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Cohen IJ. Neurotoxicity after high-dose methotrexate (MTX) is adequately explained by insufficient folinic acid rescue. Cancer Chemother Pharmacol 2017; 79:1057-1065. [PMID: 28455583 DOI: 10.1007/s00280-017-3304-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Accepted: 04/11/2017] [Indexed: 11/26/2022]
Abstract
PURPOSE To challenge the view that the dose of folinic acid rescue after high-dose methotrexate (MTX) has no significance in the prevention of neurotoxicity and to present the minority view that neurotoxicity can be prevented by an adequate dose of folinic acid, without compromising treatment results. Several fallacies that led to the misunderstanding of post MTX neurotoxicity are presented. METHODS Data mining using search engines was used to find relevant publications, and an e-mail survey of more than 60 authors of articles in this field was performed. All relevant articles identified were read in their entirety. RESULTS Examples of clinical studies with neurotoxicity following inadequate rescue are given. Some studies demonstrated no neurotoxicity when adequate doses of folinic acid rescue were started 24-36 h after the start of HDMTX rescue even after mega doses of MTX. Rescue started after 42 h was associated with neurotoxicity except in patients with low serum MTX levels after 24 and 36 h. ALL protocols with neurotoxicity, especially BFM-like protocols, are presented. Protocol is reported in which single protocol changes prevented neurotoxicity. CONCLUSIONS From the published data, when folinic acid rescue is given in a sufficiently high enough dose and is started 24-36 h after the beginning of the methotrexate exposure, and virtually all forms of post MTX neurotoxicity can be prevented without compromising therapeutic results.
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Affiliation(s)
- Ian Joseph Cohen
- The Rina Zaizov Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.
- , 139 Shir Hashirim St., 44814, Elkana, Israel.
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Goto E, Tomojiri S, Okamoto I, Tanaka K. Methotrexate poisoning with acute hepatorenal dysfunction. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 2001; 39:101-4. [PMID: 11327217 DOI: 10.1081/clt-100102887] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
A 17-year-old girl receiving high-dose methotrexate for the treatment of osteosarcoma developed complications of acute renal failure and liver dysfunction with a coagulation disorder. The methotrexate concentrations were quickly reduced from 600 micromol/L to 50 micromol/L by treatment with plasma exchange and hemodialysis at 72 hours after discontinuation of the drug. After this reduction, continuous hemodiafiltration was initiated to further lower the methotrexate concentrations because of the persistently high and then the actual rebound in the plasma concentrations after plasma exchange and hemodialysis treatment. Continuous hemodiafiltration was able to reduce the concentrations without any rebound, despite its low column clearance. The rebound in plasma methotrexate concentrations seems to be corrected by plasma methotrexate after plasma exchange and/or hemodialysis.
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Affiliation(s)
- E Goto
- Department of Emergency & Critical Care Medicine, School of Medicine, Fukuoka University, Japan.
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Abstract
BACKGROUND Inadequate survival results from single agents in the management of advanced bladder cancer have prompted several trials involving multidrug combinations to increase response rates and survival. METHODS Since the development of the MVAC regimen (methotrexate, vinblastine, doxorubicin, and cisplatin) and the CMV regimen (cisplatin, methotrexate, and vinblastine), other regimens have been tested. We evaluate results from regimens that include cisplatin combined with gemcitabine, paclitaxel, or docetaxel, and paclitaxel combined with gemcitabine or carboplatin. RESULTS Objective results observed with various new combinations are promising. Objective response (OR) rates of 41%, 59%, and 71% are reported with a regimen of gemcitabine plus cisplatin. Paclitaxel plus cisplatin produced OR rates of 65% and 72%. CONCLUSIONS The use of combination cytotoxic chemotherapy regimens in treating patients with metastatic bladder cancer has nearly doubled median survival to 12 months, with a 3-year survival of approximately 20% to 25%. Caution must be exercised in using some of the newer regimens as survival may be inferior compared with the MVAC regimen.
