What is the recommended dosage of Vancomycin (vancomycin) for a patient with Impaired renal function undergoing hemodialysis (HD)?

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 table is not valid for functionally anephric patients For such patients, an initial dose of 15 mg/kg of body weight should be given to achieve prompt therapeutic serum concentrations. 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

For a patient with impaired renal function undergoing hemodialysis (HD), the recommended dosage of Vancomycin can be determined using the provided dosage table. However, since the patient is undergoing hemodialysis, they can be considered functionally anephric.

• The initial dose should be at least 15 mg/kg of body weight.
• The maintenance dose required to maintain stable concentrations is 1.9 mg/kg/24 hr.
• Alternatively, maintenance doses of 250 to 1,000 mg can be given once every several days.
• In anuria, a dose of 1,000 mg every 7 to 10 days has been recommended 1.

From the Research

For hemodialysis patients, vancomycin is typically dosed at 18-23 mg/kg actual body weight as a loading dose, followed by maintenance doses of 8-13 mg/kg administered during the last hour of dialysis, with target trough concentrations of 15-20 mg/L for serious infections. The exact maintenance dose depends on the patient's residual renal function, body weight, and the measured vancomycin trough levels, which should be monitored regularly 2. Blood samples for trough levels should be drawn before the next hemodialysis session. Vancomycin is significantly removed by hemodialysis, which is why administration during the last hour of dialysis is crucial to maintain therapeutic levels 3. The drug's elimination is primarily renal, so patients with no residual kidney function rely entirely on dialysis for drug clearance. Dose adjustments should be made based on trough levels, clinical response, and any signs of toxicity such as nephrotoxicity or ototoxicity. Regular monitoring of vancomycin levels is essential to ensure effective antimicrobial therapy while minimizing adverse effects.

Some key considerations for vancomycin dosing in hemodialysis patients include:

• Administering vancomycin during the last 60-90 minutes of hemodialysis to prevent vascular damage and preserve patients' vascular access 2
• Using a weight-based loading dose and maintenance dose, with adjustments based on trough levels and clinical response 4
• Monitoring vancomycin levels regularly to ensure target trough concentrations are achieved and to minimize the risk of toxicity 5
• Considering the type of dialyzer used and the duration of dialysis when determining the optimal vancomycin dose 5

Overall, the goal of vancomycin dosing in hemodialysis patients is to achieve target trough concentrations while minimizing the risk of toxicity and ensuring effective antimicrobial therapy. Administering vancomycin during the last hour of dialysis at a dose of 18-23 mg/kg as a loading dose, followed by maintenance doses of 8-13 mg/kg, is a recommended approach 2, 3.