Vancomycin in Renal Replacement Therapy
Dosing in Outpatient Intermittent HDF
Loading dose – 25- 30 mg/kg (based on Actual Body Weight (ABW) – defined as the reading taken when the patient is able to stand unassisted using a calibrated scale)
Following are the calculated average doses for different weight categories:
Weight (kg) | Dose (mg) |
---|---|
<40 | 1000 |
40 - 65 | 1500 |
65.1 - 89 | 2000 |
90 - 119 | 2500 |
>120 | Maximum of 3000 |
Rationale – Approximately 20 -40 % of intradialytically administered Vancomycin (last 30-90 minutes) is removed during HD with high Flux dialyzers- this likely to be greater in Post dilutional HDF with High Flux Dialysers ( default treatment option in D& G outpatient dialysis unit). Higher loading and subsequent maintenance dosing is expected to ensure therapeutic serum concentrations throughout the dosing interval.
Maintenance dosing – Maintenance dosing should be based on pre dialysis serum Vancomycin concentration. Aim for a pre HDF level between 15 – 20mg/L. Below is a guide based on recommended weight based calculation of 10-15 mg/kg.
Pre-dialysis concentration (mg/L) | Dose (mg) |
---|---|
<10 | 1500 |
10-15 | 1000 |
15-20 | 750 |
20-25 | 500 |
>25 | Hold Vancomycin |
If pre dialysis level is not available – calculate dose at 10mg/kg body weight.
Duration for Administration of Vancomycin During Dialysis
Dose (mg) | Duration |
---|---|
500 | last 45 minutes |
750-1000 | 90 min (1.5 hours) |
1250-1500 | 135 min (2.25 hours) |
1750-2000 | 180 min (3 hours) |
2500-3000 | 270 min (4.5 hours) |
If the patient is unwilling to stay behind to complete the infusion a faster infusion can be given following discussion with the on call renal doctor, however this carries a technical risk of anaphylactoid reaction (red man syndrome)
Dose (mg) | Duration |
---|---|
500 | Last 30 minutes |
750-1000 | 60 min |
1250-1500 | 90 min |
1750-2000 | 120 min |
2500-3000 | 180 min |
Dosing in Patients Receiving Acute HD/ HDF (daily, every other day, > 3 /week)
Loading dose 25 mg/kg (based on actual body weight ABW)
Calculated average doses:
Actual Body Weight (kg) | Dose (mg) |
---|---|
<65k | 1500 |
65.1 - 89 | 2000 |
90 - 119 | 2500 |
>120 | Maximum of 3000 |
Maintenance dosing – should be based on predialysis serum Vacomycin concentration aiming for a level of 15-20 mg /L.
Dosing based on the levels calculated for an average of 15mg/kg body weight :
Concentration (mg/L) | Dose (mg) |
---|---|
<10 | 1500 |
10-15 | 1000 |
15-20 | 750 |
25 | 500 |
>25 | Hold Vancomycin |
In critically ill patients initial dose should not wait for the end of a dialysis treatment. If patient receives a loading dose and it’s followed by a full 3-5 hour session of HD/HDF the same day a supplemental dose of 500 mg during the last 30 minutes of HD is recommended.
Speed of administration as in intermittent HDF.
References
- ASHP Report June 2020 [pdf]
- Crew P. et al. Vancomycin Dosing and monitoring for patients with end stage renal disease receiving intermittent haemodialysis. American Journal of Syst. Pharm. 2015; 72:1856-64
- Nyman H.A. et.al. Removal of Vancomycin administered during dialysis by a high flux dialyzer. Haemodialysis International 2018; 22: 383-387. (Requires Knowledge Network Login for full text)
- Vandecasteele S.J. et.al.Vancomycin dosing in patient on intermittent haemodialysis. Seminars in Dialysis 2011; 24:50-55. (Requires Knowledge Network Login for full text)
- Vancomycin dosage guidelines proposed revisions GGC.
Content by Dr Nadeeka Rathnamalala and the Renal Team