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Affiliation(s)
- D Parimoo
- Division of Medical Oncology at the University of Southern California, Norris Comprehensive Cancer Center, Los Angeles, 90089-9173, USA
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Smeland E, Fuskevåg OM, Nymann K, Svendesn JS, Olsen R, Lindal S, Bremnes RM, Aarbakke J. High-dose 7-hydromethotrexate: acute toxicity and lethality in a rat model. Cancer Chemother Pharmacol 1996; 37:415-22. [PMID: 8599863 DOI: 10.1007/s002800050406] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
To elucidate mechanisms for methotrexate (MTX)-induced renal and hepatic toxicity, we investigated the acute effects of bolus plus continuous infusion of up to 0.4 g/kg 7-hydroxymethotrexate (7-OH-MTX) in the rat. We demonstrate for the first time in any species the occurrence of acute lethal toxicity within a few hours after 7-OH-MTX administration. Serum concentrations of 7-OH-MTX measured at the time of death were 1.4 mM (mean), about one-half of those achieved in some patients after infusion of high-dose MTX (HD-MTX) in the clinic. The data suggest an approximate LD50 (the dose lethal to 50% of the study population) of 0.3 g/kg and a steep dose/lethality curve for 7-OH-MTX. Moreover, acute renal and hepatic toxicity occurred as evidenced by severe morphological findings and increased serum levels of creatinine and liver transaminases. In all rats subjected to continuous infusion of 7-OH-MTX, yellow microscopic precipitations were apparent in the kidney tubules. Crystallization was also seen in bile ducts of the liver in some of the rats. These results further support that the formation of 7-OH-MTX is disadvantageous and that reported attempts to prevent its formation during MTX treatment are warranted.
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Affiliation(s)
- E Smeland
- Department of Pharmacology, Institute of Medical Biology, University of Tromsø, Norway
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Bikhazi AB, Salameh A, el-Kasti MM, Awar RA. Comparative nephrotoxic effects of cis-platinum (II), cis-palladium (II), and cis-rhodium (III) metal coordination compounds in rat kidneys. COMPARATIVE BIOCHEMISTRY AND PHYSIOLOGY. PART C, PHARMACOLOGY, TOXICOLOGY & ENDOCRINOLOGY 1995; 111:423-7. [PMID: 8564782 DOI: 10.1016/0742-8413(95)00069-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
A Sprague-Dawley rat kidney perfusion technique was used in situ to study the effects of cis-dichloro-diamine platinum, PdCl2 (2,6-diaminopyridine), and RhCl3 (2,6-diaminopyridine) on sodium and calcium retention in the whole kidney. The technique involves perfusion of both kidneys via the abdominal aorta and then through the right and left renal arteries and dorsal aorta. Compared to controls, kidneys perfused independently with the three coordination compounds showed approximately equal to 45% decrease and approximately equal to 117% increase in Na+ and Ca2+ retention, respectively. Perfusates containing the coordination compounds in addition to 15 mM ouabain showed approximately equal to 76% decrease in Na+ and insignificant increase in renal Ca2+ retention. Hence, one can rule out the presence of voltage-gated Ca(2+)-channels at the basolateral side due to membrane depolarization. These results suggest that the three metal coordination compounds showed identical nephrotoxic effects on the handling of Na+ and Ca2+ ions by inhibiting both the Na(+)-Ca(2+)-anti-porter and the Na(+)-H(+)-exchanger with laxing effects on nonvoltage-gated Ca(2+)-channels at the basolateral side. However, their effects on the Na(+)-K(+)-ATPase and the Na(+)-Ca2+ symporter was insignificant.
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Affiliation(s)
- A B Bikhazi
- Department of Physiology, American University of Beirut, New York, NY 10022, USA
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Smeland E, Bremnes RM, Andersen A, Jaeger R, Eide TJ, Huseby NE, Aarbakke J. Renal and hepatic toxicity after high-dose 7-hydroxymethotrexate in the rat. Cancer Chemother Pharmacol 1994; 34:119-24. [PMID: 8194163 DOI: 10.1007/bf00685928] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
To examine directly the hepatic and renal toxicity of 7-hydroxymethotrexate (7-OH-MTX) without interference of the parent compound methotrexate (MTX), we purified and gave 100 mg/kg 7-OH-MTX to rats, a dose resulting in serum levels of 7-OH-MTX comparable with those achieved in the clinic after the administration of high-dose MTX (HD-MTX). After only 5 h, the 7-OH-MTX-treated rats demonstrated 2.6-fold increases in serum creatinine values and 2-fold elevations in serum aspartate aminotransferase (ASAT) levels as compared with the controls. Morphologic evidence of toxicity, however, was apparent only in the kidneys. Intraluminal cellular debris containing membranous material and deteriorated organelles was seen, but no precipitate of the delivered drug. The peak serum concentration of 7-OH was up to 939 microM, and concentrations of 7-OH-MTX declined triphasically, showing a t1/2 alpha value of 2.45 min, a t1/2 beta value of 30.5 min, and a terminal half-life (t1/2 gamma) of 240 min. The total clearance value was 14.5 ml min-1 kg, and the postdistributional volume of distribution (V beta) was 5070 ml/kg. Our results may indicate a direct toxic effect of 7-OH-MTX on kidney and liver cells.
