Rosales Alejandra, Madrid Alvaro, Muñoz Marina, Dapena Jose Luis, Ariceta Gema
Department of Pediatrics, Medical University Innsbruck, Innsbruck, Austria.
Pediatric Nephrology, University Hospital Sant Joan de Deu, University of Barcelona, Barcelona, Spain.
Front Pediatr. 2021 Aug 19;9:635152. doi: 10.3389/fped.2021.635152. eCollection 2021.
High dose methotrexate (HDMTX) is used for the treatment of pediatric hemato-oncological diseases. HDMTX can induce acute kidney injury in cases of delayed elimination. The use of leucovorin remains the most effective rescue action. Further treatment options are of difficult access in the rare cases where leucovorin fails to prevent renal failure from occurring. Glucarpidase is an effective treatment in cases of methotrexate (MTX) delayed elimination, but cost is high and availability is limited. Charcoal hemoperfusion (CHP) is a very efficient procedure to remove protein-bound drugs, promoting fast MTX elimination, but is rarely considered as a treatment option. We present three pediatric cases with prolonged exposure to MTX after HDMTX and delayed elimination in which hemoperfusion was performed as rescue treatment for methotrexate intoxication. Charcoal hemoperfusion was performed with positive results and no complications as bridging until glucarpidase was available in two cases and in one case where two doses of glucarpidase led to insufficient reduction of MTX levels. CHP can be considered as a rescue treatment option in MTX intoxication, since it is an effective and safe extracorporeal method for removing MTX, in cases where rescue with leucovorin is insufficient and glucarpidase is not available or while waiting for delivery.
大剂量甲氨蝶呤（HDMTX）用于治疗小儿血液肿瘤疾病。HDMTX在消除延迟的情况下可诱发急性肾损伤。使用亚叶酸钙仍然是最有效的解救措施。在亚叶酸钙未能预防肾衰竭发生的罕见情况下，进一步的治疗选择难以获得。羧肽酶G2在甲氨蝶呤（MTX）消除延迟的情况下是一种有效的治疗方法，但成本高且可用性有限。血液灌流（CHP）是一种非常有效的清除蛋白结合药物的方法，可促进MTX快速消除，但很少被视为一种治疗选择。我们报告了3例小儿患者，在HDMTX后MTX暴露时间延长且消除延迟，其中进行血液灌流作为甲氨蝶呤中毒的解救治疗。在2例患者中，血液灌流取得了阳性结果且无并发症，作为过渡措施直至羧肽酶G2可用；在1例患者中，两剂羧肽酶G2导致MTX水平降低不足。CHP可被视为MTX中毒的一种解救治疗选择，因为在亚叶酸钙解救不足且羧肽酶G2不可用或等待其送达时，它是一种有效且安全的体外清除MTX的方法。
