Yeungnam Univ J Med.  2011 Jun;28(1):60-69.

Two Cases of Severe Pancytopenia Associated with Low-Dose Methotrexate Therapy in Patients with Chronic Kidney Disease and Rheumatoid Arthritis

• Kim HI
• Lee WH
• Oh JS
• Hong HR
• Lee IH

Abstract

Due to its efficacy and tolerability, low dose oral methotrexate(MTX) therapy has been widely used for treatment of rheumatoid arthritis(RA). However, it can rarely cause serious, life-threatening hematologic toxicities, such as pancytopenia. We report here on two patients with chronic kidney disease(CKD), who developed severe pancytopenia after 5 years (cumulative dose 1,240mg) and 4 years(cumulative dose 1,320mg) of low dose MTX therapy for treatment of RA, respectively. Both patients presented with renal insufficiency, hypoalbuminemia, concurrent use of nonsteroidal anti-inflammatory drugs, and elevated mean corpuscular volume of red blood cells(RBCs), all of which are known as risk factors of MTX-induced pancytopenia. Despite receiving treatment, which included RBC and platelet transfusions, antibiotic therapy, granulocyte colony stimulating factor, and leucovorin rescue, one patient died of sepsis. Based on our case study, prompt investigation of risk factors associated with MTX toxicity is required for all patients receiving MTX therapy. MTX treatment, even at a low dose, should be discontinued in patients with advanced CKD.

Keyword

Pancytopenia; Methotrexate; Chronic kidney disease; Rheumatoid arthritis

MeSH Terms

Arthritis, Rheumatoid
Colony-Stimulating Factors
Erythrocyte Indices
Granulocytes
Humans
Hypoalbuminemia
Kidney
Leucovorin
Methotrexate
Pancytopenia
Platelet Transfusion
Renal Insufficiency
Renal Insufficiency, Chronic
Risk Factors
Sepsis
Colony-Stimulating Factors
Leucovorin
Methotrexate