Korean J Blood Transfus.  2008 Dec;19(3):255-260.

Plasma Exchange in a Patient with a High Serum Methotrexate Level after High Dose-MTX Chemotherapy

• Ko SY
• Hwang K
• Min Y
• Sohn BS
• Suh C
• Kwon SW

Abstract

High-dose methotrexate (MTX) is frequently used for the treatment for various malignancies. The primary route of MTX excretion is through the kidneys, and so it may cause toxicities in patients with renal insufficiency. Prolonged high levels of serum MTX can result in renal dysfunction, pancytopenia and mucositis, but the strategies used for MTX removal have not been universally accepted. We report here on a case of a 55-year-old man with NK cell lymphoma and who was treated with high-dose MTX. He had been receiving hemodialysis due to acute renal failure that was induced by previous chemotherapy. After 24, 48, and 72 hours of MTX infusion, the serum MTX levels were markedly increased to 146.07micromol/L, 111.30micromol/L and 94.37micromol/L, respectively, and so leucovorin rescue was intensified. Therapeutic plasma exchange (TPE) was started on post-MTX day 4, which was after the day of the peak MTX concentration, and this was continued on days 5 and 7 to rapidly reduce the MTX level. The serum MTX level decreased to the normal range without any rebound phenomenon after 2 weeks. However, MTX-induced pancytopenia occurred and the patient then died of septic shock. It is suggested that if the MTX level is very high in spite of conventional treatments, then immediate TPE should be started to avoid MTX toxicities.

Keyword

Methotrexate; Toxicity; Plasma exchange

MeSH Terms

Acute Kidney Injury
Humans
Kidney
Killer Cells, Natural
Leucovorin
Lymphoma
Methotrexate
Middle Aged
Mucositis
Pancytopenia
Plasma
Plasma Exchange
Reference Values
Renal Dialysis
Renal Insufficiency
Shock, Septic
Leucovorin
Methotrexate