Successful multiple-exchange peritoneal dialysis in a patient with severe hematological toxicity by methotrexate: case report and literature review

Abstract

Methotrexate is an effective medication to control several diseases; however, it can be very toxic, being myelosuppression one of its main adverse effects, which increases in severity and frequency in patients with renal failure. We present the case of a 68-year-old man with chronic, end-stage renal disease associated with ANCA vasculitis, under treatment with peritoneal dialysis, who received the medication at a low dose, indicated by disease activity, which presented as a complication with severe pancytopenia with mucositis that improved with support measures and multiple-exchange peritoneal dialysis. We reviewed 20 cases published to date of pancytopenia associated with methotrexate in patients on dialysis and found high morbidity and mortality, which is why its use in this type of patient is not recommended. However, when this complication occurs, a therapeutic option could be the use of multiple-exchange peritoneal dialysis in addition to supportive therapy for drug-related toxicity, although it is recognized that studies are required to show the role of multiple-exchange peritoneal dialysis in the removal of this medication.

Peritoneal Dialysis in a Patient with Acute Kidney Injury, Thrombocytopenia, Urosepsis, and Liver Cirrhosis: A Case Report

“…In an 89-year-old woman with acute pyelonephritis, septic shock, atrial fibrillation, and worsening renal failure, HD had to be changed to PD due to type II heparin-induced thrombocytopenia [ 36 ]. PD was intensified to avoid installing an HD catheter in a patient with severe thrombocytopenia after methotrexate administration [ 37 ]. In gram-negative sepsis and AKI, DIC can contribute to a decrease in platelet count [ 38 ].…”

Dialysis and extracorporeal therapies for enhanced elimination of toxic ingestions and poisoning

“…Drug clearance depends on the volume and number of PD exchanges. The optimal prescription in the poisoning context is unclear, but case series generally report use of automated PD with hourly exchanges of various volumes [117,118]. The authors' preference in adult patients is 2 L intraperitoneal exchanges if tolerated.…”

Extracorporeal Treatment for Methotrexate Poisoning

“…About 25% of patients on long-term low-dose oral methotrexate develop some degree of toxicity that limits treatment (111-113), including myelosuppression (1%-10%) (112-120), elevated liver enzymes (10%-25%) (112,113,117, 120-123), and mucositis (5%-20%) (112,113,118). No AKI/CKD 5-15 (13,23,31-37,170,180,183,188,194,195,197,200,203,205-207, 209,210,212-216,221-224,227,230,232,235,237,245,250,268 Preexisting CKD (113,115,124,125), kidney failure (even after a single dose of 2.5 mg) (32, [126][127][128][129][130][131][132][133][134][135], or AKI during maintenance methotrexate therapy (113,(136)(137)(138) are major risk factors for developing toxicity. Other risk factors include length of exposure, weekly dosing, cumulative dose (111,115,137,139,140), and lack of folate supplementation (141).…”

“…Mortality in patients developing toxicity from oral methotrexate is 5%-30% (115)(116)(117)119,(125)(126)(127)(128)137,138,(142)(143)(144)(145). In contrast to high-dose methotrexate, therapeutic drug monitoring has little value in low-dose methotrexate toxicity (129), as no correlation exists between toxicity and methotrexate concentrations, and morbidity is reported at undetectable concentrations (68,130,137,138).…”