We report a patient with metastatic non-small cell lung cancer who developed renal toxicities manifest as acute renal failure associated with nephrogenic diabetes insipidus and distal renal tubular acidosis following sequential therapy with pemetrexed. The nephrotoxicity occurred concomitantly with severe myelosuppression. We postulate renal tubular toxicity may account for distinct patterns of injury including acute renal failure and tubular cell dysfuntion of the distal nephron.