Removal Of Methotrexate Research Articles

Synergistic catalytic degradation of Methotrexate using Ce-based high-entropy metal oxides: Insights from DFT calculations and CWPO performance

Methotrexate (MTX), a widely used anticancer drug, is a refractory organic pollutant posing serious threats to ecosystems and human health. This study focuses on the development of a novel catalyst composed of Ce-based high-entropy metal oxides (NHEMO) supported on nepheline for the catalytic wet peroxide oxidation (CWPO) process, targeting MTX degradation in simulated wastewater. The NHEMO catalyst exhibited a unique high-entropy structure that enhances catalytic performance by facilitating diverse electronic interactions, which was confirmed through X-ray diffraction (XRD) and transmission electron microscopy (TEM) analyses showing a well-defined crystal structure and uniform dispersion of metal oxides. Additionally, X-ray photoelectron spectroscopy (XPS) and energy-dispersive X-ray spectroscopy (EDS) revealed a stable metal composition and high oxidation states of active metal sites. At a reaction temperature of 160 °C, with a residence time of 150 s and an oxidation coefficient of 5, the catalyst achieved a MTX removal rate of 93.49 % and a chemical oxygen demand (COD) removal of 99.95 %. Density Functional Theory (DFT) calculations further demonstrated that H2O2 decomposes into both adsorbed (surface-bound) and free (solution-phase) hydroxyl radicals (·OH). These radicals synergistically degrade MTX through both radical and non-radical pathways, ensuring comprehensive pollutant breakdown. The catalyst also showed excellent stability and a very low metal dissolution rate during the reaction, maintaining high catalytic activity after repeated recycling. This catalyst offers high cost-effectiveness, activity, and stability, providing a promising solution for treating refractory organic pollutants in pharmaceutical wastewater.

Far-UVC Radiation Activating Percarbonate to Accelerate the Removal of Methotrexate: Degradation Efficiency, Mechanisms, and Moiety-Dependence Transformation

Far-UVC Radiation Activating Percarbonate to Accelerate the Removal of Methotrexate: Degradation Efficiency, Mechanisms, and Moiety-Dependence Transformation

Navigating methotrexate toxicity: Examining the therapeutic roles of folinic acid and glucarpidase.

Methotrexate (MTX) toxicity varies depending on factors such as dosing frequency (acute or repeated), dosage (low or high) and the administration route (oral, parenteral or intrathecal). Renal impairment can trigger or exacerbate MTX toxicity. Acute oral low-dose MTX (LDMTX) overdoses seldom lead to toxicity due to the saturable maximal bioavailable dose, but toxicity risks increase with repeated low doses (>3 days), high-dose MTX (HDMTX) or intrathecal poisoning. Folinic acid shares MTX transporters in the gut and cells and bypasses the MTX-induced dihydrofolate reductase inhibition. The required folinic acid dosage differs for low-dose and high-dose MTX toxicities. Acute LDMTX poisoning rarely requires folinic acid, while chronic LDMTX poisoning needs low-dose folinic acid until cellular function is restored. In HDMTX toxicities, early intravenous folinic acid administration is recommended, with dose and duration being guided by MTX concentrations and clinical improvement. In intrathecal MTX poisoning, folinic acid should be administered intravenously. Glucarpidase, a recombinant bacterial enzyme, has a high affinity for MTX and folate analogues in the intravascular or intrathecal systems. It decreases serum MTX concentrations by 90%-95% within 15 min. Its primary indication is for intrathecal MTX poisoning. It is rarely indicated in HDMTX toxicity unless patients have renal injury. However, there is no literature evidence supporting its use in HDMTX poisoning. Its use is limited by its significant cost and lack of availability. Haemodialysis can be potentially useful for MTX removal in cases where glucarpidase is not available. Additionally, fluid hydration, renal support and urine alkalinization are important adjunctive therapies for managing MTX toxicities.

