Vancomycin redistribution: dosing recommendations following high-flux hemodialysis.
Although increased vancomycin clearance has been reported with highly permeable hemodialysis membranes (such as polysulfone), failure to consider post-dialysis redistribution could lead to unnecessary dosage supplementation. In protocol 1, twelve hemodialysis patients admitted for vascular access thrombectomy received 15 mg/kg of vancomycin as surgical prophylaxis. Post-operatively, patients underwent high-flux hemodialysis (HFHD) for two hours using a Fresenius F-80 polysulfone dialyzer (QB = 417 +/- 49, QD = 800 ml/min). Vancomycin's intradialytic clearance increased 13-fold compared to the patient's endogenous clearance (120 +/- 59 vs. 9 +/- 8 ml/min, respectively) yet dialysate recovery indicated that only 17% of body stores were removed (179 +/- 70 mg). Although serum vancomycin levels decreased 33% during HFHD, vancomycin levels increased in all patients following dialysis and the post-rebound values reached 87% of the pre-dialysis concentration. In protocol 2, eight outpatients receiving maintenance HFHD with a F-80 dialyzer (Kt/V = 1.29 +/- 0.08) were given 20 mg/kg of vancomycin immediately following dialysis on Monday; pre- and post-levels were measured during the next three dialysis treatments. The predialysis serum vancomycin levels were > 7.5 micrograms/ml (9.7 +/- 1.0 micrograms/ml; range 8.0 to 11.0) in all patients the following Monday. Thus, vancomycin clearance is increased during HFHD, but redistribution post-HD minimizes changes in serum levels. We recommend a 20 mg/kg i.v. loading dose and subsequent doses of 15 mg/kg every seven days; to account for individual variability, weekly vancomycin levels should be drawn before dialysis.
Pollard
T A
TA
Department of Pharmacy, Emory University School of Medicine, Atlanta, Georgia.
Lampasona
V
V
Akkerman
S
S
Tom
K
K
Hooks
M A
MA
Mullins
R E
RE
Maroni
B J
BJ
D000328:Adult; D002408:Catheters, Indwelling / Q000009:adverse effects; D004305:Dose-Response Relationship, Drug; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009994:Osmolar Concentration; D011300:Preoperative Care; D006435:Renal Dialysis / Q000379:methods*; D017131:Thrombectomy; D014018:Tissue Distribution; D014640:Vancomycin / Q000008:administration & dosage* / Q000097:blood* / Q000627:therapeutic use
D014640:Vancomycin