Acute kidney injury is common among critically ill patients and frequently necessitates continuous renal replacement therapy (CRRT). Both critical illness and CRRT alter vancomycin pharmacokinetics, which complicates empiric dosing and therapeutic drug monitoring. This scoping review aimed to evaluate published evidence on vancomycin PK and dosing in critically ill adult patients receiving CRRT, with the goal of summarizing PK parameter ranges, characterizing drivers of variability, and assessing model-based dosing recommendations.
The authors conducted a systematic scoping review following PRISMA-ScR guidelines. Comprehensive searches of Ovid MEDLINE via PubMed, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were performed for studies published through April 2026. Eligible studies were English-language reports involving critically ill adults receiving CRRT that assessed vancomycin pharmacokinetics and dosing using single- or multiple-dose population pharmacokinetic methods. Study screening used a standardized form, and any disagreements were resolved by consensus.
The literature search identified 114 potentially relevant studies. After screening and full-text assessment, 24 studies met the inclusion criteria and were included in the review. The included reports provided population PK estimates, reported ranges of key PK parameters, and in some cases presented dose-simulation results to explore loading and maintenance regimens for patients on CRRT.
Across included studies, reported vancomycin total clearance (CL) ranged from 1.5 to 4.8 L/h. CRRT was a consistent and substantial contributor to total vancomycin clearance; in the studies reviewed, CRRT accounted for at least 50% of total clearance. The review emphasizes that CRRT-specific factors—particularly CRRT modality and CRRT intensity—were primary determinants of vancomycin removal. These factors produced meaningful differences in vancomycin CL between patients and study cohorts.
Vancomycin volume of distribution (Vd) reported in the included studies varied broadly, with values spanning 0.4 to 1.4 L/kg. This wide range reflects the influence of critical illness physiologic changes—such as capillary leak, fluid resuscitation, and altered protein binding—on drug distribution. The review highlights substantial interindividual variability in both Vd and CL among critically ill patients on CRRT.
Population pharmacokinetic analyses included in the review consistently documented high interindividual variability, limiting the generalizability of a single fixed dosing regimen. Several studies performed dose-simulation exercises informed by their PK models. These simulations suggested loading dose ranges of 15–30 mg/kg and maintenance dose ranges of 5–20 mg/kg per day, depending on patient characteristics and CRRT settings. The authors report that model-informed precision dosing approaches were supported by simulation results and may help individualize therapy in this complex population.
The combined findings indicate that vancomycin dosing during CRRT is highly variable and not reliably predicted by standard dosing rules. Because CRRT modality and intensity substantially influence clearance, and because patients demonstrate wide variation in Vd and PK parameters, the review underscores the need for individualized dosing strategies. Specifically, the authors emphasize the role of therapeutic drug monitoring and model-informed precision dosing to achieve pharmacokinetic/pharmacodynamic targets while minimizing under- or overexposure.
The review notes gaps in the evidence base that limit definitive dosing recommendations. While population PK studies and simulations provide important insights, the authors call for prospective validation of personalized dosing strategies. In particular, future research should link validated PK/PD targets to clinical outcomes in critically ill patients on CRRT, and should evaluate implementation of model-informed dosing approaches in routine care.
Vancomycin pharmacokinetics in critically ill adults receiving CRRT are markedly altered and highly variable. CRRT contributes substantially to vancomycin clearance, and CRRT modality and intensity are key determinants of drug removal. Reported PK ranges include total clearance of 1.5–4.8 L/h and volume of distribution of 0.4–1.4 L/kg. Dose-simulation studies support loading doses of 15–30 mg/kg and maintenance dosing of 5–20 mg/kg daily in simulated scenarios, and they favor model-informed precision dosing combined with therapeutic drug monitoring. The authors conclude that individualized dosing and monitoring are essential and recommend future studies to validate personalized dosing strategies and to connect PK/PD targets with clinical outcomes in this population.