Methotrexate anti-cancer drug removal using Gd-doped Fe3O4: Adsorption mechanism, thermal desorption and reusability

One of the means of removing anthropogenic contaminants such as anti-cancer drugs from widely understood water environments is through adsorption. However, it is imperative to ensure that adsorbed contaminants do not find their way back into the environment, hence the quest for this study. Gadolinium (Gd)-doped Fe3O4 was synthesized, characterized, and applied for the removal of methotrexate (MEX), an anti-cancer drug. The incorporation of Gd did not alter the crystal structure of magnetite, having crystallite size and the d-spacing of 10 nm and 2.516 Å respectively. The magnetic saturation slightly reduced from 71 before doping to 67 emu g −1 after adding 5% atomic weight of Gd. The BET-specific surface area increased from 87 to 102 m2 g−1 when the content of Gd was 15%. The particle size is within the range of 10–20 nm. The dopant shifted the isoelectric point of the adsorbent nanoparticles to a more positive value which favored the adsorption of methotrexate at pH 7. The adsorption capacity increased from 28 mg g−1 (0%_Gd) to 64 mg g−1 (5%_Gd). The addition of CaCl2, due to the hydrophobic effect increased the amount of MEX that was removed. To ensure that the adsorbed MEX did not escape to the environment, Gd-doped Fe3O4 was thermally decomposed from the surface of the doped magnetite and reused for up to 4 cycles. The proposed mechanisms of adsorption were due to electrostatic and hydrogen bond interaction.

Degradation of methotrexate by unactivated and solar-activated peroxymonosulfate in water: Moiety-specific reaction kinetics and transformation product-associated risks

Anticancer drugs have raised worldwide concern owing to their ubiquitous occurrence and ecological risks, necessitating the development of efficient removal strategies in water and wastewater treatment. Although peroxymonosulfate (PMS) is known to be a promising chemical in water decontamination, limited information is available regarding the removal efficiency of anticancer drugs by PMS and solar/PMS systems. This study first reports the moiety-specific reaction kinetics and mechanisms of methotrexate (MTX), an anticancer drug with widespread attention, by PMS (unactivated) and solar-activated PMS in water. It was found that MTX abatement by the direct PMS oxidation followed second-order kinetics, and the pH-dependent rate constants increased from 0.4 M−1 s−1 (pH 5.0) to 1.3 M−1 s−1 (pH 8.0), with a slight decrease to 1.1 M−1 s−1 at pH 9.0. The presence of chloride and bromide exerted no obvious influence on the removal of MTX by PMS. Furthermore, the chemical reactivity of MTX and its seven substructures with different reactive species was evaluated, and the degradation contributions of the reactive species involved were quantitatively analyzed in the solar/PMS system. The product analysis suggested similar reaction pathways of MTX by PMS and solar/PMS systems. The persistence, bioaccumulation, and toxicity of the transformation products were investigated, indicating treatment-driven risks. Notably, MTX can be removed efficiently from both municipal and hospital wastewater effluents by the solar/PMS system, suggesting its great potential in wastewater treatment applications. Overall, this study systematically evaluated the elimination of MTX by the unactivated PMS and solar/PMS treatment processes in water. The obtained findings may have implications for the mechanistic understanding and development of PMS-based processes for the degradation of such micropollutants in wastewater.

Extracorporeal Treatment for Methotrexate Poisoning: Systematic Review and Recommendations from the EXTRIP Workgroup.

Methotrexate is used in the treatment of many malignancies, rheumatological diseases, and inflammatory bowel disease. Toxicity from use is associated with severe morbidity and mortality. Rescue treatments include intravenous hydration, folinic acid, and, in some centers, glucarpidase. We conducted systematic reviews of the literature following published EXtracorporeal TReatments In Poisoning (EXTRIP) methods to determine the utility of extracorporeal treatments in the management of methotrexate toxicity. The quality of the evidence and the strength of recommendations (either "strong" or "weak/conditional") were graded according to the GRADE approach. A formal voting process using a modified Delphi method assessed the level of agreement between panelists on the final recommendations. A total of 92 articles met inclusion criteria. Toxicokinetic data were available on 90 patients (89 with impaired kidney function). Methotrexate was considered to be moderately dialyzable by intermittent hemodialysis. Data were available for clinical analysis on 109 patients (high-dose methotrexate [>0.5 g/m2]: 91 patients; low-dose [≤0.5 g/m2]: 18). Overall mortality in these publications was 19.5% and 26.7% in those with high-dose and low-dose methotrexate-related toxicity, respectively. Although one observational study reported lower mortality in patients treated with glucarpidase compared with those treated with hemodialysis, there were important limitations in the study. For patients with severe methotrexate toxicity receiving standard care, the EXTRIP workgroup: (1) suggested against extracorporeal treatments when glucarpidase is not administered; (2) recommended against extracorporeal treatments when glucarpidase is administered; and (3) recommended against extracorporeal treatments instead of administering glucarpidase. The quality of evidence for these recommendations was very low. Rationales for these recommendations included: (1) extracorporeal treatments mainly remove drugs in the intravascular compartment, whereas methotrexate rapidly distributes into cells; (2) extracorporeal treatments remove folinic acid; (3) in rare cases where fast removal of methotrexate is required, glucarpidase will outperform any extracorporeal treatment; and (4) extracorporeal treatments do not appear to reduce the incidence and magnitude of methotrexate toxicity.

