Forty-eight hours after infusion and despite of intensified treatment, MTX levels remained persistently high (202 μmol/L, toxic >1 μmol/L) and the patient developed leukocytosis (34.5 × 109/l), progressive acute renal failure (increase of serum creatinine to 2.94 mg/dL, eGFR 21 ml/min/1.73 m2), liver failure with elevated liver enzymes (AST 125 UI/L, ALT 193 UI/L) and coagulopathy (Quick 47%) treated with vitamin K and plasma. Here, GPT is linked to Hepatic failure.