Clearance of Vancomycin during High-Efficiency Hemodialysis
Nattha Klansuwan B Pharm*, Chaveewan Ratanajamit B Pharm, PhD (Epidemiology)**, Srirat Kasiwong B Pharm, PhD (Pharmacokinetics)***, Adisorn Wangsiripaisan MD****
Affiliation : * Department of Pharmacy, Sadao Hospital, Songkhla ** Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Songkhla *** Department of Pharmaceutical Chemistry, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Songkhla **** Nephrology Unit, Department of Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla
Background : Vancomycin is commonly used for the treatment of MRSA infections in critically ill patients with
renal diseases. Vancomycin is mainly eliminated through the kidney. Its excretion is therefore substantially
reduced in severe renal impaired patients. Although several studies have demonstrated that significant amounts
of vancomycin are removed during High-Flux/High-Efficiency Hemo Dialysis (HF/HEHD), more data are
required to optimize clinical applications.
Objective : Predict the appropriate vancomycin intradialytic dosage and dosing interval among patients
receiving HEHD.
Materials and Methods : Twenty patients who were receiving HEHD with cellulose triacetate dialyzer were
included to determine the vancomycin intradialytic clearance. Two patients were included twice and one
patient was included three times due to reinfections. This gave rise to 24 patient-times. The study was carried
out at Songklanagarind Hospital between January 2003 and March 2004.
Results : In a prospective opened label design, each patient received 1g vancomycin, 1 hour infusion, immediately
after completion of HEHD. Six scheduled blood samples were drawn as follows: (1) 60 minutes following
completion of vancomycin infusion (Cmax); (2) immediately before starting the second HEHD; (3) 2 hours after
starting the second HEHD; (4) immediately after completion of the second HEHD; (5) immediately before
starting the third HEHD; and (6) immediately after the third HEHD ended (Cmin). The authors measured
vancomycin serum levels using HPLC technique. The serum concentrations were used to calculate all relevant
pharmacokinetic parameters. The pharmacokinetic parameters (mean (cid:31) SD) were: intradialytic clearance
(CLHD) 93.4 (cid:31) 37.1 mL/min; intradialytic elimination rate constant (ke) 1.1 (cid:31) 0.5 hr-1; overall elimination half-
life (t1/2) 77.1 (cid:31) 37.8 hr; volume of distribution (Vd) 82.1 (cid:31) 40.3 L; Cmax 25.8 (cid:31) 8.12 mg/L (range 12.04-48.80);
Cmin 6.2 (cid:31) 3.1 mg/L; and % removal during the second HEHD 37.9 (cid:31) 12.9. Subtherapeutic levels were found in
66.7% (16/24) and 91.6% (22/24) of patients after the second and the third HEHD, respectively.
Conclusion : HEHD with cellulose triacetate dialyzer removes significant amount of vancomycin. Based on the
authors’ findings, a loading dose of 1 g, and 500 mg after every subsequent HEHD is recommended.
Keywords : Clearance, Hemodialysis, Vancomycin, Pharmacokinetics
