Calrecia (Calcium Chloride Dihydrate)
Infusion solution for calcium replacement during renal replacement therapy and plasma exchange
Quick Facts About Calrecia
Key Takeaways About Calrecia
- Hospital-only medicine: Calrecia is administered exclusively under medical supervision during extracorporeal blood purification procedures such as CRRT, SLEDD, and therapeutic plasma exchange
- Calcium replacement role: It restores ionised calcium levels that are reduced when citrate is used as an anticoagulant in the extracorporeal blood circuit
- Regular monitoring required: Systemic ionised calcium levels must be checked regularly and the infusion rate adjusted to keep calcium within the target range
- Not for peripheral IV use: Calrecia must only be infused via an extracorporeal blood purification device or a separate central venous access — never through a peripheral vein, intramuscularly, or subcutaneously
- Maximum 3 litres per day: The recommended maximum daily dose is 3 L/day, and the product is not intended for chronic use
What Is Calrecia and What Is It Used For?
Calrecia is a calcium chloride dihydrate infusion solution (100 mmol/L) used in adults and children during continuous renal replacement therapy (CRRT), sustained low-efficiency daily dialysis (SLEDD), and therapeutic plasma exchange (TPE) to maintain blood calcium levels within the desired physiological range.
Calrecia belongs to a category of medicines known as electrolyte replacement solutions. It is specifically designed for use in critical care and nephrology settings where patients require extracorporeal blood purification — procedures in which blood is circulated through a machine outside the body for filtration or treatment before being returned to the patient.
During these procedures, a substance called citrate is commonly used as a regional anticoagulant to prevent the blood from clotting inside the extracorporeal circuit. Citrate works by binding (chelating) ionised calcium, which is essential for the clotting cascade. While highly effective at preventing circuit clotting, citrate-based anticoagulation causes a significant reduction in the patient's systemic ionised calcium levels. If left uncorrected, this calcium depletion can lead to dangerous clinical consequences including cardiac arrhythmias, neuromuscular excitability, and haemodynamic instability.
Calrecia addresses this problem by providing a concentrated, precisely formulated source of calcium ions. Each 1000 mL of solution contains 14.7 g of calcium chloride dihydrate, yielding 100 mmol of calcium and 200 mmol of chloride. The solution has a theoretical osmolarity of 300 mOsm/L and a pH of 5.0–7.0, making it well-suited for infusion into the extracorporeal circuit or via a dedicated central venous access line.
Clinical indications
Calrecia is indicated for the following clinical procedures:
- Continuous Renal Replacement Therapy (CRRT): Used in critically ill patients with acute kidney injury (AKI) who require continuous blood purification, typically in intensive care units. CRRT runs continuously over 24 hours and is gentler on haemodynamically unstable patients than conventional intermittent dialysis.
- Sustained Low-Efficiency Daily Dialysis (SLEDD): A hybrid technique combining features of CRRT and conventional haemodialysis, typically running for 6–12 hours. It offers haemodynamic stability with higher solute clearance than standard CRRT.
- Therapeutic Plasma Exchange (TPE): A procedure that removes the patient's plasma and replaces it with donor plasma or albumin solution. TPE is used to treat autoimmune conditions, haematological disorders, and certain neurological diseases. Citrate anticoagulation during TPE necessitates calcium replacement.
Ionised calcium plays a critical role in cardiac function, blood clotting, neuromuscular transmission, and bone metabolism. During citrate-based anticoagulation, calcium levels can drop to dangerously low levels within minutes. Calrecia ensures that systemic ionised calcium is continuously maintained at a safe, physiological concentration throughout the procedure.
What Should You Know Before Using Calrecia?
Calrecia must not be used in patients with hypercalcaemia (high blood calcium) or hyperchloraemia (high blood chloride). Special caution is needed in patients taking digitalis glycosides or those with conditions affecting calcium metabolism. Your healthcare team will closely monitor your calcium and electrolyte levels throughout treatment.
Before your medical team administers Calrecia, several important factors must be assessed. As with any intravenous electrolyte therapy, correct patient selection and ongoing monitoring are essential for safe and effective treatment. The following sections detail the contraindications, precautions, and special considerations that apply to Calrecia use.