Magnetite graphene oxide modified with β-cyclodextrin as an effective adsorbent for the removal of methotrexate and doxorubicin hydrochloride from water

The purpose of this investigation was to analyze the performance of magnetite graphene oxide modified with β-cyclodextrin (GO@Fe3O4@β-CD) for adsorption of methotrexate (MTX) and doxorubicin (DOX) from aqueous solutions. Characterization of GO@Fe3O4@β-CD was carried out using some methods. The perfect conditions for the adsorption of MTX and DOX were 7.0, 45min, 20mg, and 25°C for solution pH, contact time, adsorbent dose, and temperature, respectively, with removal efficiency values of 97.8% and 98.5% for MTX and DOX, respectively. The adsorption kinetic of MTX and DOX via GO@Fe3O4@β-CD followed pseudo second-order (PSO) model, while the adsorption isotherm obeyed Langmuir model by monolayer adsorption with maximum adsorption capacities of 198.5 and 204.5mgg-1 for MTX and DOX, respectively. Therefore, it could be argued that HCl and 0.1mol L-1 NaOH would reflect adequate elution properties for GO@Fe3O4@β-CD recovery.

Development of a self-limiting model of methotrexate-induced mucositis reinforces butyrate as a potential therapy

Gastrointestinal mucositis is a complication of anticancer treatment, with few validated in vitro systems suitable to study the complex mechanisms of mucosal injury. Therefore, we aimed to develop and characterize a chemotherapeutic-induced model of mucositis using 3D intestinal organoids. Organoids derived from mouse ileum were grown for 7 days and incubated with different concentrations of the chemotherapeutic agent methotrexate (MTX). Metabolic activity, citrulline levels and cytokine/chemokine production were measured to determine the optimal dosage and incubation time. The protective effects of folinic acid on the toxicity of MTX were investigated by pre-treating organoids with (0.0005–50 µg/mL) folinic acid. The impact of microbial-derived short-chain fatty acids was evaluated by supplementation with butyrate in the organoid model. MTX caused a dose-dependent reduction in cell metabolic activity and citrulline production that was salvaged by folinic acid treatment. Overall, MTX causes significant organoid damage, which can be reversed upon removal of MTX. The protective effect of folinic acid suggest that the organoids respond in a clinical relevant manner. By using the model for intervention, it was found that prophylactic treatment with butyrate might be a valuable strategy for prophylactic mucositis prevention.

Addition or removal of concomitant methotrexate alters adalimumab effectiveness in rheumatoid arthritis but not psoriatic arthritis

Objective: Randomized trials have shown that concomitant methotrexate (MTX) augments the effectiveness of tumour necrosis factor (TNF) inhibitors in rheumatoid arthritis (RA), but its benefit in psoriatic arthritis (PsA) has not been demonstrated. The goal of this study was to examine whether the impact of concomitant MTX on therapeutic outcomes in patients with PsA was similar to its effects in RA.Methods: We used data from highly comparable and concurrent observational studies of patients with PsA (N = 1424) or RA (N = 3148) who initiated adalimumab therapy during routine clinical care. The 28-joint Disease Activity Score (DAS28) and patient-reported pain scores were evaluated in patients who received 24 months of continuous treatment with adalimumab monotherapy or adalimumab + MTX and in patients who initiated or stopped concomitant MTX during ongoing adalimumab therapy.Results: Twenty-four months of continuous treatment with adalimumab + MTX was superior to adalimumab monotherapy in RA patients, while no significant difference was observed in patients with PsA. RA patients who added MTX during the study showed significant individual improvements in DAS28 and pain scores at 6 months after the change in therapy, while those who removed MTX had slight increases in disease activity. In contrast, in patients with PsA, neither initiation nor removal of MTX during continuous adalimumab therapy had a significant effect on therapeutic outcomes.Conclusion: Addition of MTX to adalimumab confers further therapeutic benefit in patients with RA, but not in those with PsA, suggesting differences in MTX effects in these two patient populations.Clinicaltrials.gov NCT01078090, NCT01077258, NCT01111240

