Risk of Acute Kidney Injury Based on Vancomycin Target Trough Attainment Strategy: Area-Under-the-Curve-Guided Bayesian Software, Nomogram, or Trough-Guided Dosing

Abstract

Background: Guidelines support area-under-the-curve (AUC) monitoring for vancomycin dosing which may lower overall doses and reduce acute kidney injury (AKI). Objective: The aim of this study was to compare incidence of AKI across 3 vancomycin dosing modalities: AUC-targeted Bayesian pharmacokinetic software, AUC-targeted empiric dosing nomogram, and trough-guided dosing using clinical pharmacists’ judgment. Methods: This retrospective study included adult patients with a pharmacy dosing consult who received ≥1 dose of vancomycin and ≥1 serum vancomycin level documented between January 1, 2018, and December 31, 2019. Patients with baseline serum creatinine ≥2 mg/dL, weight ≥100 kg, receiving renal replacement therapy, AKI prior to vancomycin therapy, or vancomycin ordered only for surgical prophylaxis were excluded. The primary analysis was incidence of AKI adjusted for baseline serum creatinine, age, and intensive care unit admission. A secondary outcome was adjusted incidence of an abnormal trough value (<10 or >20 μg/mL). Results: The study included 3459 encounters. Incidence of AKI was 21% for Bayesian software (n = 659), 22% for the nomogram (n = 303), and 32% for trough-guided dosing (n = 2497). Compared with trough-guided dosing, incidence of AKI was lower in the Bayesian (adjusted odds ratio [OR] = 0.72, 95% confidence interval [CI]: 0.58-0.89) and the nomogram (adjusted OR = 0.71, 95% CI: 0.53-0.95) groups. Compared with trough-guided dosing, abnormal trough values were less common in the Bayesian group (adjusted OR = 0.83, 95% CI: 0.69-0.98). Conclusion and Relevance: Study results suggest that use of AUC-guided Bayesian software reduces the incidence of AKI and abnormal trough values compared with trough-guided dosing.

Acute Kidney Injury Incidence With Bayesian Dosing Software Versus 2-Level First-Order Area Under the Curve–Based Dosing of Vancomycin With Piperacillin-Tazobactam

“…Another recent retrospective study found a reduction in AKI with Bayesiandosed vancomycin compared with trough-guided dosing (aOR = 0.72, 95% CI = 0.58-0.89), though similar rates of AKI were seen when comparing Bayesian dosing with an AUC nomogram dosing strategy. 16 There are a few reasons why MIPD/Bayesian dosing may have resulted in a reduced incidence of AKI for patients on VPT within our study. The Bayesian dosing software provides several different models, including one for obese patients which was utilized for some of the included patients in this study.…”

“…Another recent retrospective study found a reduction in AKI with Bayesian-dosed vancomycin compared with trough-guided dosing (aOR = 0.72, 95% CI = 0.58-0.89), though similar rates of AKI were seen when comparing Bayesian dosing with an AUC nomogram dosing strategy. 16…”

Effects of inpatient creatinine testing frequency on acute kidney injury identification and staging: a historical cohort study

“…Clinical pharmacists have further demonstrated their contribution to patients recovering from an AKI episode by establishing post-discharge follow-up services [ 36 , 37 ]. Pharmacists play also a crucial role in AKI prevention by monitoring nephrotoxic drug levels [ 38 ], although some studies present conflicting conclusions [ 39 ]. Initial results from a large randomized controlled trial revealed that pharmacists, as part of a trained multidisciplinary team, adjusted doses, or initiated drug level monitoring in nearly 70% of patients with AKI [ 40 ].…”