Contraindications
Calrecia must not be used if you have:
- Hypercalcaemia: An elevated level of calcium in the blood. Adding exogenous calcium in this setting could worsen symptoms and lead to serious complications including cardiac arrhythmias, renal calculi, and soft tissue calcification.
- Hyperchloraemia: An elevated level of chloride in the blood. Since Calrecia provides 200 mmol of chloride per litre, its use in hyperchloraemic patients could exacerbate metabolic acidosis.
Warnings and Precautions
Inform your doctor before receiving Calrecia if any of the following apply to you:
- Digitalis glycoside therapy: If you are taking medications such as digoxin or digitoxin for heart conditions, calcium supplementation must be managed with extreme caution. Calcium potentiates the effects of digitalis glycosides, significantly increasing the risk of life-threatening cardiac arrhythmias, including ventricular fibrillation.
- Disorders of calcium metabolism: Conditions that affect how your body handles calcium require careful evaluation. These include nephrocalcinosis (calcium deposits in the kidneys), hypercalciuria (excessive calcium excretion in urine), and vitamin D overdose or intoxication. In these situations, exogenous calcium may accumulate or be poorly regulated.
- Conditions affecting parathyroid function: Hyperparathyroidism or hypoparathyroidism can alter calcium homeostasis, making dosing adjustments necessary.
Your healthcare team will take the following monitoring steps during treatment:
- Inspect the bag and solution visually before use to confirm clarity and integrity
- Regularly check the infusion site in the blood lines for evidence of blood clot formation
- Ensure that systemic ionised calcium is measured at regular intervals and that the infusion rate is adjusted accordingly
- Monitor parathyroid hormone (PTH) levels and other markers of bone metabolism
- Check overall electrolyte balance and acid-base status throughout the procedure
Pregnancy and Breastfeeding
If you are pregnant, suspect pregnancy, or are planning to become pregnant, you should inform your healthcare provider before receiving Calrecia. There is currently insufficient clinical data regarding the use of Calrecia during pregnancy. It should only be administered to pregnant patients when the treating physician considers it absolutely necessary and the potential benefit outweighs the potential risk to the foetus.
Breastfeeding is generally considered possible during treatment with Calrecia. Calcium is a normal constituent of breast milk, and the additional calcium provided by Calrecia is unlikely to pose a risk to the nursing infant. However, you should always discuss this with your healthcare provider for personalised guidance.
The decision to use Calrecia during pregnancy should be based on a thorough risk-benefit analysis. The underlying clinical condition requiring CRRT, SLEDD, or TPE often represents a greater risk to the mother and foetus than the calcium replacement solution itself. Standard maternal and foetal monitoring protocols should be followed.
How Does Calrecia Interact with Other Drugs?
Calrecia can interact with thiazide diuretics, digitalis glycosides, and certain antibiotics (tetracyclines, ceftriaxone). It is also incompatible with solutions containing inorganic phosphate or carbonates. Always inform your medical team of all medications you are taking.
Drug interactions with calcium-containing infusion solutions are clinically significant and can affect both the safety and efficacy of treatment. Because Calrecia is administered in a controlled hospital environment, your medical team will already be aware of most potential interactions. However, it is important that you disclose all current medications, including over-the-counter drugs and supplements, to your healthcare team before starting treatment.
Major interactions
The following drug interactions are considered clinically significant and may require dose adjustment, alternative therapy, or enhanced monitoring:
| Drug / Class | Interaction Mechanism | Clinical Significance | Management |
|---|---|---|---|
| Digitalis glycosides (digoxin, digitoxin) | Calcium enhances myocardial sensitivity to digitalis, potentiating both therapeutic and toxic effects | High — risk of fatal cardiac arrhythmias including ventricular fibrillation | Close cardiac monitoring; slow calcium infusion rate; consider alternative anticoagulation strategies |
| Thiazide diuretics (hydrochlorothiazide, chlorthalidone) | Thiazides reduce renal calcium excretion, leading to calcium retention | Moderate — increased risk of hypercalcaemia | Monitor serum calcium more frequently; adjust Calrecia infusion rate as needed |
| Ceftriaxone | Calcium-ceftriaxone precipitates can form in vitro and in vivo, particularly in neonates | High — risk of particulate formation; potentially fatal in neonates | Never administer simultaneously through the same infusion line; flush lines between infusions |
| Tetracycline antibiotics | Calcium forms insoluble chelation complexes with tetracyclines, reducing antibiotic bioavailability | Moderate — reduced antibiotic efficacy | Avoid simultaneous infusion; use separate access lines and stagger timing |
Solution incompatibilities
Calrecia must not be mixed or co-infused with solutions containing the following substances, as they can form insoluble precipitates that pose a risk of embolism or catheter blockage:
- Inorganic phosphate salts: Calcium and phosphate readily combine to form calcium phosphate precipitates, which are insoluble and potentially dangerous if introduced into the bloodstream.
