title: Successful rescue in a patient with high dose methotrexate-induced nephrotoxicity and acute renal failure.
abstract: We describe the case of a 35-year old male who developed acute renal failure following high dose methotrexate therapy for Burkitt's non Hodgkin lymphoma. Serum methotrexate levels reached 37 micromol/l, and remained higher than 1 micromol/l for more than a week. Folinic acid rescue was intensified to 200-400 mg intravenously every 4 hours. As methotrexate binds markedly to proteins, plasma exchange was initially chosen, 4 sessions being performed from day 2 to day 4. The methotrexate pharmacokinetic profile was not significantly modified during plasma exchange, and serum drug level was 3 micromol/l. Continuous veno-venous hemodiafiltration was therefore performed from day 5 to day 10. This procedure also seemed ineffective, with evidence of low ultrafiltrate clearance. No extrarenal toxicity was observed in our patient. Thus, conventional extrarenal procedures appear to have a limited role in the setting of overexposure to methotrexate. The use of very high doses of folinic acid in our case probably played a major role in the eventual favorable outcome.
authors.affiliation: Service de Réanimation Polyvalente, Département de Médecine, Institut Gustave-Roussy, Villejuif, France.
authors.forename: L
authors.initials: L
authors.lastname: Kepka
authors.forename: A
authors.initials: A
authors.lastname: De Lassence
authors.forename: V
authors.initials: V
authors.lastname: Ribrag
authors.forename: B
authors.initials: B
authors.lastname: Gachot
authors.forename: F
authors.initials: F
authors.lastname: Blot
authors.forename: C
authors.initials: C
authors.lastname: Theodore
authors.forename: M
authors.initials: M
authors.lastname: Bonnay
authors.forename: C
authors.initials: C
authors.lastname: Korenbaum
authors.forename: G
authors.initials: G
authors.lastname: Nitenberg
mesh_terms: D058186:Acute Kidney Injury / Q000139:chemically induced / Q000378:metabolism / Q000628:therapy*; D000328:Adult; D000931:Antidotes / Q000627:therapeutic use*; D002051:Burkitt Lymphoma / Q000150:complications / Q000188:drug therapy / Q000378:metabolism; D004305:Dose-Response Relationship, Drug; D006801:Humans; D002955:Leucovorin / Q000627:therapeutic use*; D008297:Male; D008727:Methotrexate / Q000009:adverse effects* / Q000493:pharmacokinetics
chemical_list: D000931:Antidotes; D002955:Leucovorin; D008727:Methotrexate