Hi Kim,
When I asked our pharmacokinetics PharmD. about thoughts on pre-HD dosing as recommended in a paper for short daily HD, here’s what was said (and agree with):
The difficulty in all this analysis by Decker et al (AJN 2012) is the single premise that getting a very high peak concentration is our goal that should be sought with aminoglycoside dosing in your population. My argument is that what does it mean to have a single high peak concentration for only ~ 1 hour (i.e. before its rapidly dialyzed off from pre-dialysis dosing) every 48 to 72 hours? I would rather see slightly lower, but sustained concentrations for a little longer time period in order to ensure adequate concentration-dependent killing. They did state that AUC is better with post-HD dosing, and I believe it may be the more effective therapeutic target to pursue. Their statement that toxicities (inferring auditory & vestibular) are simply related to AUC is incorrect. Duration appears to be a major risk factor for those toxicities. There is no evidence for AUC & toxicity development with aminoglycosides. I would recommend continuing with post-dialysis dosing.
As for post-HD 3x/week dosing, you can see our catheter related bacteremia order set here, see Appendix II on p. 2 for tobramycin dosing/monitoring:
https://www.kidneyhealth.ca/files/orders/W-00522.pdf
Lori Wazny, Pharm.D.
MB Renal Program