Use of high doses of the methotrexate in children suffering from some form of cancer: specificities of the accompanying therapy, assessing the toxicity

Introduction. Methotrexate (MTX) is one of the most commonly used anti-tumor preparations which confirm it effectiveness against the large spectrum of the oncological diseases in children. Today the use of high doses of the MTX (g/m2 ) in the monotherapy or in combination with other chemotherapeutic agent is a standard of treatment of such nosology as osteosarcoma, tumors of the central nervous system (CNS), lymphomas, acute lymphoblastic leukemia. Despite of the developed recommendations on the fluid therapy, therapeutic monitoring, use of leukovorin which allowed to reduce the expected toxicity among some patients it is not always possible to prevent the development of complications. Ex post evaluation of different doses of schedule of the high-dose MTX is necessary in order to formulate new and effective treatment strategies with respect to the individual specifics of the patients. Materials and methods . During the period from October 2015 to February 2018, a patient cohort (n = 26) who received high-dose MTX therapy with the following nosology: osteosarcoma – 4, hemoblastosis – 11, and CNS – 11 tumors was evaluated. The average age of the patients was 7.3 years old; ratio of boys:girls – 2.25: 1. The used doses were ranged from 1 to 12 g/m 2 , the doses schedules ranged from 4 to 36 hours; the total number of courses during the observation period was 94; the average number of courses per patient was 3. In all cases, the level of MTX in the blood serum was monitored with correction of the dose of leucovorin according to international recommendations. Estimated toxicity parameters were the following: allergic reactions, skin and mucous membrane damage, neurologic disorders, myelosuppression, hepatic transaminase and creatinine growth. Results. Transitory toxicity was noted for 100 % of patients, of which clinically significant was in 62.7 % of cases. The development of complications that had required the use of antibacterial and blood transfusion therapy occurred after 36 courses of therapy (38.2 %), of wich in 24 cases (66.6 %) MTX was performed in combination with other antitumor agents. No cases of acute kidney injury were presented, there was no significant difference in creatinine level before and after high-dose MTX courses. The highest frequency of episodes of hepatotoxicity was noted in the group of patients diagnosed with “osteosarcoma”. After reduction the episodes of toxicity with the use of high-dose MTX, all patients continued programmed chemotherapy. Conclusions. Against the background of an adequate accompanying therapy (infusion therapy with alkalization of urine, pharmacodynamic monitoring, correction of the leucovorin dose), it is possible to achieve satisfactory tolerability of high doses of MTX. The combination of high doses of MTX with other antitumor drugs leads to a significant increase in the toxicity. Despite of the noted complications of therapy, continuation of treatment with the use of previous doses of MTX (does not require reduction) is possible, and a decrease in the rate of MTX removal is not always a predictor of episodes of the toxicity.

Preparation of Metal–Organic Frameworks UiO-66 for Adsorptive Removal of Methotrexate from Aqueous Solution

