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Methotrexate Toxicity Treated With Continuous vs. Intermittent Dialysis and Glucarpidase in Methotrexate Induced AKI: A Case Report
NKF 2016 Spring Clinical Meetings Abstracts
Case Report 169
171
“THERE ARE SOME FRACTURES…IN THE STENTS!” POSITIVE CROSS-MATCHin IS NOT A BARRIER FOR Primary Pregnancy a Patient With Membranous Nephropathy Navneet Kaur, Sandeep Aggarwal, Hasan Arif, Ellie Kelepouris. Drexel UniverSUCCESSFUL COMBINED LIVER-KIDNEY sity College of Medicine,A Department Medicine, Division of Nephroland Vinai Circulating Anti-PLA Caseof Internal Report TRANSPLANTATION: Katragadda, Kalathil K 2R Antibodies: ogy, Philadelphia, PA. Sureshkumar, Allegheny General Hospital, Pittsburgh, PA, An1AVF is an ideal vascular model for hemodialysis with 1 some important USA Laith Al-Rabadi, MBBS,1,* Rivka Ayalon, MD, Ramon G.aneurysms Bonegio, MD, PhD,stenosis, complications including or pseudoaneurysms, thrombosis, 3 4 Combined liver kidneyE. transplant (LKT) is2,y theAlan preferred infection, steal M. syndrome, and ischemic neuropathy. We present a case of an Jennifer Ballard, MD, M. Fujii, MD, Joel Henderson, MD, PhD, treatment for end stage liver disease patients with 1 AVF stenosis requiring stent placements, 1complicated by stent fractures and David J. Salant, H. Beck Jr, MD, PhD AVF loss. advanced irreversible chronic kidney disease.MD, Liver and Laurence This is a 61 year old Asian male with a PMH of ESRD on hemodialysis and allograft from the same donor may protect the renal HBV infection presenting with a non-functional radiocephalic AVF. He had a allograft against humoral injury in positive cross-match similar episode 7 months ago treated at an outpatient vascular access center There is little information about pregnancy outcomes in patients with active membranous nephropathy (MN), recipients who undergo LKT. with a thromboaspiration, and two stent placements after noted to have an receptor (PLA especially those with circulating autoantibodies phospholipase A2PTA 2R), the major A 51-year-old White male with Child class C cirrhosis to M-type80% stenosis at the juxta-anastomotic segment; he refused surgical revision. autoantigen in primary MN. Weforpresent what we believe to be the first known case of successful pregnancy in from NASH and dialysis dependence 6 months Imaging now showed the prior two stents with fractures and crossed at the year prior pregnancy, a 39-year-old woman with PLA underwent deceased donor orthotopic liver transplant MN. In thelevel 2R-associated of the elbowtojoint (Image 1). the patient developed hypoalbuminemia (albumin, g/dL), and proteinuria (protein excretion, g/d). Kidney bi- prolonged followedanasarca, 6 hours later by kidney transplant from1.3-2.2 the same Clinically, a stenosis is suspected with29.2 reduced quality of dialysis, after AVF puncture, or increased pressures and diagnosed donor. Patient had pre-transplant calculated PRA ofand 99%the patientbleeding was seropositive for anti-PLA autoantibodies. opsy revealed MN with staining for PLA 2R, 2Rvenous with angiography when vessel lumen (2 reduced more Treatment mowith positive T and cell cross match against the donor. She did not Brespond to conservative therapy and was treated with intravenous rituximab doses of than 1 g 50%. each). dalities for AVF stenosis are surgical revision, PTA, or stent implantation; PTA donor specific antibodies (DSA) were Pre-transplant Several weeks after presentation, she was found to be 6 weeks pregnant and was closely followed up without and stents being less invasive. If angioplasty fails to restore flow, stent placepositive further for B51immunosuppressive (6700MFI) and DQ7treatment. (10000MFI). There remained with protein excretion in the 8- to 12-g/d range. Proteinuria ment is considered. Generally, an uncovered metal stent can be used in an were 3 HLA mismatches. He did not receive induction Ata38 weeks, healthy baby girlin was born, Circulating anti-PLA AVF while covered stent amay be a better option an AVG. A covered stent 2R levels declined but were still detectable. therapy and wasproteinuria maintained tacrolimus and is a metal stentAtembedded expandedthepolytetrafluoroethylene graft without at on birth or at her subsequent 6-month postnatal visit. the time inof an delivery, mother still mycophenolic acid. Repeat T and anti-PLA B cell cross matches 3 material. had detectable circulating 