Case report: management of methotrexate toxicity in an anephric patient

We describe the case of an anephric woman on chronic hemodialysis who developed breast cancer with positive axillary nodes. After mastectomy, we attempted to treat her with adjuvant chemotherapy. She suffered severe toxicity involving the skin, gastrointestinal tract and bone marrow after a single dose of 15 mg (10 mg m-2) of methotrexate. She received high doses of leukovorin and hemodialysis was continued. Although hemodialysis caused little acute change in the serum methotrexate levels, over a period of 3 weeks the levels did decrease, her symptoms of toxicity subsided, and she recovered. The case demonstrates the limited effectiveness of hemodialysis for treating methotrexate toxicity and suggests that leukovorin is useful for reversing it.