A low cytotoxic metal–organic framework (MOF) UiO-66 (UiO stands for University of Oslo) and NH2-UiO-66, that showed high cell viability of HFF-2 via 3-(4, 5-dimethylthiazol-2-yl) 2, 5-diphenyl tetrazolium assay, was reported as an effective adsorbent (antidotal) agents. The structure of MOFs was confirmed by Fourier transform infrared, Field emission scanning electron microscopy (FESEM) and X-ray diffraction. Thermal behavior of MOFs was investigated using with thermogravimetric analyzer in nitrogen atmosphere to check the thermal stability. FESEM showed NH2-UiO-66 displayed symmetrical crystals with triangular base pyramid morphology, with the particle size around 100 nm and uniform size distribution. The specific surface areas were calculated using the Brunauer–Emmett–Teller method and surface area and total pore volume of NH2-UiO-66 were calculated to be 1258 m2/g and 0.51 cm3/g, respectively. Methotrexate salt (MTX) was selected as the model drug which was adsorbed into inner pores and channels of MOFs by diffusion manner. The interaction between MOFs and MTX and the effect of pH on interaction between them in aqueous solution was investigated. The final results showed that UiO-66 have high adsorbing capacity and great affinity to MTX.

The Antiepileptic Drugs Phenobarbital and Carbamazepine Reduce Transport of Methotrexate in Rat Choroid Plexus by Down-Regulation of the Reduced Folate Carrier

Intrathecal methotrexate (MTX) has been associated with severe neurotoxicity. Because carrier-associated removal of MTX from the cerebrospinal fluid (CSF) into blood remains undefined, we determined the expression and function of MTX transporters in rat choroid plexus (CP). MTX neurotoxicity usually manifests as seizures requiring therapy with antiepileptic drugs (AEDs) such as phenobarbital (PB). Because we have demonstrated that PB reduces activity of MTX influx carrier reduced folate carrier (Rfc1) in liver, we investigated the influence of the AEDs PB, carbamazepine (CBZ), or gabapentin on Rfc1-mediated MTX transport in CP. Reverse transcriptase-polymerase chain reaction and Western blot analysis showed similar expression of the MTX influx carrier Rfc1 and organic anion transporter 3 or efflux transporter multidrug resistance-associated protein 1 (Mrp1) and breast cancer resistance protein (Bcrp) in rat CP tissue and choroidal epithelial Z310 cells. Confocal microscopy revealed subcellular localization of Rfc1 and Bcrp at the apical and of Mrp1 at the basolateral CP membrane. Uptake, efflux, and inhibition studies indicated MTX transport activity of Rfc1, Mrp1, and Bcrp. PB and CBZ but not gabapentin significantly inhibited Rfc1-mediated uptake of MTX in CP cells. Studies on the regulatory mechanism showed that PB significantly inhibited Rfc1 translation but did not alter carrier gene expression. Altogether, removal of intrathecal MTX across the blood-CSF barrier may be achieved through Rfc1-mediated uptake from the CSF followed by MTX extrusion into blood, particularly via Mrp1. Antiepileptic treatment with PB or CBZ causes post-transcriptional down-regulation of Rfc1 activity in CP. This mechanism may result in enhanced MTX toxicity in patients with cancer who are receiving intrathecal MTX chemotherapy by reduced CSF clearance of the drug.

High-dose continuous venovenous hemofiltration combined with charcoal hemoperfusion for methotrexate removal.

Methotrexate (MTX) is used to treat various disorders and can be safely administered at high doses if renal function is adequate, high urine output (UOP) is maintained, urine is alkalinized and leucovorin rescue is given. Despite those measures, toxicity (mucositis, diarrhea, renal dysfunction and myelosuppression) occurs with prolonged high serum drug concentrations [1]. Dialysis-based methods of removal are largely ineffective because MTX is highly protein bound [1]. Use of charcoal hemoperfusion has also been reported but is minimally effective. We report the first case of high-dose continuous venovenous hemofiltration (CVVH) after charcoal hemofiltration for MTX removal in a patient with toxicity following lymphoma treatment.

Treatment of Methotrexate Intoxication with Various Modalities of Continuous Extracorporeal Therapy and Glucarpidase

