Initial approach to trough-based vancomycin dose adjustments for adult patients receiving intermittent high-flux hemodialysis

Administer an IV loading dose* of 20 to 25 mg/kg (actual body weight).^¶
An initial maintenance IV dose of 10 mg/kg^Δ, 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:^◊
Pre-dialysis vancomycin serum concentration	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 20 mcg/mL	No change in therapy
21 to 30 mcg/mL	Decrease dose by 250 to 500 mg
>30 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; IHHD: intermittent high-flux hemodialysis.

* 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).

¶ If morbidly obese, an adjusted dosing weight is suggested. A calculator to determine adjusted dosing weight is available in UpToDate.

Δ In patients receiving IHHD, the differences between actual body weight pre-dialysis ("wet weight") and post-dialysis "dry weight" can be up to 3 kg. We use actual body weight (usually available at the time of ordering) for determination of the initial supplemental dose; subsequent supplemental doses are determined by pre-dialysis concentrations utilizing fixed dosing ranges (rounded to increments of 250 mg) so are not dependent on patient weight.

◊ 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 30 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.

Courtesy of Richard H Drew, PharmD. Adapted from: Duke University Hospital Adult Pharmacokinetics Policy, Department of Pharmacy (May 2022).

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Initial approach to trough-based vancomycin dose adjustments for adult patients receiving intermittent high-flux hemodialysis