Dias Maria Rita, Nicolau Carla, Ferreira Hugo, Chacim Sérgio, Oliveira Isabel, de Câmara Negalha Gonçalo, Mariz José Mário, Costa José Maximino
Department of Nephrology, Hospital Garcia de Orta, Unidade Local de Saúde de Almada-Seixal, Almada, Portugal.
Department of Nephrology, Hospital Curry Cabral, Unidade Local de Saúde de São José, Lisboa, Portugal.
Front Nephrol. 2025 Aug 25;5:1644079. doi: 10.3389/fneph.2025.1644079. eCollection 2025.
High-dose methotrexate (HDMTX) is central to treating primary central nervous system lymphoma but carries a risk of acute kidney injury (AKI), which can delay methotrexate (MTX) clearance and increase toxicity. Glucarpidase is the treatment of choice for MTX toxicity, but limited access in many countries may necessitate alternatives. We present the first reported adult case of combined high-flux hemodialysis (HFHD) and HA230 hemoadsorption for MTX clearance.
A 66-year-old woman with newly diagnosed primary central nervous system lymphoma began induction chemotherapy including HDMTX. Forty-eight hours post-infusion, she developed KDIGO stage 3 AKI, with plasma MTX levels of 26.278 µmol/L despite maintained urine output and early supportive measures. On Day 3, MTX levels remained elevated at 15.567 µmol/L, accompanied by severe metabolic alkalosis. She was admitted to intensive care, where she underwent HFHD combined with post-filter HA230 hemoadsorption, followed by intravenous glucarpidase as soon as it became available. A second extracorporeal session occurred 48 hours later. MTX levels decreased by 91.93% (estimated elimination half-life ≈ 0.83 hours) and 71.02% (half-life ≈ 2.12 hours) after the first and second sessions, respectively. No significant rebound in MTX levels or dialysis-related complications occurred. The patient recovered renal function and completed further treatment without MTX.
This case demonstrates the effectiveness of combined HFHD and HA230 hemoadsorption as a bridging or alternative strategy when glucarpidase is delayed or unavailable. While evidence remains limited, it supports further investigation into extracorporeal MTX removal and contributes to the evolving field of Onconephrology.
高剂量甲氨蝶呤（HDMTX）是治疗原发性中枢神经系统淋巴瘤的核心药物，但存在急性肾损伤（AKI）风险，这可能会延迟甲氨蝶呤（MTX）清除并增加毒性。羧肽酶G2是MTX毒性的首选治疗药物，但在许多国家难以获得，可能需要其他替代方法。我们报告了首例成人联合高通量血液透析（HFHD）和HA230血液吸附以清除MTX的病例。
一名66岁新诊断为原发性中枢神经系统淋巴瘤的女性开始接受包括HDMTX的诱导化疗。输注后48小时，她出现了KDIGO 3期AKI，尽管尿量维持正常且采取了早期支持措施，但血浆MTX水平仍为26.278µmol/L。第3天，MTX水平仍高达15.567µmol/L，并伴有严重代谢性碱中毒。她被收入重症监护病房，在那里接受了HFHD联合滤器后HA230血液吸附治疗，随后在有羧肽酶G2时立即静脉注射。48小时后进行了第二次体外治疗。第一次和第二次治疗后，MTX水平分别下降了91.93%（估计消除半衰期≈0.83小时）和71.02%（半衰期≈2.12小时）。MTX水平无明显反弹，也未出现透析相关并发症。患者肾功能恢复，无需MTX完成了进一步治疗。
该病例证明了在羧肽酶G2延迟或无法获得时，联合HFHD和HA230血液吸附作为一种过渡或替代策略的有效性。虽然证据仍然有限，但它支持对体外清除MTX进行进一步研究，并为肿瘤肾脏病学这一不断发展的领域做出了贡献。