Methotrexate, administered for treatment of pediatric and adult malignancies, is a direct renal toxin, which can lead to renal dysfunction, decreased methotrexate clearance, elevated methotrexate concentrations, and systemic toxicity. Although plasma methotrexate concentrations have been shown to decline precipitously after a single dose of glucarpidase, this drug is investigational and available only through compassionate use. Therefore, alternative treatments for methotrexate removal may be required. We describe a 13-year-old girl (body surface area 1.2 m(2)) with osteosarcoma who was treated with high-dose methotrexate 12 g/m(2) infused over 4 hours. Forty-eight hours after the infusion, her plasma methotrexate concentrations were elevated at 446 micromol/L. She exhibited severe signs of methotrexate toxicity, including encephalopathy, liver failure, and acute kidney injury, and could not tolerate conventional hemodialysis. Over the next 12 days, the patient was treated with continuous venovenous hemodialysis (CVVHD), single-pass albumin dialysis (SPAD), continuous venovenous hemodiafiltration (CVVHDF), and glucarpidase to enhance methotrexate elimination. Compared with standard CVVHD, SPAD did not significantly increase methotrexate removal as measured by elimination half-life and methotrexate saturation coefficient. The highest clearance rate among extracorporeal therapies was achieved by CVVHDF, with an effluent rate of 4950 ml/hour. The patient's clinical condition steadily improved, and all extracorporeal therapies were stopped 168 hours after methotrexate administration. The patient was discharged home and continued with chemotherapy, including methotrexate, which was dosed based on iothalamate glomerular filtration rates on the day before infusion. Although extracorporeal treatments appeared to enhance methotrexate clearance, the administration of glucarpidase resulted in the most rapid percentage decline (86%) in methotrexate concentration. Until glucarpidase is readily available, intermittent hemodialysis should be used to enhance methotrexate clearance. If the patient is unable to tolerate hemodialysis, use of CVVHDF with maximum effluent rates will enhance methotrexate clearance.

EFFECT OF CHARCOAL HEMOPERFUSION FOR REMOVAL OF PLASMA METHOTREXATE IN A PATIENT WITH ACUTE RENAL FAILURE

Strategies effective for accelerating methotrexate removal in delayed methotrexate excretion have not been universally accepted. The authors report a case of a 12-year-old girl with osteosarcoma who developed acute renal failure immediately after the first administration of high-dose methotrexate. Plasma methotrexate was effectively removed with repeated charcoal hemoperfusion in addition to plasma exchange and leucovorin rescue. Charcoal hemoperfusion was most effective for reducing plasma methotrexate with approximately 50% of methotrexate being reduced during each of the procedures. No rebound increase in MTX levels was observed. The patient received further therapy with other cancer drugs and has been well for 3.5 years.

Impaired Clearance of Methotrexate in Organic Anion Transporter 3 (Slc22a8) Knockout Mice: A Gender Specific Impact of Reduced Folates

To elucidate the role of the renal basolateral transporter, Oat3, in the disposition of methotrexate. Chinese hamster ovary cells expressing mouse Oat3 were used to determine kinetics and specificity of inhibition of methotrexate transport. Methotrexate clearance was then examined in vivo in wildtype and Oat3 knockout mice. NSAIDs, beta-lactams, and uremic toxins inhibited mOat3-mediated methotrexate uptake by 70-100%, while folate, leucovorin, and 5-methyltetrahydrofolate inhibited transport by 25-50%. A Km of 60.6 +/- 9.3 microM for methotrexate transport was determined. Oat3 knockout mice exhibited reduced methotrexate-to-inulin clearance ratios versus wildtype. Male wildtype mice, but not knockouts or females, demonstrated significantly accelerated methotrexate clearance in response to reduced folates. Reduced folates also markedly inhibited hepatic methotrexate accumulation in males, but not females, and the response was independent of Oat3 function. Oat3 contributes to methotrexate clearance, but represents only one component responsible for methotrexate's elimination. Therefore, in patients, dysfunctional hOAT3 polymorphisms or drug competition for hOAT3 transport may severely impact methotrexate elimination only when redundant means of methotrexate removal are also compromised. Furthermore, the present findings suggest that reduced-folate administration only influences methotrexate disposition in males, with the renal reduced-folate response influenced by OAT3 function.

