Low-Dose Methotrexate Toxicity in a Hemodialysis Patient: A Case Report

Abstract

Methotrexate (MTX) is an effective drug used to treat various diseases, especially rheumatological diseases. However, myelosuppression is a severe side effect, the frequency of which increases in patients with renal insufficiency. Here, we presented a chronic hemodialysis patient who developed pancytopenia and mucositis after using low-dose MTX to treat psoriasis.

Keywords

• Methotrexate Toxicity
• Hemodialysis
• psoriasis

References

1. Haustein UF, Rytter M. Methotrexate in psoriasis: 26 years’ experience with low-dose long-term treatment. J Eur Acad Dermatol Venereol. 2000 Sep;14(5):382-8. doi: 10.1046/j.1468- 3083.2000.00058.x.
2. Howard SC, McCormick J, Pui CH, Buddington RK, Harvey RD. Preventing and managing toxicities of high-dose methotrexate. Oncologist. 2016 Dec;21(12):1471-82. doi: 10.1634/ theoncologist.2015-0164.
3. Lim AY, Gaffney K, Scott DG. Methotrexate-induced pancytopenia: serious and under-reported? Our experience of 25 cases in 5 years. Rheumatology (Oxford). 2005 Aug;44(8):1051-5. doi: 10.1093/rheumatology/keh685.
4. Gutierrez-Ureña S, Molina JF, García CO, Cuéllar ML, Espinoza LR. Pancytopenia secondary to methotrexate therapy in rheumatoid arthritis. Arthritis Rheum. 1996 Feb;39(2):272-6. doi: 10.1002/art.1780390214.
5. Rheumatoid arthritis Clinical Trial Archive Group: The effect of age and renal function on the effi cacy and toxicity of methotrexate in rheumatoid arthritis. J Rheumatol. 1995 Feb;22(2):218-23.
6. Yiğit IP, Ulu R, Yıldız Y, Doğukan A, Çeliker H. Severe pancytopenia ınduced by low-dose methotrexate in a hemodialysis patient. Turkish Nephrology Dialysis and Transplantation Journal. 2010;19(2):147-9 (in Turkish).
7. Yang CP, Kuo MC, Guh JY, Chen HC. Pancytopenia after low dose methotrexate therapy in a hemodialysis patient: case report and review of literature. Ren Fail. 2006;28(1):95-7. doi: 10.1080/08860220500461328.
8. Akdag I, Ersoy A. Development of pancytopenia after single low-dose methotrexate therapy in patients with chronic kidney disease: a review of the literature. Turk J Int Med. 2020;2(3):83- 90. doi: 10.46310/tjim.766086.

9. Sun CY, Lin HC, Chen YC, Tsai CR, Wu MS. Leukemoid reaction after methotrexate-induced pancytopenia in a patient undergoing continuous ambulatory peritoneal dialysis. Chang Gung Med J. Sep-Oct 2006;29(5):513-7.
10. Ellman MH, Ginsberg D. Low dose methotrexate and severe neutropenia in patients undergoing renal dialysis. Arthritis Rheum. 1990 Jul;33(7):1060-1. doi: 10.1002/art.1780330724.
11. Mori S, Hidaka M, Kawakita T, Hidaka T, Tsuda H, Yoshitama T, Migita K, Ueki Y. Factors associated with myelosuppression related to low-dose methotrexate therapy for inflammatory rheumatic diseases. PLoS One. 2016 Apr 29;11(4):e0154744. doi: 10.1371/journal.pone.0154744.
12. Boey O, Van Hooland S, Woestenburg A, Van der Niepen P, Verbeelen D. Methotrexate should not be used for patients with end-stage kidney disease. Acta Clin Belg. 2006 Jul- Aug;61(4):166-9. doi: 10.1179/acb.2006.028.
13. Diskin CJ, Stokes TJ, Dansby LM, Radcliff L, Carter TB. Removal of methotrexate by peritoneal dialysis and hemodialysis in a single patient with end-stage renal disease. Am J Med Sci. 2006 Sep;332(3):156-8. doi: 10.1097/00000441-200609000- 00013.
14. Aristizabal-Alzate A, Nieto-Rios JF, Ocampo-Kohn C, Serna- Higuita LM, Bello-Marquez DC, Zuluaga-Valencia GA. Successful multiple-exchange peritoneal dialysis in a patient with severe hematological toxicity by methotrexate: case report and literature review. J Bras Nefrol. 2019 Jul-Sep;41(3):427-32. doi: 10.1590/2175-8239-JBN-2018-0095.
15. Wall SM, Johansen MJ, Molony DA, DuBose TD Jr, Jaffe N, Madden T. Effective clearance of methotrexate using high-flux hemodialysis membranes. Am J Kidney Dis. 1996 Dec;28(6):846- 54. doi: 10.1016/s0272-6386(96)90384-4.
16. Green JM. Glucarpidase to combat toxic levels of methotrexate in patients. Ther Clin Risk Manag. 2012;8:403-13. doi: 10.2147/ TCRM.S30135.