2R of immunoglobulin G1 (IgG1), IgG3, and IgG4 subclasses, although at In our patient, an appropriate attempt was made to salvage the access with days later were negative and DSA decreased to 2700MFI found in cord blood. Potential reasons for the low titers. Only trace amounts of IgG4 anti-PLA2R werePTA and nitinol self-expandable stents after he refused surgical revision. Unfor B51 and 1400MFI for DQ7. Renal allograft biopsy fetal circulation are discussed. discrepancy between anti-PLA2R levels in the maternal and fortunately, stent location across the antecubetal fossa and repeated puncture performed 2 weeks later for delayed graft function showed Am Jinjury Kidney Dis. 67(5):775-778. ª 2016 byrenal the National Kidney Foundation, Inc. for hemodialysis likely contributed to the eventual stent fractures and loss of only tubular without rejection. Subsequently, the AVF. Although, it was likely unavoidable, there is potential to prevent this
allograft function improved and serum creatinine was 1.3 with patient and technician education. INDEX WORDS: syndrome; pregnancy; M-type phospholipase A2 mg/dl 3 months after LKT.Membranous nephropathy (MN); nephroticImage 1: There is an in-stent stenosis and a stent fracture noted. receptor (PLA R); autoantibody; placenta; rituximab; immunoglobulin G (Ig G) subclass. 2 Absorption of lymphocytotoxic antibodies and complement factors by nonparenchymal donor hepatic cells appears to be responsible for protecting the renal allograft from humoral injury.
P
regnant patients with autoimmune disease may deliver newborns with a spectrum of clinical manifestations due to the transplacental passage of 170 circulating autoantibodies. Pregnant patients with HIVAN AND PCP MASQUERADING AS A PULMONARY RENAL lupus or myasthenia gravis can deliver babies with SYNDROME. Navneet Kaur, Ellie Kelepouris, Suganthi Soundarajan, Alden Doyle. Drexel University Medicine,1,2 Department of corresponding disease inCollege the ofneonate. Neonatal Internal Medicine, Division of Nephrology, Philadelphia, PA. membranous nephropathy (MN) not associated with A 25 year-old African American man without significant PMH and congenital infection wasandfirst in was 1990 and reported normal hemoglobin serumdescribed creatinine levels transferred to fromthe a community on a weekend with kidneyantiattributed passivehospital transfer of maternal injury, nasal congestion, pulmonary infiltrates, and fever. He received 3 3 bodies to putative than a decade hemodialysis sessionsrenal prior toantigens. transfer whenMore noted with serum 4 creatinine of 9et andalpotassium of 6.7.the He denied any travel,involved smoking, later, Debiec identified first antigen or drug use history other than marijuana use. On exam, he had in aalcohol such cases as neutral endopeptidase (NEP), high fever and 3+ lower extremity edema. Urinalysis there reported aas metalloprotease present the surface ofRBCs, the podocyte 3+ blood and 4+ protein. Ouron microscopy revealed WBCs, rare casts but clear cellular casts. regulation CXR revealed of bilateral andgranular involved innothe proteolytic vasoacpulmonary infiltrates though with comfortable breathing and normal tiveoxygen peptides. Debiec et al described a mother saturation on room air. He had a hemoglobin of 7 withwith smear a showing rare schistocytes. Complements were normal. mutation preventing NEP expression who had formed Based on rapidly rising creatinine and urinalysis with significant anti-NEP antibodies due to fetomaternal alloimmuprotein and blood, a presumptive diagnosis of RPGN was made with nization fromofaa previous miscarriage; antibodies consideration pulmonary renal syndrome. Hethese received plasma exchange and pulse steroids in addition to empiric were to cross the placenta and causeantibiotics. subepithelial The following day, bronchoscopy failed to identify pulmonary deposits in and thean fetal of a subsequent preghemorrhage HIV testkidney returned positive; BAL pathology showed evidence of PCP. Aphospholipase renal ultrasound showed echogenic nancy. M-type A2 enlarged, receptor (PLA2R) kidneys. Renal biopsy showed collapsing FSGS consistent with wasHIVAN. later identified as the major autoantigen for pri5 maryRPGN MNis ain adults. Little literature exists medical emergency requiring rapid diagnosis and about treatment. The urgency mandates treatmentwith course nephrotic adjustment as synnew pregnancy outcomes in patients information becomes available. We made the presumptive diagnosis of drome due to primary MN, with no data available RPGN with a potential pulmonary renal syndrome based on available information only to discover later2R-associated that our patient wasdisease. a new about pregnancy in PLA We presentation of HIV associated with both HIVAN and an atypical PCP present what we believe to be the first known case of pneumonia. pregnancy in a patient with PLA2R-associated MN who was seropositive for anti-PLA2R autoantibodies throughout the course of her pregnancy. Am J Kidney Dis. 2016;67(5):A1-A118