- Carbonate-containing solutions: Calcium carbonate precipitates can form when calcium chloride is mixed with bicarbonate or carbonate solutions.
- Any solution whose compatibility with calcium has not been established: Calrecia is not intended as a vehicle for drug admixtures. No medication should be added to the bag.
Calrecia is not intended for the addition of any medication and is not for use as a peripheral intravenous infusion. It must only be infused using an extracorporeal blood purification device specifically designed for 100 mmol/L calcium chloride solutions, or via a separate central venous access line as recommended by the device manufacturer.
What Is the Correct Dosage of Calrecia?
Calrecia dosage is individually determined by the treating physician based on systemic ionised calcium measurements. The infusion rate is continuously adjusted to maintain target calcium levels. The maximum recommended dose is 3 litres per day, and the product is not intended for chronic use.
Calrecia is always administered in a hospital or clinical setting under the direct supervision of a physician experienced in extracorporeal blood purification procedures. You will not need to manage your own dosage — your medical team will handle all aspects of the infusion, including rate adjustments based on laboratory results.
Adults
In adult patients, the dosing of Calrecia follows a goal-directed protocol based on regular measurement of systemic ionised calcium (iCa). The general principles are:
Standard dosing protocol for adults
- Target ionised calcium: Typically 1.0–1.2 mmol/L (may vary by protocol and clinical context)
- Monitoring frequency: Ionised calcium should be measured at least every 4–6 hours, and more frequently at initiation or after rate changes
- Rate adjustment: The infusion rate is titrated up or down based on measured iCa levels relative to the target range
- Maximum daily dose: 3 litres per 24 hours
- Duration: For the duration of the extracorporeal blood purification procedure; not intended for chronic administration
The exact flow rate of Calrecia depends on multiple factors, including the blood flow rate through the extracorporeal circuit, the citrate infusion rate, the patient's endogenous calcium metabolism, and the type of procedure being performed. Modern extracorporeal blood purification devices often have integrated protocols that calculate the appropriate calcium replacement rate based on these variables.
Children
Calrecia is approved for use in paediatric patients, although clinical experience in children is more limited than in adults. Dosing in children follows the same goal-directed principle as in adults:
Paediatric dosing considerations
- Same monitoring principles apply: Regular ionised calcium measurements with rate adjustment to maintain target levels
- Lower absolute volumes: Children will typically require lower total volumes due to smaller blood volumes and lower citrate doses
- Close monitoring essential: Paediatric patients may have less physiological reserve and may be more susceptible to rapid calcium fluctuations
- Specialist supervision: Paediatric CRRT and related procedures should be performed under the supervision of a paediatric nephrologist or intensivist
Elderly patients
No specific dose adjustment is required solely on the basis of age. However, elderly patients frequently have comorbidities that may affect calcium metabolism, including chronic kidney disease, osteoporosis, vitamin D deficiency, and cardiovascular disease. Additionally, polypharmacy is more common in older patients, increasing the risk of drug interactions (particularly with digitalis glycosides and thiazide diuretics). Enhanced monitoring may be warranted.
Overdose
Since Calrecia is administered exclusively by healthcare professionals in a controlled environment, overdose is unlikely but not impossible. Excessive administration results in hypercalcaemia, which can be a serious and potentially life-threatening condition.
