Sodium Bicarbonate for Severe Metabolic Acidemia and Acute Kidney Injury: The BICARICU-2 Randomized Clinical Trial
In the BICAR-ICU-2 trial of critically ill patients with severe metabolic acidemia and moderate-to-severe acute kidney injury, intravenous sodium bicarbonate did not reduce 90-day mortality, though it did lower the need for kidney replacement therapy.
Background
Whether correcting severe metabolic acidemia with sodium bicarbonate improves survival in patients with acute kidney injury has been uncertain. BICAR-ICU-2 was designed to answer this for ICU patients with severe acidemia and moderate-to-severe AKI.
Study design
Randomized, open-label trial of 640 patients across 43 French ICUs (2019–2023). Adults with severe metabolic acidemia (pH ≤7.20) and moderate-to-severe AKI were randomized 1:1 to intravenous sodium bicarbonate (targeting arterial pH ≥7.30) or no bicarbonate. The primary outcome was 90-day all-cause mortality.
Key findings
Among 627 analyzed patients, 90-day mortality was 62.1% with bicarbonate versus 61.7% with control (absolute difference 0.4%, 95% CI −7.2 to 8.0; P=0.91), with no effect at day 28 or 180. However, kidney replacement therapy was used in 35% of the bicarbonate group versus 50% of controls (absolute difference −15.5%, 95% CI −23.1 to −7.8). Other secondary outcomes and adverse events did not differ.
Clinical implications
Sodium bicarbonate does not improve survival in this high-mortality population, so it should not be given to reduce death. Its reduction in dialysis requirement is a meaningful, though secondary, finding that may inform decisions about acid-base management when avoiding renal replacement therapy is a goal.
Category
Research
Source
JAMA
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