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Affiliation(s)
- E Smeland
- Department of Pharmacology, University of Tromsø, Norway
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Abstract
Advances in treatment have dramatically increased the survival rate of children and adolescents with cancer. These treatments, however, may be associated with damage to vital organ systems, which may not be evident until many years after the initial diagnosis of cancer and may adversely affect long-term survival and/or the quality of life of former patients. The effects of treatment on three specific organ systems, heart, lungs, and kidneys, are reviewed here.
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Affiliation(s)
- D M Green
- Department of Pediatrics, Roswell Park Cancer Institute, Buffalo, NY 14263
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Ferrari S, Sassoli V, Orlandi M, Strazzari S, Puggioli C, Battistini A, Bacci G. Serum methotrexate (MTX) concentrations and prognosis in patients with osteosarcoma of the extremities treated with a multidrug neoadjuvant regimen. J Chemother 1993; 5:135-41. [PMID: 8515297 DOI: 10.1080/1120009x.1993.11739222] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The relationship between the serum concentration of methotrexate and the prognosis has been studied in 108 patients with osteosarcoma of the extremities treated from September 1986 to December 1989 at the Chemotherapy Department of Rizzoli Hospital. The protocol of neoadjuvant chemotherapy included high doses of methotrexate (HDMTX) adriamycin, cisplatinum, ifosfamide and VP-16. After a median follow-up of 40.4 months (range 24-62), 84 (77.7%) of the patients studied remained continuously disease-free (CDF) and 24 relapsed. Significantly higher mean serum MTX concentrations were observed in the patients who remained CDF (669.5 mumol/l) than in the patients who relapsed (571.9 mumol/l) (p < .004). The breaking point of prognostic significance for the serum MTX levels seems to be 700 mumol/l. In fact, according to the mean MTX concentrations, the patients with less than 700 mumol/l showed a significantly lower disease-free survival than the patients with higher mean MTX concentrations (68.12% vs 94.87% p < .0013). The distribution of prognostic variables between the two groups was the same in terms of site and histological type of tumor and alkaline phosphatase serum levels at diagnosis. In the group which had more than 700 mumol/l MTX, a higher percentage of good histological response after primary chemotherapy was observed. This is probably independent from the MTX because no significant preoperative MTX serum levels between good and partially responding patients were observed.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- S Ferrari
- Sezione di Chemioterapia dei Tumori dell'Apparato Locomotore, Instituti Ortopedici Rizzoli, Bologna, Italy
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Robbins ME, Bywaters TB, Jaenke RS, Hopewell JW, Matheson LM, Tothill P, Whitehouse E. Long-term studies of cisplatin-induced reductions in porcine renal functional reserve. Cancer Chemother Pharmacol 1992; 29:309-15. [PMID: 1537078 DOI: 10.1007/bf00685950] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Mature Large White female pigs aged approx. 10 months received single intravenous doses of 1.5, 2, or 2.5 mg/kg cisplatin. The glomerular filtration rate (GFR) and the effective renal plasma flow (ERPF) in individual kidneys were measured prior to and at 4-week intervals for up to 24 weeks after cisplatin administration by renography using [99mTc]-diethylenetriamminepentaacetic acid (DTPA) and iodohippurate sodium I 131, respectively. The left kidney of each cisplatin-treated pig and that of three age-matched control pigs was then removed, and GFR and ERPF values were measured in the remaining kidney at 4-week intervals for a further 24 weeks after unilateral nephrectomy (UN). Pigs treated with cisplatin showed no significant reduction in GFR or ERPF for up to 24 weeks after drug infusion. As measured using inductively coupled plasma mass spectrometry, the mean renal platinum concentration in the left kidney removed at UN was 77.5 +/- 9.1 ng/g kidney per mg/kg cisplatin. Histological evaluation of these kidneys revealed narrow interconnecting rays of interstitial fibrosis in the deep cortex and medulla; in these areas, glomeruli exhibited thickened Bowman's capsules and occasionally shrunken sclerotic capillaries. In cisplatin-treated pigs, UN was associated with a marked reduction in the ability of the remaining kidney to increase its function in terms of GFR and, to a lesser extent, of ERPF. The increase seen in GFR following UN in the cisplatin-treated pigs was only ca. 50%-70% of that seen in age-matched UN controls. Histologically, these kidneys revealed resolution of the peritubular fibrosis observed at UN; occasional sclerotic glomeruli were also evident. Platinum remained detectable in these kidneys, the mean levels being 18.8 +/- 4.9 ng/g kidney per mg/kg cisplatin. These findings confirm previous observations and illustrate the need for caution in considering further treatment of patients who have previously received cisplatin along with a second potentially nephrotoxic agent.