EGFP fluorescence as an indicator of cancer cells response to methotrexate

Methotrexate action in viable cells was monitored by registering changes in EGFP (Enhanced Green Fluorescent Protein) fluorescence intensity. Treatment with 1 μM methotrexate for 48 h of human colorectal adenocarcinoma C85 cells, stably transfected to express EGFP, caused 5-fold increase in EGFP fluorescence assayed by flow cytometry with no distinct increase in EGFP protein level. This was correlated with morphological changes, including an increase of cell granularity and cell shape flattening, as well as cell cycle G 1 phase arrest revealed by DNA content analysis. Methotrexate removal allowed the morphology of the cells in culture to revert in 10 days to normal. The cells that survived methotrexate exposure were propagated as C85r cell subline and displayed kinetics of methotrexate sensitivity parallel to that of the parental C85 line. As the increase in EGFP fluorescence could also be visualized by fluorescence microscopy, this reporter system may be employed to image methotrexate action in cancer cells in living models.

High-dose methotrexate-induced nephrotoxicity in patients with osteosarcoma.

High-dose methotrexate (HDMTX)-induced renal dysfunction can be life threatening, because it delays methotrexate (MTX) excretion, thereby exacerbating the other toxicities of MTX. HDMTX-induced nephrotoxicity has been managed with high-dose leucovorin, dialysis-based methods of MTX removal, thymidine, and with the recombinant enzyme, carboxypeptidase-G2 (CPDG2), which cleaves MTX to inactive metabolites. The objectives of the current study were to estimate the current incidence of HDMTX-induced renal dysfunction in patients with osteosarcoma and to compare the efficacy and recovery of renal function for dialysis-based methods of MTX removal with treatment using CPDG2. The literature was reviewed for osteosarcoma trials, use of dialysis-based methods for MTX removal, and reports of MTX-induced nephrotoxicity, including information regarding recovery of renal function. Clinical trial databases of select osteosarcoma studies were reviewed. The efficacy of CPDG2 and renal recovery after CPDG2 rescue was obtained from the database of a compassionate-release trial. Approximately 1.8% of patients with osteosarcoma (68 of 3887 patients) who received HDMTX developed nephrotoxicity Grade >/= 2. The mortality rate among those patients was 4.4% (3 of 68 patients). Dialysis-based methods of MTX removal were used frequently but had limited effectiveness in removing MTX compared with the rapid reductions > 98% in plasma MTX concentrations achieved with CPDG2. CPDG2 did not appear to increase the time to recovery of renal function compared with supportive treatment that included dialysis-based methods. HDMTX-induced renal dysfunction continues to occur in approximately 1.8% of patients with osteosarcoma who are treated on clinical protocols with optimal supportive care. For patients with delayed MTX excretion and high plasma MTX concentrations, CPDG2 should be considered over hemodialysis to lower plasma MTX concentrations rapidly and efficiently.

Successful removal of methotrexate (MTX) by high flux hemodialysis (HD)

Successful removal of methotrexate (MTX) by high flux hemodialysis (HD)

Long-term exposure to methotrexate induces immunophenotypic changes, decreased methotrexate uptake and increased dihydrofolate gene copy number in jurkat T cells

Methotrexate (MTX) treatment of rheumatoid arthritis may require increasing doses to maintain clinical efficacy. An overall plateau of clinical response is reached after only six months of treatment. To study the immunologic, biochemical and genetic effects of MTX on T cells, the Jurkat T cell line was made MTX-resistant by serial addition of methotrexate sodium into culture medium. Cells proliferated and divided successfully in MTX concentrations ranging to 15 μM. MTX resistance of Jurkat T cells in vitro was accompanied by significantly ( P < 0.05) decreased expression of CD2, CD3, CD4, CD28, and CD69, IL-2 production, and MTX uptake assessed by cell association or disassociation of 3 [H] -MTX or fluoresceinated MTX (FMTX) , respectively. In addition, there was DHFR gene amplification and increased levels of DHFR in all resistant cell lines. Both permanent and transient phenotypic changes developed in resultant cell lines exposed to increasing concentrations of MTX in vitro. Expression of CD4 and CD25 and sensitivity to MTX returned to near-parental levels after removal of MTX from culture medium, whereas expression of CD26 and MTX uptake were significantly increased. Expression of CD2, CD3, CD69 and IL-2 production as well as the DHFR levels did not return to the parental phenotype after removal from MTX. We conclude that MTX-cultured cells express depressed levels of cell-surface markers vital for T cell function and activation. The return of enhancement of these cell-surface markers critical to T cell activation suggests a possible mechanism for the severe flares experienced by rheumatoid arthritis patients when drug treatment is discontinued.