Researchers have determined that intravenous sodium bicarbonate treatment has no effect on mortality in critically ill patients with severe acidemia and moderate to severe acute kidney injury (AKI). The treatment can, however, decrease the use of kidney replacement therapy (KRT). The results are from the BICARICU-2 randomized trial, which took place at 43 intensive care units (ICUs) in France. In contrast to the absence of mortality advantage, the treatment had a 41% reduced risk of KRT onset, indicating the potential for early dialysis prevention in carefully selected patients. The study was published in JAMA by Boris J. and colleagues.
The BICARICU-2 trial, run by Dr. Boris Jung and others at Lapeyronie University Hospital, Montpellier, was an open-label, multicenter, randomized controlled trial that lasted from October 2019 to December 2023. 640 adults with severe metabolic acidemia (arterial pH ≤7.20) and moderate to severe AKI were randomly assigned in a 1:1 ratio to either receive intravenous sodium bicarbonate (4.2% solution, maximum dose 500 mEq over 24 hours) or no sodium bicarbonate, with treatment starting within 15 minutes of enrollment. The primary endpoint was all-cause mortality at 90 days, with secondary outcomes including 28-day and 180-day mortality, KRT initiation, and ICU-acquired infections. Data analysis included 627 evaluable patients.
Results
At 90 days, mortality due to all causes was 62.1% in the sodium bicarbonate group and 61.7% in the control group (P = 0.91), with no difference between the two arms. Mortality at 28 and 180 days also had no variation.
Among secondary outcomes, though, a decrease in the requirement for KRT was noted in the sodium bicarbonate arm (35% vs 50%).
The median duration of time to KRT initiation was longer in the bicarbonate group (31 hours) than in the control group (16 hours).
Hazard for KRT initiation by 28 days was 0.59 (95% CI, 0.46–0.75), indicating 41% reduced risk.
ICU-acquired bloodstream infections were noted in 4% of the bicarbonate group versus 9% in controls.
In patients who needed KRT, infection developed in 10% versus 4% in those not needing KRT.
The BICARICU-2 trial showed that intravenous sodium bicarbonate is not beneficial to the survival of critically ill patients with severe acidemia and AKI but substantially decreases the need for kidney replacement therapy. These results justify its selective, careful administration in the treatment of severe metabolic acidosis to avoid or postpone dialysis, yet highlight the need for further studies to improve patient selection and maximize therapy duration.
Reference:
Jung B, Jabaudon M, De Jong A, et al. Sodium Bicarbonate for Severe Metabolic Acidemia and Acute Kidney Injury: The BICARICU-2 Randomized Clinical Trial. JAMA. Published online October 29, 2025. doi:10.1001/jama.2025.20231
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