血液净化治疗改善甲氨蝶呤延迟排泄的效果观察

Effect of blood purification on delayed excretion of methotrexate

目的 观察血液净化治疗改善甲氨蝶呤延迟排泄的效果。方法 收集2011年2月至2014年 6月北京积水潭医院收治的3例骨肉瘤患儿的临床资料，分析血液净化治疗解救甲氨蝶呤延迟排泄的效果。结果 3例患者均为女性儿童，治疗前及治疗中均采用标准的水化碱化治疗方案，治疗后均常规采用亚叶酸钙进行解救。其中2例出现甲氨蝶呤延迟排泄合并肾损伤，于治疗后9.0～10.0 d恢复正常，但均合并严重的急性肝损伤及骨髓抑制；1例未出现急性肾损伤，合并严重的急性肝损伤，但无严重的骨髓抑制发生。3例患儿进行血液净化治疗干预共7次；首次进行血液净化治疗干预的时间分别为甲氨蝶呤给药后38.0 h、48.0 h和4.0 h，采用的血液净化治疗方式分别为血液透析联合血液灌流、高通量血液透析联合血液灌流和血液滤过联合血液灌流。血液滤过联合血液灌流治疗甲氨蝶呤血药浓度下降率最高；联合血液灌流治疗的甲氨蝶呤血药浓度下降率高。其中1例经血液净化治疗后甲氨蝶呤血药浓度出现反弹。结论 早期行血液净化治疗可有效解救甲氨蝶呤延迟排泄，并有可能减轻骨髓抑制的严重程度，联合血液灌流可有效降低甲氨蝶呤的血药浓度，需要进一步研究。

Objective To observe the effect of blood purification on delayed excretion of methotrexate（MTX）. Methods Three female children with osteosarcoma at Beijing Jishuitan Hospital from February 2011 to June 2014 were retrospectively analyzed. Results The children had vigorous hydration and alkalinization therapy; calcium folinate were used after high-dose MTX administration. Two children had MTX delayed excretion complicated with kidney injury, severe acute liver injury and myelosuppression; 1 child had MTX delayed excretion complicated with liver injury. The 3 children had the first time of hemodialysis＋hemoperfusion, high-flux hemodialysis＋hemoperfusion and hemofiltration＋hemoperfusion at 38.0 h, 48.0 h, 4.0 h after MTX administration, respectively; they had 7 rounds of blood purification in total. The children with hemofiltration＋hemoperfusion had the highest decline rate of MTX blood concentration. One child had relapse after treatment. Conclusion Early blood purification therapy is effective in the management of delayed MTX excretion and bone marrow suppression; the combination of hemodialysis and hemoperfusion can lower the blood concentration of MTX.