Background Glucarpidase (Voraxaze) is effective in the treatment of methotrexate (MTX)-induced renal dysfunction but many cases this can be handled with standard treatment.
Purpose To describe the progress of a patient with MTX-induced renal failure in whose management glucarpidase was not used.
Materials and Methods A 13 year-old girl with acute lymphoblastic leukaemia treated with high-dose MTX. Baseline laboratory tests were normal, except for elevated transaminases and GGT.
Results The patient received her first consolidation cycle with 500 mg/m2 of MTX in 30 minutes, followed by 4500 mg/m2 in 23.5 hours, oral mercaptopurine 30 mg/m²/day and triple intrathecal therapy. Simultaneously, she received hyperhydration/alkalinisation (3000 ml/m²/day).There was no pharmacological interaction to MTX. 24 hours after the MTX infusion stared, the serum creatinine level (Cr) had tripled (see the table below).The following measures were taken: hyperhydration/alkalinisation (4500 ml/m²/day), colestyramine (3 g/6 h) and folinic acid rescue at 500 mg/m²/6 h 31 hours after the start of the MTX infusion. Although the protocol provides for the possibility of administering glucarpidase, it was decided not to do this because the methotrexate level was <250μM and glucarpidase administration can be delayed until 96 hours after the start of MTX infusion. Difficulty in the subsequent monitoring, the absence of effect in renal function improvement and high cost were the reasons for delaying the treatment until at least having levels at 36 and 48 hours. Although Cr values were still high, elimination kinetics of the drug were seen as adequate. Without the use of glucarpidase, methotrexate levels were undetectable at day nine. The patient recovered her baseline renal function and did not have mucositis or liver toxicity.
Conclusions An early intervention with supportive treatment based on folinic acid, hyperhydration and urine alkalinisation was effective in the management of MTX-induced renal toxicity.
No conflict of interest.
Statistics from Altmetric.com
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.