CASE REPORT
A 39-year-old multiparous woman with morbid obesity presented for workup of severe nephrotic syndrome several months 172
before her current pregnancy. She had been treated for resistant METHOTREXATE TOXICITY TREATED WITH CONTINUOUS hypertension and lower-extremity during theINpast year, VS INTERMITTENT DIALYSIS ANDedema GLUCARPIDASE butMETHOTREXATE her proteinuria had been overlooked. presentation, serum Christopher INDUCED AKI: A CASEAt REPORT, Kern, Robert Fleyshman, Suzanne Boyle, Hahnemann University Hoscreatinine level was 1.52 mg/dL (corresponding to estimated pital, Philadelphia, USA glomerular filtrationPA, rate of 46 mL/min/1.73 m2 as calculated by dose methotrexate (HDMTX) therapy can cause a crystal the High isotope-dilution mass spectrometry –traceable 4-variable nephropathy. MTX is excreted unchanged in the urine. In acute kidney MDRD [Modification of Dietcausing in Renal Disease] Study equainjury (AKI), MTX accumulates, extra-renal toxicity, including tion); serum albuminsuppression. level, 1.5We g/dL; anda case 24-hour urine protein severe bone marrow present of MTX-induced excretion, 29.2 multiple g. The modalities kidney biopsy specimen revealed AKI, in which were employed to reduce the features MTX concentration, including continuous venovenous hemodialtypical of primary MNleucovorin, with additional strong staining for the ysisR(CVVHD), hemodialysis (iHD), andS1). glucarpidase. PLA antigen intermittent within immune deposits (Fig Many of the 2 A 55-year-old black male with history of acute lymphocytic leukemia subepithelial deposits were completely surrounded by new was admitted for cycle 4 of HDMTX therapy. Prior cycles were unbasement membrane (Fig(cr)S2), andmg/dL. 35%Within of 3the complicated. At initiation,material his creatinine was 0.77 days, 4.16 mg/dL. At day 2, serum MTX level was 56 umol/L. At day 4, 17.9 umol/L. By day 4, cr was 4.78 mg/dL, despite administering leucovorin and attempting urinary alkalinization. He was oliguric with From the 1Department of Medicine, Renal Section, and Designs of volume as well as con2 overload. Given these clinical features, 3 4 partments of Obstetrics and Pediatrics, andinitiPacern for extra-renal toxicity fromGynecology, high MTX levels, CVVHD was thology and Laboratory Medicine, Boston University Medical ated on day 5, but suspended on day 6 to administer glucarpidase (50 units/kg). MTX MA. level decreased from 6.6 to 2.8 umol/L, but within 24 Center, Boston, *hours, rebounded to 5.2 umol/L. CVVHD was resumed for several Current affiliation: Department of Internal Medicine, Division but dialysis-catheter causedof frequent interruptions. of days, Nephrology, Universitymalfunctions of Utah School Medicine, Salt Lake On day 11, he started iHD, with 8 sessions over 12 days, and MTX City, UT. level went from 1.31 to 0.19 umol/L with frequent oscillations. y Current Department of Obstetrics andinGynecology, This caseaffiliation: highlights challenges in lowering MTX levels AKI. GluMedstar Washington Center, DC. metabocarpidase is a bacterialHospital enzyme that cleavesWashington, MTX into inactive lites, whichJune can then hepatically metabolized. While effective, its 27, Received 29,be 2015. Accepted in revised form October cost Originally and availability limit its use. Here, while a standard dose of glu2015. published online December 29, 2015. carpidase reduced the MTX level, it failed to sustain it. This is likely Address correspondence to Laurence H. Beck Jr, MD, PhD, due to MTX’s large volume of distribution and rebound from intracelRenal 650 Albany St,symptomatic Boston, MA 02118. for E-mail: lularSection, reservoirs.X-504, Thus, for patients with indications [email protected] dialysis, it might be prudent to forgo the cost of glucarpidase and continue withby dialysis for alleviation of symptoms as wellInc. as to reduce � 2016 the National Kidney Foundation, MTX levels. 0272-6386
