JAMA

Sodium bicarbonate fails to reduce mortality in severe acidemia with AKI

November 5, 2025

Study details: The BICARICU-2 trial (NCT04010630) was a multicenter, open-label, randomized study conducted in 43 French ICUs from 2019 to 2023, enrolling 640 adults with severe metabolic acidemia (pH ≤7.20) and moderate to severe acute kidney injury (AKI). Patients were randomized to receive IV sodium bicarbonate to target arterial pH ≥7.30 or no bicarbonate. Primary outcome was day 90 all-cause mortality; secondary outcomes included day 28 and 180 mortality, organ support, ICU/hospital length of stay, infections, and major adverse kidney events.

Results: Among 627 analyzed patients, day 90 mortality was similar between groups (62.1% bicarbonate vs. 61.7% control; absolute difference 0.4%; 95% confidence interval, −7.2 to 8.0; P = 0.91). No significant differences were found in day 28 or 180 mortality, organ support, or adverse events. Notably, kidney replacement therapy was less frequent in the bicarbonate group (35% vs. 50%), but this didn't translate into improved survival.

Clinical impact: Sodium bicarbonate infusion doesn't improve 90-day mortality in critically ill patients with severe metabolic acidemia and moderate to severe AKI. While it may reduce the need for kidney replacement therapy, routine use for mortality benefit isn't supported by these results.

Source:

Jung B, et al; BICARICU-2 Study Group. (2025, October 29). JAMA. Sodium Bicarbonate for Severe Metabolic Acidemia and Acute Kidney Injury: The BICARICU-2 Randomized Clinical Trial. https://pubmed.ncbi.nlm.nih.gov/41159812/