title: Use of plasma exchange in methotrexate removal in a patient with osteosarcoma and acute renal insufficiency.
abstract: Acute renal failure induced by methotrexate (MTX) can be lethal because renal excretion of the drug can be delayed. Pre-existing renal impairment, abstention, or underdosage of folinic acid and inadequate hydration facilitate toxicity. The prolonged high serum levels of MTX result in severe mucositis and pancytopenia, but strategies useful to accelerate MTX removal have not been universally accepted. We report a case of a 13-year-old girl with osteosarcoma who was treated with high-dose MTX because of thoracic tumor recurrence. No side effects were observed after 2 cycles of high-dose MTX; however, after the third cycle there was a delayed MTX elimination followed by clinical toxicity. Forty hours post-MTX infusion the serum level of MTX was 5.39 x 10(-4) mol/L. Treatment was based on symptomatic measures, such as maintenance of an abundant and alkaline diuresis and parenteral administration of folinic acid. Concomitantly, plasma exchange was employed to accelerate MTX removal and reduce its toxicity. After 24 days, she was discharged from the hospital, and her renal function recovered gradually.
authors.affiliation: Escola Paulista de Medicina, Hematology and Transfusion Medicine Service, Universidade Federal de São Paulo, Brazil. cecyn@uol.com.br
authors.forename: Karin Zattar
authors.initials: KZ
authors.lastname: Cecyn
authors.forename: Juno
authors.initials: J
authors.lastname: Lee
authors.forename: Tsutomo
authors.initials: T
authors.lastname: Oguro
authors.forename: Antônio Sérgio
authors.initials: AS
authors.lastname: Petrilli
authors.forename: José Orlando
authors.initials: JO
authors.lastname: Bordin
mesh_terms: D058186:Acute Kidney Injury / Q000139:chemically induced* / Q000517:prevention & control; D000293:Adolescent; D000964:Antimetabolites, Antineoplastic / Q000009:adverse effects / Q000493:pharmacokinetics* / Q000627:therapeutic use; D004231:Diuresis; D005260:Female; D005266:Femoral Neoplasms / Q000601:surgery; D006801:Humans; D002955:Leucovorin / Q000008:administration & dosage; D008727:Methotrexate / Q000009:adverse effects / Q000493:pharmacokinetics* / Q000627:therapeutic use; D012516:Osteosarcoma / Q000188:drug therapy* / Q000556:secondary / Q000601:surgery; D010951:Plasma Exchange; D013899:Thoracic Neoplasms / Q000556:secondary
chemical_list: D000964:Antimetabolites, Antineoplastic; D002955:Leucovorin; D008727:Methotrexate