http://dx.doi.org/10.1053/j.ajkd.2015.10.031 775 A61
Case Report 169
171
“THERE ARE SOME FRACTURES…IN THE STENTS!” POSITIVE CROSS-MATCHin IS NOT A BARRIER FOR Primary Pregnancy a Patient With Membranous Nephropathy Navneet Kaur, Sandeep Aggarwal, Hasan Arif, Ellie Kelepouris. Drexel UniverSUCCESSFUL COMBINED LIVER-KIDNEY sity College of Medicine,A Department Medicine, Division of Nephroland Vinai Circulating Anti-PLA Caseof Internal Report TRANSPLANTATION: Katragadda, Kalathil K 2R Antibodies: ogy, Philadelphia, PA. Sureshkumar, Allegheny General Hospital, Pittsburgh, PA, An1AVF is an ideal vascular model for hemodialysis with 1 some important USA Laith Al-Rabadi, MBBS,1,* Rivka Ayalon, MD, Ramon G.aneurysms Bonegio, MD, PhD,stenosis, complications including or pseudoaneurysms, thrombosis, 3 4 Combined liver kidneyE. transplant (LKT) is2,y theAlan preferred infection, steal M. syndrome, and ischemic neuropathy. We present a case of an Jennifer Ballard, MD, M. Fujii, MD, Joel Henderson, MD, PhD, treatment for end stage liver disease patients with 1 AVF stenosis requiring stent placements, 1complicated by stent fractures and David J. Salant, H. Beck Jr, MD, PhD AVF loss. advanced irreversible chronic kidney disease.MD, Liver and Laurence This is a 61 year old Asian male with a PMH of ESRD on hemodialysis and allograft from the same donor may protect the renal HBV infection presenting with a non-functional radiocephalic AVF. He had a allograft against humoral injury in positive cross-match similar episode 7 months ago treated at an outpatient vascular access center There is little information about pregnancy outcomes in patients with active membranous nephropathy (MN), recipients who undergo LKT. with a thromboaspiration, and two stent placements after noted to have an receptor (PLA especially those with circulating autoantibodies phospholipase A2PTA 2R), the major A 51-year-old White male with Child class C cirrhosis to M-type80% stenosis at the juxta-anastomotic segment; he refused surgical revision. autoantigen in primary MN. Weforpresent what we believe to be the first known case of successful pregnancy in from NASH and dialysis dependence 6 months Imaging now showed the prior two stents with fractures and crossed at the year prior pregnancy, a 39-year-old woman with PLA underwent deceased donor orthotopic liver transplant MN. In thelevel 2R-associated of the elbowtojoint (Image 1). the patient developed hypoalbuminemia (albumin, g/dL), and proteinuria (protein excretion, g/d). Kidney bi- prolonged followedanasarca, 6 hours later by kidney transplant from1.3-2.2 the same Clinically, a stenosis is suspected with29.2 reduced quality of dialysis, after AVF puncture, or increased pressures and diagnosed donor. Patient had pre-transplant calculated PRA ofand 99%the patientbleeding was seropositive for anti-PLA autoantibodies. opsy revealed MN with staining for PLA 2R, 2Rvenous with angiography when vessel lumen (2 reduced more Treatment mowith positive T and cell cross match against the donor. She did not Brespond to conservative therapy and was treated with intravenous rituximab doses of than 1 g 50%. each). dalities for AVF stenosis are surgical revision, PTA, or stent implantation; PTA donor specific antibodies (DSA) were Pre-transplant Several weeks after presentation, she was found to be 6 weeks pregnant and was closely followed up without and stents being less invasive. If angioplasty fails to restore flow, stent placepositive further for B51immunosuppressive (6700MFI) and DQ7treatment. (10000MFI). There remained with protein excretion in the 8- to 12-g/d range. Proteinuria ment is considered. Generally, an uncovered metal stent can be used in an were 3 HLA mismatches. He did not receive induction Ata38 weeks, healthy baby girlin was born, Circulating anti-PLA AVF while covered stent amay be a better option an AVG. A covered stent 2R levels declined but were still detectable. therapy and wasproteinuria maintained tacrolimus and is a metal stentAtembedded expandedthepolytetrafluoroethylene graft without at on birth or at her subsequent 6-month postnatal visit. the time inof an delivery, mother still mycophenolic acid. Repeat T and anti-PLA B cell cross matches 3 material. had detectable circulating 2R of immunoglobulin G1 (IgG1), IgG3, and IgG4 subclasses, although at In our patient, an appropriate attempt was