title: Serum cystatin C predicts vancomycin trough levels better than serum creatinine in hospitalized patients: a cohort study.
abstract: BACKGROUND
  Serum cystatin C can improve glomerular filtration rate (GFR) estimation over creatinine alone, but whether this translates into clinically relevant improvements in drug dosing is unclear.
  
  
  METHODS
  This prospective cohort study enrolled adults receiving scheduled intravenous vancomycin while hospitalized at the Mayo Clinic in 2012. Vancomycin dosing was based on weight, serum creatinine with the Cockcroft-Gault equation, and clinical judgment. Cystatin C was later assayed from the stored serum used for the creatinine-based dosing. Vancomycin trough prediction models were developed by using factors available at therapy initiation. Residuals from each model were used to predict the proportion of patients who would have achieved the target trough with the model compared with that observed with usual care.
  
  
  RESULTS
  Of 173 patients enrolled, only 35 (20%) had a trough vancomycin level within their target range (10 to 15 mg/L or 15 to 20 mg/L). Cystatin C-inclusive models better predicted vancomycin troughs than models based upon serum creatinine alone, although both were an improvement over usual care. The optimal model used estimated GFR by the Chronic Kidney Disease Epidemiology Collaborative (CKD-EPI) creatinine-cystatin C equation (R(2) = 0.580). This model is expected to yield 54% (95% confidence interval 45% to 61%) target trough attainment (P <0.001 compared with the 20% with usual care).
  
  
  CONCLUSIONS
  Vancomycin dosing based on standard care with Cockcroft-Gault creatinine clearance yielded poor trough achievement. The developed dosing model with estimated GFR from CKD-EPIcreatinine-cystatin C could yield a 2.5-fold increase in target trough achievement compared with current clinical practice. Although this study is promising, prospective validation of this or similar cystatin C-inclusive dosing models is warranted.
authors.forename: Erin N
authors.initials: EN
authors.lastname: Frazee
authors.forename: Andrew D
authors.initials: AD
authors.lastname: Rule
authors.forename: Sandra M
authors.initials: SM
authors.lastname: Herrmann
authors.forename: Kianoush B
authors.initials: KB
authors.lastname: Kashani
authors.forename: Nelson
authors.initials: N
authors.lastname: Leung
authors.forename: Abinash
authors.initials: A
authors.lastname: Virk
authors.forename: Nikolay
authors.initials: N
authors.lastname: Voskoboev
authors.forename: John C
authors.initials: JC
authors.lastname: Lieske
mesh_terms: D000900:Anti-Bacterial Agents / Q000008:administration & dosage / Q000493:pharmacokinetics*; D015415:Biomarkers / Q000097:blood; D003404:Creatinine / Q000097:blood*; D055316:Cystatin C / Q000097:blood*; D005260:Female; D005919:Glomerular Filtration Rate; D006760:Hospitalization; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D051436:Renal Insufficiency, Chronic / Q000097:blood / Q000503:physiopathology; D014640:Vancomycin / Q000008:administration & dosage / Q000493:pharmacokinetics*
chemical_list: D000900:Anti-Bacterial Agents; D015415:Biomarkers; D055316:Cystatin C; D014640:Vancomycin; D003404:Creatinine