Signs and symptoms of hypercalcaemia include:
- General: Fatigue, lethargy, disorientation, weakness, dehydration, chalky taste sensation, flushing
- Neuromuscular: Tingling, hyperreflexia, muscle weakness, loss of muscle tone
- Gastrointestinal: Nausea, vomiting, constipation, abdominal pain, tendency to develop peptic ulcers, colic, intestinal obstruction
- Cardiovascular: Tachycardia, bradycardia, irregular heart rhythm (arrhythmias) with risk of cardiac arrest, hypertension, ECG changes, syncope, vasodilation with hypotension
- Renal: Polyuria (excessive urine output) followed by oliguria or anuria (reduced or absent urine output), nephrocalcinosis (calcium deposits in the kidneys), hypercalciuria
In cases of very high calcium levels (hypercalcaemic crisis), patients may experience severe vomiting, colicky abdominal pain, intestinal atony, intestinal obstruction, profound weakness, altered consciousness, and initially increased urination followed by markedly decreased or absent urination. This is a medical emergency requiring immediate intervention.
If you experience any of these symptoms during treatment, inform your healthcare team immediately. Management typically involves stopping the Calrecia infusion, aggressive hydration with normal saline, loop diuretics (such as furosemide) to promote calcium excretion, and continuous cardiac monitoring.
What Are the Side Effects of Calrecia?
Side effects of Calrecia and the associated CRRT/SLEDD/TPE procedures include hypothermia, fluid imbalances, electrolyte disturbances (low potassium, low phosphate), acid-base abnormalities, low blood pressure, and high or low calcium levels. Incorrect application can cause local tissue damage. The exact frequency of these effects is not known.
Like all medicines, Calrecia can cause side effects, although not everybody will experience them. It is important to understand that many of the side effects listed below are related to the underlying extracorporeal blood purification procedure itself (CRRT, SLEDD, or TPE) rather than specifically to Calrecia. Your medical team is trained to recognise and manage these effects promptly.
Side effects related to the treatment procedure
The following effects may occur as a consequence of the extracorporeal blood purification treatment in general:
Procedure-Related Effects
- Hypothermia (low body temperature) — blood cooling during extracorporeal circulation
- Fluid imbalances (hypervolaemia or hypovolaemia) — too much or too little fluid in the body
- Hypokalaemia (low potassium) — due to dialysis clearance of potassium
- Hypophosphataemia (low phosphate) — due to phosphate removal during filtration
- Acid-base disturbances (metabolic acidosis or alkalosis)
- Hypotension (low blood pressure) — related to fluid shifts during treatment
Side effects specific to Calrecia
The following side effects are specifically associated with the use of Calrecia itself:
Hypercalcaemia
- Elevated blood calcium levels due to excessive infusion of calcium chloride
- Symptoms may include nausea, vomiting, constipation, muscle weakness, confusion, cardiac arrhythmias
- Managed by reducing or stopping the Calrecia infusion rate
Infusion Site Reactions
- Irritation at the infusion site
- Extravasation (leakage of fluid into surrounding tissue) causing burning sensation
- In severe cases: gangrene, tissue necrosis (tissue death), cellulitis (skin infection), and induration (hardening) of soft tissues
The exact frequency of these side effects cannot be calculated from available data because they depend heavily on the clinical context, the specific procedure being performed, the patient's underlying condition, and the accuracy of the infusion setup. Your medical team will take every precaution to minimise these risks, including regular monitoring and careful equipment checks.
It is important to report any suspected adverse reactions after the medicine has been authorised. This allows continuous monitoring of the medicine's benefit-risk balance. Healthcare professionals and patients are encouraged to report suspected adverse reactions through their national pharmacovigilance system.
How Should Calrecia Be Stored?
Store Calrecia protected from cold — do not freeze. Use before the expiry date on the label. The contents must be used immediately after opening. It is for single use only; discard any remaining solution and damaged packaging.
Proper storage of Calrecia is essential to ensure the solution remains safe and effective for patient use. Although storage is primarily the responsibility of hospital pharmacy and nursing staff, understanding the requirements is important for ensuring quality and safety.
Storage conditions
- Temperature: Store protected from cold. Do not refrigerate and do not freeze. Freezing can alter the physical properties of the solution and damage the bag integrity, rendering the product unusable.
- Light: No special precautions for light protection are required.
- Expiry date: Do not use after the expiry date (EXP) printed on the bag label and outer carton. The expiry date refers to the last day of the stated month.
- After opening: The contents must be used immediately after opening. The solution does not contain preservatives, so microbial contamination is a risk once the bag has been opened.
- Single use only: Calrecia is intended for single use. Any remaining solution after the procedure must be discarded. Do not reuse or store opened bags.
- Damaged packaging: Do not use if the bag, protective overwrap, or connector is damaged. Inspect each bag carefully before use.
