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Kidney Week

Abstract: PO0283

AKI: Rare Side Effect of Pemetrexed

Session Information

Category: Acute Kidney Injury

  • 102 AKI: Clinical, Outcomes, and Trials


  • Alam, Junaid Mohammed, HCA, Kingwood, Texas, United States
  • Srinivasan, Aswin, HCA, Kingwood, Texas, United States
  • Ahmed, Haris, HCA, Kingwood, Texas, United States
  • Wilson, Branden C., HCA, Kingwood, Texas, United States
  • Rahman, Brotee, HCA, Kingwood, Texas, United States

Pemetrexed was approved by FDA in 2004 to treat local or advanced metastatic non-small cell lung cancer. It works by disrupting folate dependent processes and in turn preventing cell replication. Folate deficiency leads to increased pemetrexed toxicity. We report a rare and deleterious case of acute kidney injury associated with pemetrexed toxicity.

Case Description

63-year old male with PMH of stage IV non-small cell lung cancer and HTN presented with acute onset of skin desquamation of his facial, groin and buttocks regions along with severe mouth pain and odynophagia. The chemotherapy regimen was changed from pembrolizumab to pemetrexed two days prior. Severe odynophagia limited his oral intake. His BP on arrival was 86/60 and was fluid resuscitated. CBC was unremarkable except for platelet count of 56,000/uL and absolute neutrophil count of 372 cells/uL. CMP demonstrated BUN of 38mg/dL and serum Creatinine of 4.2mg/dL. His baseline Creatinine one month prior to presentation was .6. MRI of his abdomen was unremarkable. Initial treatment included aggressive fluid hydration, a granulocyte colony stimulating factor (TBO-Filgrastim) and empiric IV antibiotics given the severe neutropenia. Additionally, 5mg of folic acid intravenously was started to counter the anti-folate effects of pemetrexed. Increase in oral intake was encourage and pemetrexed was discontinued. His Creatinine returned to baseline within a few days. After resolution of mucositis, odynophagia and skin desquamation, he was discharged back home with changes to his chemotherapy regimen.


Pemetrexed is a second line agent that has been used to treat 84% of the second most common cancer in both men and women in the US. The most common adverse reactions are fatigue, skin desquamation, nausea, stomatitis, neutropenia and pharyngitis. A significantly less common adverse effect is AKI that can occur and if not identified can lead to acute renal failure. In our patient, his AKI is thought to be multifactorial from pre-renal due to decreased oral intake and intrinsic due to the toxicity of pemetrexed. Although aggressive fluid administration is imperative, the anti-folate effects of pemetrexed must be reversed with folic acid in order to prevent the patient from going onto dialysis. Prompt recognition of this adverse effect can lead to suitable treatment and recovery of his kidney function.