Effects of hemoperfusion plus high-flux hemodialysis in a patient with methotrexate toxicity

Acute methotrexate toxicity resulting from methotrexate-induced renal failue is a medical emergency requiring extracorporeal removal of methotrexate. The optimum method of methotrexate removal has not yet been established. We report a case of osteosarcoma with lung metastasis that was treated with high-dose methotrexate as adjuvant chemotherapy. Although no problems occurred after the first 5 courses of methotrexate, methotrexate-induced renal failure and methotrexate toxicity appeared after the sixth course. The patient was treated, either with hemoperfusion plus high-flux hemodialysis, or hemoperfusion alone, and pre- and post-treatment serum methotrexate concentrations were monitored. The reduction in methotrexate by hemoperfusion alone for 2 hours was 54%, compared to a mean reduction of 59% by hemoperfusion combined with high-flux hemodialysis, for 3 hours. Rebound increases in methotrexate levels were small (less than 1 μmol/L) with either method. The combination of hemoperfusion and hemodialysis resulted in good control of volume status, as well as improvement in serum chemistry values.