Keep all medicines out of the sight and reach of children. In the hospital setting, Calrecia should be stored in a secure medication storage area in accordance with institutional protocols and local regulatory requirements.
What Does Calrecia Contain?
Calrecia contains calcium chloride dihydrate (14.7 g per 1000 mL) as the active substance, dissolved in water for injections. Each 1000 mL provides 100 mmol calcium and 200 mmol chloride, with a theoretical osmolarity of 300 mOsm/L.
Composition
| Component | Quantity | Role |
|---|---|---|
| Calcium chloride dihydrate | 14.7 g | Active ingredient |
| Ca2+ (calcium ions) | 100 mmol | Electrolyte |
| Cl− (chloride ions) | 200 mmol | Electrolyte |
| Water for injections | q.s. to 1000 mL | Solvent |
Physical properties
- Theoretical osmolarity: 300 mOsm/L
- pH range: 5.0–7.0
- Appearance: Clear, colourless solution, practically free from visible particles
Packaging
Calrecia is supplied in bags containing 1500 mL of ready-to-use solution. Each bag is equipped with a connection tube and coupling and is covered by a protective overwrap. The packaging is designed for direct connection to compatible extracorporeal blood purification devices.
- Pack size: 8 bags of 1500 mL per carton
- Presentation: Two bags joined by a tear seam; separate before use
- Connection system: Purpose-designed coupling that fits only its designated counterpart, preventing misconnection
Handling instructions (for healthcare professionals)
Before use, the following steps must be observed:
- Separate the two bags at the tear seam
- Open the outer overwrap immediately before use
- Inspect the bag carefully: verify the label, check the expiry date, confirm the solution is clear and colourless, and ensure neither the bag nor the overwrap is damaged
- Hang the bag using the designated suspension hole
- Remove the protective cap from the coupling. Do not touch the exposed surfaces, especially the tip. The internal components are sterile and should not be treated with additional disinfectant.
- Connect the coupling to its designated counterpart and press together, then twist clockwise until a click confirms secure connection
- Proceed according to the treatment protocol and device manufacturer instructions
Plastic packaging can occasionally become damaged during transport. Even minor damage to the bag seal, welded seams, or corners can lead to microbial contamination. Thorough visual inspection before every use is therefore essential. Use the solution only if it is clear, colourless, and the bag and coupling are intact.
Frequently Asked Questions About Calrecia
Medical References
This article is based on the approved Summary of Product Characteristics (SmPC) and Patient Information Leaflet (PIL) for Calrecia, supplemented by international clinical guidelines and peer-reviewed literature. All medical claims are verified against the following sources:
- European Medicines Agency (EMA). "Calrecia — Summary of Product Characteristics." Fresenius Medical Care Deutschland GmbH. Official European prescribing information for Calrecia.
- KDIGO (Kidney Disease: Improving Global Outcomes) (2024). "Clinical Practice Guidelines for Acute Kidney Injury." International guidelines for management of acute kidney injury including CRRT protocols.
- Oudemans-van Straaten HM, et al. (2021). "Citrate anticoagulation for continuous renal replacement therapy." Critical Care. 25:349. Comprehensive review of citrate-based anticoagulation protocols and calcium replacement strategies in CRRT.
- Slowinski T, et al. (2015). "Safety and efficacy of regional citrate anticoagulation in continuous venovenous haemodialysis." Nephrology Dialysis Transplantation. 30(7):1116–1122. Clinical trial demonstrating safety of citrate anticoagulation with calcium replacement in CRRT.
- World Health Organization (WHO) (2023). "Model List of Essential Medicines." WHO Essential Medicines WHO reference for essential medicines in critical care settings.
- Tolwani A. (2012). "Continuous Renal-Replacement Therapy for Acute Kidney Injury." New England Journal of Medicine. 367(26):2505–2514. NEJM Landmark review of CRRT techniques including citrate anticoagulation.
- British National Formulary (BNF). "Calcium chloride." National Institute for Health and Care Excellence (NICE). Reference for calcium chloride prescribing in the United Kingdom.
Evidence grading: This article uses the GRADE framework (Grading of Recommendations Assessment, Development and Evaluation) for evidence-based medicine. Evidence level 1A represents the highest quality of evidence, based on systematic reviews of randomized controlled trials.
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