超高浓度甲氨蝶呤中毒抢救成功1例并文献复习

A case of successful rescue of ultra-high concentration methotrexate poisoning and literature review

患儿因确诊急性淋巴细胞白血病(B系高危)5月余,为进行巩固阶段化疗再次住院。按照治疗方案给予大剂量甲氨蝶呤(HDMTX)5 g/m 2化疗,解救药物亚叶酸钙剂量按照首剂甲氨蝶呤起第43小时(即满42小时)进行解救,亚叶酸钙每次用量为15 mg/m^2,48小时甲氨蝶呤血药浓度:32μmol/L。考虑甲氨蝶呤中毒,暂停所有化疗,按照甲氨蝶呤(MTX)中毒方案予大剂量亚叶酸钙解救,并加强补液水化、碱化,强迫利尿等处理,72小时甲氨蝶呤血药浓度16.9μmol/L;继续予大剂量亚叶酸钙、水化、碱化。患儿腹痛无改善,第82小时起行连续性肾脏替代治疗(CRRT)。96小时甲氨蝶呤血药浓度仍达到7.2μmol/L,考虑CRRT效果不佳,故于MTX后124小时开始行血浆置换,血浆置换后继续行CRRT。第120小时,甲氨蝶呤血药浓度下降到3.8μmol/L。中毒第7天即148小时,为加快解毒再次行血浆置换。第192小时甲氨蝶呤血药浓度下降到0.52μmol/L。

The patient was diagnosed with acute lymphoblastic leukemia(B-line high-risk)for more than 5 months,and was hospitalized again for consolidation chemotherapy.According to the treatment plan,the patient was treated with high-dose methotrexate(HDMTX)5 g/m^2 for chemotherapy,and the rescue drug-calcium folinate,was used according to the first dose of MTX at 43 h(that is,full 42 h).The dosage of calcium folinate was 15 mg/m 2,and plasma concentration of MTX at 48 h was 32μmol/L.Considering the MTX poisoning,the chemotherapy was suspended and the patient was rescued with large dose of calcium folinate according to MTX poisoning regimen,and the treatment of fluid rehydration,alkalization and forced diuresis was strengthened.At 72 h,MTX plasma concentration was 16.9μmol/L.The large-dose calcium folinate was continuously given to the patient,then hydration and alkalization still went on.The child's abdominal pain showed no signs of remission,and continuous renal replacement therapy(CRRT)was conducted from the 82nd hour.The plasma concentration of MTX still reached 7.2μmol/L at 96 h.Considering the poor efficacy of CRRT,plasma exchange was carried out at 124 h after MTX,followed by CRRT.At 120 h,the MTX plasma concentration dropped to 3.8μmol/L.On the 7th day(148 h)of the poisoning,plasma exchange was carried out again to accelerate the detoxification.The plasma concentration of MTX dropped to 0.52μmol/L at 192 h.