What is the recommended Vancomycin (vancomycin) dose and frequency for patients with Impaired renal function (renal impairment)?

From the Guidelines

Vancomycin dosing in renal impairment should be carefully adjusted based on the patient's creatinine clearance (CrCl) to minimize the risk of nephrotoxicity and ototoxicity, with a typical regimen of 15-20 mg/kg every 12-24 hours for mild to moderate renal impairment (CrCl 30-60 mL/min), every 24-48 hours for severe renal impairment (CrCl 10-30 mL/min), and every 48-72 hours for end-stage renal disease (CrCl <10 mL/min) 1.

Key Considerations

• For patients with normal renal function, IV vancomycin 15–20 mg/kg/dose (actual body weight) every 8–12 h, not to exceed 2 g per dose, is recommended 1.
• Therapeutic drug monitoring is essential, aiming for trough concentrations of 10-15 mg/L for most infections or 15-20 mg/L for severe infections like endocarditis, osteomyelitis, or meningitis 1.
• Regular monitoring of renal function and vancomycin levels is crucial throughout therapy to ensure efficacy while minimizing toxicity.

Dosing Adjustments

• Mild to moderate renal impairment (CrCl 30-60 mL/min): 15-20 mg/kg every 12-24 hours.
• Severe renal impairment (CrCl 10-30 mL/min): 15-20 mg/kg every 24-48 hours.
• End-stage renal disease (CrCl <10 mL/min): 15-20 mg/kg every 48-72 hours, with additional doses guided by serum levels.
• Hemodialysis: a loading dose of 15-20 mg/kg followed by 15-20 mg/kg after each dialysis session is typically used.

Rationale

• Vancomycin is primarily eliminated by glomerular filtration, and reduced renal function leads to drug accumulation, increasing the risk of nephrotoxicity and ototoxicity 1.
• The goal of vancomycin therapy is to achieve effective trough concentrations while minimizing the risk of toxicity, and regular monitoring of renal function and vancomycin levels is crucial to achieve this goal.

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 vancomycin dose and frequency for patients with renal impairment can be calculated using the provided dosage table.

• The dosage of vancomycin is about 15 times the glomerular filtration rate in mL/min.
• For example, a patient with a creatinine clearance of 50 mL/min would require a vancomycin dose of 770 mg/24 hours.
• The initial dose should be no less than 15 mg/kg, even in patients with mild to moderate renal insufficiency.
• 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 2.

From the Research

Vancomycin Dosing for Renal Impairment

• The relationship between vancomycin clearance and renal function has been studied, with vancomycin clearance and creatinine clearance being highly correlated (r = 0.92) in patients not on dialysis 3.
• A nomogram for vancomycin dosage adjustment has been developed based on this relationship, allowing for dosage adjustment in patients with various degrees of renal functional impairment 3.
• A vancomycin dosing chart has also been developed, which provides an exact dose and dosing interval based on the patient's body weight and creatinine clearance, with the goal of achieving an average steady-state serum concentration of approximately 15 mg/L 4.

Dosage Recommendations

• For patients with renal impairment, the dosage of vancomycin may need to be adjusted to avoid nephrotoxicity, with some studies suggesting that a dose of 1000-1500 mg/day may be optimal for patients with low renal function (CLCr < 45 mL/min) 5.
• For patients with augmented renal clearance (CLCr > 130 mL/min), a higher dose of up to 3500 mg/day or even 4500 mg/day may be necessary to achieve adequate exposure 5.
• The use of area under the curve (AUC)-based dosing has been proposed as a strategy for individualized vancomycin therapy in critically ill patients, with the goal of achieving a 24-hour AUC of 400-600 mg*h/L 6.

Monitoring and Adjustment

• Monitoring of vancomycin serum concentrations is recommended to ensure that the desired therapeutic range is achieved and to minimize the risk of nephrotoxicity 7, 5.
• The use of 6-hour urine creatinine clearance measurement has been proposed as a method for estimating vancomycin clearance in critically ill patients with normal renal function, allowing for adjustment of the vancomycin dose to achieve the desired AUC 6.