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Approach to vancomycin dose adjustments for patients receiving intermittent high-flux hemodialysis

Administer an IV loading dose* of 25 mg/kg (estimated dry weight).^¶
A maintenance IV dose of 10 mg/kg (estimated dry weight), usually 500 or 750 mg, is given in the last 1 to 2 hours of each high-flux dialysis session.
A "spot" serum concentration should be obtained prior to the third dialysis session following initiation of therapy and the dose adjusted as follows:^Δ
Estimated vancomycin trough concentration: Extrapolate by reducing predialysis level by 40% to account for drug removal during a 4-hour dialysis session	Maintenance dose adjustment (dose given in the last 1 to 2 hours of each dialysis session)
<15 mcg/mL	Increase dose by 250 to 500 mg
15 to 25 mcg/mL	No change in therapy
26 to 35 mcg/mL	Decrease dose by 250 to 500 mg
>35 mcg/mL	Hold vancomycin dose^◊
Following dose adjustment, a repeat vancomycin serum concentration should be measured prior to the third dialysis session, with subsequent adjustment (if necessary) according to the principles above.
Once the predialysis vancomycin concentration is within the target range, it should be rechecked weekly.

The approach described is for patients receiving intermittent hemodialysis via high-flux membranes three times per week. Vancomycin is significantly cleared by high-flux dialysis membranes (ie, approximately 40% cleared in a 4-hour session). Refer to the UpToDate topic on vancomycin dosing for discussion of approach to patients receiving intermittent hemodialysis via older, less permeable low-flux membranes.

IV: intravenous.
* A maximum loading dose of 3 grams may be given; however, many use a loading dose of no more than 2 grams (especially in older patients and in patients with nonsevere infection).
¶ In obese patients, use actual body weight (estimated dry weight). If morbidly obese, an adjusted dosing weight is suggested. A calculator to determine adjusted dosing weight is available in UpToDate.
Δ In critically ill patients or other concern for altered pharmacokinetics (eg, residual renal function, acutely post-transplant), a pre-dialysis vancomycin concentration should be assessed prior to each dialysis session until stable dosing has been established.
◊ The vancomycin serum concentration should be repeated prior to each subsequent dialysis session until it falls below 35 mcg/mL, at which time vancomycin administration during the last 2 hours of hemodialysis should be resumed with dose reduction of 500 to 1000 mg. Following dose adjustment, repeat vancomycin serum concentration should be measured prior to the following dialysis session, with subsequent adjustment (if necessary) as summarized above.

Adapted from: Duke University Hospital Adult Pharmacokinetics Policy, Department of Pharmacy (June 2014). Courtesy of Richard H Drew, PharmD.

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