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Serum cystatin C predicts vancomycin trough levels better than serum creatinine in hospitalized patients: a cohort study.
Crit Care. 2014 May 29;18(3):R110
Authors: Frazee EN, Rule AD, Herrmann SM, Kashani KB, Leung N, Virk A, Voskoboev N, Lieske JC
Abstract
INTRODUCTION: 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 using factors available at therapy initiation. Residuals from each model were used to predict the proportion of patients that would have achieved the target trough with the model compared to 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 or 15 to 20 mg/L). Cystatin C-inclusive models better predicted vancomycin troughs than models based upon serum creatinine alone, though 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 (R2 = 0.580). This model is expected to yield 54% (95% CI 45% to 61%) target trough attainment (P < 0.001 compared to 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 to current clinical practice. Although this study is promising, prospective validation of this or similar cystatin C-inclusive dosing models is warranted.
PMID: 24887089 [PubMed - as supplied by publisher]