What is the recommended vancomycin dose for patients with impaired renal function?

From the FDA Drug Label

DOSAGE TABLE FOR VANCOMYCIN IN PATIENTS WITH IMPAIRED RENAL FUNCTION (Adapted from Moellering et al. 1) Creatinine ClearancemL/minVancomycin Dosemg/24 h 1001,545 901,390 801,235 701,080 60925 50770 40620 30465 20310 10155 The initial dose should be no less than 15 mg/kg, even in patients with mild to moderate renal insufficiency.

The recommended vancomycin dose for patients with impaired renal function can be calculated using the provided dosage table, which is based on creatinine clearance.

• The dosage of vancomycin hydrochloride for injection per day in mg is about 15 times the glomerular filtration rate in mL/min.
• For functionally anephric patients, an initial dose of 15 mg/kg of body weight should be given to achieve prompt therapeutic serum concentrations, and the dose required to maintain stable concentrations is 1.9 mg/kg/24 hr.
• In patients with marked renal impairment, it may be more convenient to give maintenance doses of 250 to 1,000 mg once every several days rather than administering the drug on a daily basis.
• In anuria, a dose of 1,000 mg every 7 to 10 days has been recommended 1.

From the Research

Vancomycin dosing in patients with impaired renal function should be adjusted based on creatinine clearance, with a loading dose of 15-20 mg/kg and maintenance doses given at intervals of 12-24 hours for CrCl 50-90 mL/min, 24-48 hours for CrCl 10-50 mL/min, and 48-72 hours for CrCl <10 mL/min, as supported by the most recent study 2. The recommended vancomycin dose for patients with impaired renal function is a topic of ongoing research, with various studies providing guidance on dosage adjustments based on creatinine clearance (CrCl) and renal function.

• For patients with CrCl 50-90 mL/min, the dose is typically 15-20 mg/kg every 12-24 hours.
• For patients with CrCl 10-50 mL/min, the dose is typically 15-20 mg/kg every 24-48 hours.
• For patients with CrCl <10 mL/min, the dose is typically 15-20 mg/kg every 48-72 hours. A study from 2021 2 investigated the safety and efficiency of vancomycin in patients with moderate and severe renal dysfunction, finding that the mean vancomycin trough concentration achieved for the first time was 9.3 and 11.6 µg/mL in the moderate and severe renal dysfunction groups, respectively.
• The effective trough concentration endpoint was achieved by 50% and 43% of the patients in the severe and moderate renal dysfunction groups, respectively.
• No significant difference was found in the acute kidney injury (AKI) rate between the groups. Another study from 2019 3 evaluated the incidence of nephrotoxicity after a loading dose of vancomycin in patients with severe renal impairment, finding that patients in the high-dose group had a reduced risk of nephrotoxicity compared to the low-dose group.
• The study suggested that vancomycin loading doses do not increase nephrotoxicity compared to lower doses in patients with severe renal dysfunction. Therapeutic drug monitoring is essential, with target trough concentrations of 10-15 mg/L for most infections and 15-20 mg/L for severe infections like endocarditis, osteomyelitis, or meningitis, as vancomycin is primarily eliminated by the kidneys and impaired renal function increases the risk of toxicity, particularly nephrotoxicity and ototoxicity 4. Regular assessment of kidney function and vancomycin levels helps optimize efficacy while minimizing adverse effects.
• The serum creatinine change was significantly different between the groups, with the moderate group showing a slight deterioration and the severe renal dysfunction group showing an improvement 2. It may be necessary to increase the dose for patients with severe renal dysfunction while implementing a vancomycin loading dose and monitoring trough concentrations and adverse effects. Overall, the most recent and highest-quality study 2 provides the best guidance on vancomycin dosing in patients with impaired renal function, emphasizing the importance of adjusting doses based on creatinine clearance and monitoring trough concentrations to minimize adverse effects.