made to salvage the access with days later were negative and DSA decreased to 2700MFI found in cord blood. Potential reasons for the low titers. Only trace amounts of IgG4 anti-PLA2R werePTA and nitinol self-expandable stents after he refused surgical revision. Unfor B51 and 1400MFI for DQ7. Renal allograft biopsy fetal circulation are discussed. discrepancy between anti-PLA2R levels in the maternal and fortunately, stent location across the antecubetal fossa and repeated puncture performed 2 weeks later for delayed graft function showed Am Jinjury Kidney Dis. 67(5):775-778. ª 2016 byrenal the National Kidney Foundation, Inc. for hemodialysis likely contributed to the eventual stent fractures and loss of only tubular without rejection. Subsequently, the AVF. Although, it was likely unavoidable, there is potential to prevent this
allograft function improved and serum creatinine was 1.3 with patient and technician education. INDEX WORDS: syndrome; pregnancy; M-type phospholipase A2 mg/dl 3 months after LKT.Membranous nephropathy (MN); nephroticImage 1: There is an in-stent stenosis and a stent fracture noted. receptor (PLA R); autoantibody; placenta; rituximab; immunoglobulin G (Ig G) subclass. 2 Absorption of lymphocytotoxic antibodies and complement factors by nonparenchymal donor hepatic cells appears to be responsible for protecting the renal allograft from humoral injury.
P
regnant patients with autoimmune disease may deliver newborns with a spectrum of clinical manifestations due to the transplacental passage of 170 circulating autoantibodies. Pregnant patients with HIVAN AND PCP MASQUERADING AS A PULMONARY RENAL lupus or myasthenia gravis can deliver babies with SYNDROME. Navneet Kaur, Ellie Kelepouris, Suganthi Soundarajan, Alden Doyle. Drexel University Medicine,1,2 Department of corresponding disease inCollege the ofneonate. Neonatal Internal Medicine, Division of Nephrology, Philadelphia, PA. membranous nephropathy (MN) not associated with A 25 year-old African American man without significant PMH and congenital infection wasandfirst in was 1990 and reported normal hemoglobin serumdescribed creatinine levels transferred to fromthe a community on a weekend with kidneyantiattributed passivehospital transfer of maternal injury, nasal congestion, pulmonary infiltrates, and fever. He received 3 3 bodies to putative than a decade hemodialysis sessionsrenal prior toantigens. transfer whenMore noted with serum 4 creatinine of 9et andalpotassium of 6.7.the He denied any travel,involved smoking, later, Debiec identified first antigen or drug use history other than marijuana use. On exam, he had in aalcohol such cases as neutral endopeptidase (NEP), high fever and 3+ lower extremity edema. Urinalysis there reported aas metalloprotease present the surface ofRBCs, the podocyte 3+ blood and 4+ protein. Ouron microscopy revealed WBCs, rare casts but clear cellular casts. regulation CXR revealed of bilateral andgranular involved innothe proteolytic vasoacpulmonary infiltrates though with comfortable breathing and normal tiveoxygen peptides. Debiec et al described a mother saturation on room air. He had a hemoglobin of 7 withwith smear a showing rare schistocytes. Complements were normal. mutation preventing NEP expression who had formed Based on rapidly rising creatinine and urinalysis with significant anti-NEP antibodies due to fetomaternal alloimmuprotein and blood, a presumptive diagnosis of RPGN was made with nization fromofaa previous miscarriage; antibodies consideration pulmonary renal syndrome. Hethese received plasma exchange and pulse steroids in addition to empiric were to cross the placenta and causeantibiotics. subepithelial The following day, bronchoscopy failed to identify pulmonary deposits in and thean fetal of a subsequent preghemorrhage HIV testkidney returned positive; BAL pathology showed evidence of PCP. Aphospholipase renal ultrasound showed echogenic nancy. M-type A2 enlarged, receptor (PLA2R) kidneys. Renal biopsy showed collapsing FSGS consistent with wasHIVAN. later identified as the major autoantigen for pri5 maryRPGN MNis ain adults. Little literature exists medical emergency requiring rapid diagnosis and about treatment. The urgency mandates treatmentwith course nephrotic adjustment as synnew pregnancy outcomes in patients information becomes available. We made the presumptive diagnosis of drome due to primary MN, with no data available RPGN with a potential pulmonary renal syndrome based on available information only to discover later2R-associated that our patient wasdisease. a new about pregnancy in PLA We presentation of HIV associated with both HIVAN and an atypical PCP present what we believe to be the first known case of pneumonia. pregnancy in a patient with PLA2R-associated MN who was seropositive for anti-PLA2R autoantibodies throughout the course of her pregnancy. Am J Kidney Dis. 2016;67(5):A1-A118
