CASE REPORT article
Front. Nephrol.
Sec. Blood Purification
Volume 5 - 2025 | doi: 10.3389/fneph.2025.1644079
Case report: Effective methotrexate removal by combined hemodialysis and polymeric resin hemoadsorption
Provisionally accepted
Maria Rita Dias1,2*
Carla Nicolau3,4Hugo Ferreira5Sérgio Chacim5Isabel Oliveira5Gonçalo de Câmara Negalha5José Mário Mariz5José Maximino Costa5- 1Hospital Garcia de Orta EPE, Almada, Portugal
- 2Unidade Local de Saude de Almada-Seixal, Almada, Portugal
- 3Hospital Curry Cabral, Lisbon, Portugal
- 4Unidade Local de Saude Sao Jose, Lisbon, Portugal
- 5Instituto Portugues de Oncologia do Porto Francisco Gentil EPE, Porto, Portugal
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Background: 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.Case Summary: 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 dialysisrelated complications occurred. The patient recovered renal function and completed further treatment without MTX.Conclusions: 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.
Keywords: Methotrexate, High-dose methotrexate, Drug Toxicity, Acute Kidney Injury, hemodialysis, Hemoadsorption, Hemoperfusion, HA230
Received: 09 Jun 2025; Accepted: 04 Aug 2025.
Copyright: © 2025 Dias, Nicolau, Ferreira, Chacim, Oliveira, de Câmara Negalha, Mariz and Costa. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
* Correspondence: Maria Rita Dias, Hospital Garcia de Orta EPE, Almada, Portugal
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