of the illness and care of the family. Health professionals dealing with patients with ESKD need to acquire skills in these areas. Continuing collaboration between renal medicine and palliative medicine is essential. The cultural and religious beliefs of patients may inform or determine their view on medical decision-making including in relation to the withholding or withdrawing of dialysis and the care of the dying.