CASE REPORT
A 39-year-old multiparous woman with morbid obesity presented for workup of severe nephrotic syndrome several months 172
before her current pregnancy. She had been treated for resistant METHOTREXATE TOXICITY TREATED WITH CONTINUOUS hypertension and lower-extremity during theINpast year, VS INTERMITTENT DIALYSIS ANDedema GLUCARPIDASE butMETHOTREXATE her proteinuria had been overlooked. presentation, serum Christopher INDUCED AKI: A CASEAt REPORT, Kern, Robert Fleyshman, Suzanne Boyle, Hahnemann University Hoscreatinine level was 1.52 mg/dL (corresponding to estimated pital, Philadelphia, USA glomerular filtrationPA, rate of 46 mL/min/1.73 m2 as calculated by dose methotrexate (HDMTX) therapy can cause a crystal the High isotope-dilution mass spectrometry –traceable 4-variable nephropathy. MTX is excreted unchanged in the urine. In acute kidney MDRD [Modification of Dietcausing in Renal Disease] Study equainjury (AKI), MTX accumulates, extra-renal toxicity, including tion); serum albuminsuppression. level, 1.5We g/dL; anda case 24-hour urine protein severe bone marrow present of MTX-induced excretion, 29.2 multiple g. The modalities kidney biopsy specimen revealed AKI, in which were employed to reduce the features MTX concentration, including continuous venovenous hemodialtypical of primary MNleucovorin, with additional strong staining for the ysisR(CVVHD), hemodialysis (iHD), andS1). glucarpidase. PLA antigen intermittent within immune deposits (Fig Many of the 2 A 55-year-old black male with history of acute lymphocytic leukemia subepithelial deposits were completely surrounded by new was admitted for cycle 4 of HDMTX therapy. Prior cycles were unbasement membrane (Fig(cr)S2), andmg/dL. 35%Within of 3the complicated. At initiation,material his creatinine was 0.77 days, 4.16 mg/dL. At day 2, serum MTX level was 56 umol/L. At day 4, 17.9 umol/L. By day 4, cr was 4.78 mg/dL, despite administering leucovorin and attempting urinary alkalinization. He was oliguric with From the 1Department of Medicine, Renal Section, and Designs of volume as well as con2 overload. Given these clinical features, 3 4 partments of Obstetrics and Pediatrics, andinitiPacern for extra-renal toxicity fromGynecology, high MTX levels, CVVHD was thology and Laboratory Medicine, Boston University Medical ated on day 5, but suspended on day 6 to administer glucarpidase (50 units/kg). MTX MA. level decreased from 6.6 to 2.8 umol/L, but within 24 Center, Boston, *hours, rebounded to 5.2 umol/L. CVVHD was resumed for several Current affiliation: Department of Internal Medicine, Division but dialysis-catheter causedof frequent interruptions. of days, Nephrology, Universitymalfunctions of Utah School Medicine, Salt Lake On day 11, he started iHD, with 8 sessions over 12 days, and MTX City, UT. level went from 1.31 to 0.19 umol/L with frequent oscillations. y Current Department of Obstetrics andinGynecology, This caseaffiliation: highlights challenges in lowering MTX levels AKI. GluMedstar Washington Center, DC. metabocarpidase is a bacterialHospital enzyme that cleavesWashington, MTX into inactive lites, whichJune can then hepatically metabolized. While effective, its 27, Received 29,be 2015. Accepted in revised form October cost Originally and availability limit its use. Here, while a standard dose of glu2015. published online December 29, 2015. carpidase reduced the MTX level, it failed to sustain it. This is likely Address correspondence to Laurence H. Beck Jr, MD, PhD, due to MTX’s large volume of distribution and rebound from intracelRenal 650 Albany St,symptomatic Boston, MA 02118. for E-mail: lularSection, reservoirs.X-504, Thus, for patients with indications [email protected] dialysis, it might be prudent to forgo the cost of glucarpidase and continue withby dialysis for alleviation of symptoms as wellInc. as to reduce � 2016 the National Kidney Foundation, MTX levels. 0272-6386
http://dx.doi.org/10.1053/j.ajkd.2015.10.031 775 A61