Can vancomycin (Vancomycin) cause intrinsic renal disease, specifically Impaired renal function?

From the Guidelines

Yes, vancomycin can cause intrinsic renal disease, specifically acute tubular necrosis (ATN), and its use requires careful consideration of the risk of nephrotoxicity, particularly in patients with pre-existing kidney disease or those receiving concomitant nephrotoxic medications. Vancomycin-induced nephrotoxicity typically occurs in 5-25% of patients receiving the antibiotic and is more common with higher trough levels (especially >20 mg/L), prolonged therapy (>7 days), and in patients with unstable renal function 1. The mechanism involves direct toxicity to proximal tubular cells through oxidative stress and mitochondrial damage. To minimize this risk, dosing should be adjusted based on renal function, with careful monitoring of trough levels (typically aiming for 10-15 mg/L for most infections, or 15-20 mg/L for severe infections like endocarditis) 1.

Key Considerations

• Kidney function should be monitored regularly during therapy with serum creatinine measurements.
• Adequate hydration and avoiding concurrent nephrotoxic agents when possible can help reduce risk.
• If vancomycin-induced nephrotoxicity occurs, it is usually reversible upon discontinuation of the drug, though recovery may take days to weeks.
• The use of vancomycin in patients with renal insufficiency requires careful dose adjustment and monitoring, as the presence of renal insufficiency was a significant predictor of vancomycin failure in a multivariate analysis of patients with ventilator-associated pneumonia (VAP) 1.
• Alternative therapies, such as linezolid, may be preferred in patients at risk for, or already with, renal insufficiency, as they may have a lower risk of nephrotoxicity and improved clinical outcomes 1.

Monitoring and Dosing

• Monitoring of trough serum vancomycin concentrations is recommended to reduce nephrotoxicity, particularly in patients receiving aggressive dose targeting or who are at risk of toxicity 1.
• Vancomycin dosages of 15–20 mg/kg (based on actual body weight) given every 8–12 h are required for most patients with normal renal function to achieve the suggested trough serum concentrations 1.
• Individual pharmacokinetic adjustments and verification of achievement of target serum concentrations are recommended 1.

From the FDA Drug Label

Systemic vancomycin exposure may result in acute kidney injury (AKI). The risk of AKI increases as systemic exposure/serum levels increase. Interstitial nephritis has also been reported in patients receiving vancomycin.

Vancomycin can cause nephrotoxicity, which may result in acute kidney injury (AKI). The risk of AKI increases with higher systemic exposure or serum levels of vancomycin. Additionally, interstitial nephritis has been reported in patients receiving vancomycin, indicating that it can cause intrinsic renal disease 2, 2.

From the Research

Vancomycin and Intrinsic Renal Disease

• Vancomycin has been associated with nephrotoxicity, which can lead to intrinsic renal disease 3, 4, 5, 6, 7.
• The risk of vancomycin-induced nephrotoxicity increases with higher doses, longer duration of therapy, and concurrent use of other nephrotoxic agents 4, 6, 7.
• Factors that can contribute to the development of vancomycin-induced nephrotoxicity include:
  • Higher vancomycin trough levels (>20 mg/L) 4, 6, 7
  • Total daily dose > 4 grams 6, 7
  • Therapy exceeding 6 days 6
  • Preexisting renal disease 5, 6
  • Obesity 6
  • Hypotensive episodes 6
  • Increasing severity of illness 6
• The mechanism of vancomycin-induced nephrotoxicity is not fully understood, but it is thought to be related to the production of reactive oxygen species and oxidative stress 7.
• Patients with chronic kidney disease are at increased risk of developing vancomycin-induced nephrotoxicity 5.
• Monitoring of vancomycin trough levels and renal function is recommended to prevent and detect nephrotoxicity 3, 5.