Acute Kidney Injury Associated with Area under the Curve versus Trough Monitoring of Vancomycin in Obese Patients

Abstract

Vancomycin is a first-line agent used in the treatment of methicillin-resistant Staphylococcus aureus ; however, vancomycin is associated with acute kidney injury (AKI). Previous literature demonstrates decreased incidence of AKI using 24-hour area under the concentration-time curve (AUC 24 ) monitoring, but its safety is unknown in obese populations. Patients ≥18 years, with Body Mass Indices (BMI) ≥30 kg/m 2 , admitted between August 2015-July 2017 or October 2017-September 2019, who received vancomycin for ≥72 hours and had level(s) drawn within 96 hours of initiation were included. The primary outcome was incidence of AKI. Secondary outcomes included inpatient mortality rate, median inpatient length of stay, median vancomycin trough concentration, and median vancomycin AUC 24 . AKI was identified using the highest serum creatinine value compared to the value immediately prior to vancomycin initiation based on Kidney Disease Improving Global Outcomes (KDIGO) criteria. Overall, 1024 patients met inclusion criteria, with 142 out of 626 patients in the trough group and 65 out of 398 patients in the AUC 24 group meeting criteria for AKI (22.7% vs. 16.3%, p=0.008). Logistic regression of the data to account for confounding factors maintained significance for the reduction in incidence of AKI with AUC 24 monitoring compared to trough monitoring (p=0.010). Monitoring of vancomycin with AUC 24 was associated with a decreased risk of AKI when compared with trough monitoring in obese patients.

Vancomycin area under the curve versus trough only guided dosing and the risk of acute kidney injury: Systematic review and meta‐analysis

“…One study was excluded as it was descriptive and used each patient as their own control 24 . After these articles were excluded, 10 studies were included in the primary analysis 25–34 . A full description of the study selection process can be found in Figure 1.…”

“…A summary of the study characteristics is reported in Table 1. Three studies reported significant reductions in AKI with AUC‐guided dosing, 25,27,32 while six studies 26,28–30,33,34 favored AUC‐guided dosing but with nonsignificant results. One study favored trough‐guided dosing, though the results were not statistically significant 31 .…”

“…The results of our study indicate that AUC‐guided dosing strategies are less likely to result in vancomycin‐mediated nephrotoxicity than trough‐based dosing strategies. Of the three studies identifying a difference in AKI incidence, two 25,27 reported a statistically significant higher trough level in the trough‐guided dosing groups, while the third 32 did not provide this data. This signifies that the observed difference in AKI may be due to the inherently higher trough concentrations in the trough‐guided group.…”

“…24 After these articles were excluded, 10 studies were included in the primary analysis. [25][26][27][28][29][30][31][32][33][34] A full description of the study selection process can be found in Figure 1. Publication dates ranged from 2017 to 2021 and a total of 4231 patients were included.…”

Machine Learning-Based Model for Estimating Vancomycin Maintenance Dose to Target the Area under the Concentration Curve of 400–600 mg·h/L in Japanese Patients

“…However, with patients obesity should be cautioned about the risk of overdose when increase in VCM concentrations is anticipated. 30) In particular, VCM dose greater than 4000 mg has been reported to increase the risk of nephrotoxicity. 6,[30][31][32] Previous studies defined patients with BMI > 30 kg/m 2 as obese.…”