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Affiliation(s)
- M E Robbins
- Research Institute (University of Oxford), Churchill Hospital, U.K
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Abstract
Life prolongation in cancer patients is attended by a greater frequency of renal lesions associated with chemotherapy, and in the last few years cancer patients cured or in lasting remission have begun to haunt dialysis centres. Before blaming the renal toxicity of cytotoxic drugs, it is necessary to exclude all other causes of renal dysfunction (pre-renal, obstructive, iatrogenic or cancer-related). The renal toxicity of certain drugs, such as cisplatin, cyclophosphamide, ifosfamide, streptozocin, nitrosoureas, methotrexate, mitomycin C and recombinant IL2, is of importance as it is frequent and limits their use. The dangers of anticancerous drugs combinations, concomitant administration of other nephrotoxic drugs (antibiotics, non-steroidal anti-inflammatory agents) and extracellular dehydration created by gastrointestinal disorders must be borne in mind. Careful evaluation of renal function prior to chemotherapy, application of preventive measures with proven efficacy and repeated laboratory tests in short-mid- and long-term should reduce the frequency of renal complications while preserving or even improving therapeutic effectiveness.
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Affiliation(s)
- M Kessler
- Service de Néphrologie, C.H.R.U. Nancy, Vandoeuvre
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Ewen C, Hendry JH. The effects of the platinum anti-tumour agents on renal cell kinetics and the response to a second cytotoxic agent. CELL AND TISSUE KINETICS 1990; 23:61-70. [PMID: 2180572 DOI: 10.1111/j.1365-2184.1990.tb01333.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Following 15 mg kg-1 cisplatin to mice, the labelling index (LI) in the kidney decreased from 0.4% to less than 0.01% at 1-3 d, increased to 1.9% at day 16 and returned to control levels by day 30. Cytotoxicity was assessed by counts of viable tubule cross-sections and recovery was incomplete up to 14 months after treatment. Cisplatin treatment impaired the regeneration response to a dose of 16 mg kg-1 uranyl nitrate (UN) given 14 d after cisplatin when assessed by an increase in LI and sub-capsular tubule count. However, there was recovery with greater time intervals. At nine months after cisplatin there was no difference in response to UN of controls and mice previously treated by cisplatin. Prior treatment with paraplatin or iproplatin at LD50 doses produced not only no histopathological changes but also no impairment of the subsequent responses to UN.
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Affiliation(s)
- C Ewen
- Department of Radiobiology, Paterson Institute for Cancer Research, Christie Hospital and Holt Radium Institute, Manchester, U.K
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Nilsson JR. Tetrahymena in Cytotoxicology: with special reference to effects of heavy metals and selected drugs. Eur J Protistol 1989. [DOI: 10.1016/s0932-4739(89)80074-4] [Citation(s) in RCA: 84] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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Abstract
The pathophysiology of preeclampsia includes ischemia and microinfarctions of the kidney, which could induce renal tubular cells to release enzymes into urine. We therefore measured the concentrations of two markers of renal tubular damage, N-acetyl-beta-D-glucosaminidase and alanine aminopeptidase, in urine specimens from women with mild or severe preeclampsia and compared the results with those from healthy pregnant and nonpregnant women. The median urinary concentrations of N-acetyl-beta-D-glucosaminidase and alanine aminopeptidase in women without preeclampsia increased progressively through the first, second, and third trimesters and reached maximum values of 1.12 and 0.77 U/mmol creatinine, respectively. Median concentrations of the two enzymes were significantly higher in women with mild preeclampsia (N-acetyl-beta-D-glucosaminidase = 1.40, alanine aminopeptidase = 1.12 U/mmol creatinine) or severe preeclampsia (N-acetyl-beta-D-glucosaminidase = 2.90, alanine aminopeptidase = 1.26 U/mmol creatinine). This increased enzyme excretion indicates subclinical preeclamptic renal tubular damage.
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Affiliation(s)
- M P Goren
- Department of Pathology and Laboratory Medicine, St. Jude Children's Research Hospital, Memphis, TN 38101
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