Is vancomycin (Vancomycin) nephrotoxicity reversible?

From the Guidelines

Vancomycin nephrotoxicity is generally reversible in most cases when the medication is discontinued promptly, with kidney function typically returning to baseline within 5-7 days after stopping vancomycin. To minimize the risk of nephrotoxicity, vancomycin should be dosed appropriately based on patient weight, renal function, and therapeutic drug monitoring, with target trough levels of 10-15 mg/L for most infections or 15-20 mg/L for serious infections like endocarditis or osteomyelitis, as recommended by the Infectious Diseases Society of America 1. Patients receiving vancomycin should have their kidney function monitored regularly through serum creatinine and BUN measurements, typically every 2-3 days during therapy.

Key Considerations

• Risk factors that increase nephrotoxicity include concurrent nephrotoxic medications, high trough levels (>20 mg/L), prolonged therapy (>7 days), high daily doses, pre-existing kidney disease, and advanced age.
• Monitoring of trough serum vancomycin concentrations to reduce nephrotoxicity is best suited for patients receiving aggressive dose targeting to produce sustained trough serum concentrations of 15–20 mg/L or who are at risk of toxicity, such as patients receiving concurrent treatment with nephrotoxins 1.
• Vancomycin causes kidney injury primarily through oxidative stress to proximal tubular cells, with acute tubular necrosis being the most common pathological finding.

Recommendations for Practice

• Trough vancomycin monitoring is recommended for serious infections and patients who are morbidly obese, have renal dysfunction (including those receiving dialysis), or have fluctuating volumes of distribution, as stated in the clinical practice guidelines by the Infectious Diseases Society of America 1.
• Individual pharmacokinetic adjustments and verification of achievement of target serum concentrations are recommended, especially when individual doses exceed 1 g 1.

From the Research

Vancomycin Nephrotoxicity Reversibility

• The reversibility of vancomycin nephrotoxicity has been studied in several research papers.
• According to a study published in the Journal of hospital medicine 2, the overall reversibility of nephrotoxicity either prior to or within 72 hours of vancomycin discontinuation was 77.8%.
• Another study published in PloS one 3 found that patients with vancomycin nephrotoxicity had a characteristic clinical profile, including a high serum trough level of vancomycin, a rapidly developed and severe acute kidney injury, and a recovery of renal function often shortly after discontinuation of vancomycin.
• A study published in Kidney international 4 noted that the risk of vancomycin-induced nephrotoxicity is incremental with higher trough levels and longer duration of vancomycin use.
• Other studies have identified potential risk factors for vancomycin nephrotoxicity, including the use of concomitant nephrotoxic agents, such as furosemide and torasemide 5, and the use of high doses of vancomycin 6.
• However, the study published in Academic emergency medicine 6 found that high single-dose vancomycin loading was not associated with increased nephrotoxicity in emergency department sepsis patients.

Factors Influencing Reversibility

• The reversibility of vancomycin nephrotoxicity may be influenced by several factors, including the severity of the nephrotoxicity, the duration of vancomycin use, and the presence of underlying kidney disease.
• A study published in European journal of hospital pharmacy 5 found that patients with diabetes mellitus, voriconazole, and fluconazole may be at increased risk of vancomycin nephrotoxicity.
• The use of vancomycin at high doses (>20 mg/kg) was not associated with an increased rate of nephrotoxicity compared with lower doses, according to a study published in Academic emergency medicine 6.

Clinical Implications

• The reversibility of vancomycin nephrotoxicity has important clinical implications, as it may influence the decision to continue or discontinue vancomycin therapy in patients who develop nephrotoxicity.
• Clinicians should be aware of the potential risk factors for vancomycin nephrotoxicity and monitor patients closely for signs of nephrotoxicity, particularly those with underlying kidney disease or those receiving concomitant nephrotoxic agents 2, 3, 4, 5, 6.