Mount Sinai Med-Lit Review
Clinical question: Does sodium bicarbonate infusion in patients with moderate to severe acute kidney injury and severe metabolic acidosis reduce 90-day all-cause mortality?
Background: The BICARICU-1 trial evaluated sodium bicarbonate infusion in patients with severe metabolic acidosis, examining 28-day mortality and seven-day organ failure as primary endpoints. Overall, there was no difference between the treatment and control groups. However, a subgroup analysis of patients with acute kidney injury showed reduced 28-day mortality (63% in the control group versus 46% in the treatment group). The BICARICU-2 trial was designed to further evaluate mortality outcomes in patients with severe metabolic acidemia and moderate to severe acute kidney injury.
Study design: Multicenter, randomized, clinical trial
Setting: A total of 43 intensive care units (ICUs) across France from October 6, 2019, through December 19, 2023. Follow-up was completed on June 17, 2024.
Synopsis: A total of 3,202 ICU patients with severe metabolic acidosis and moderate to severe acute kidney injury were screened for eligibility. Of these, 2,562 were excluded, and 640 were randomized. After exclusion of 13 patients, 313 patients were analyzed in the control group and 314 in the sodium bicarbonate group. All-cause 90-day mortality did not differ significantly between the bicarbonate group (62.1%) and the control group (61.7%). There was also no significant difference in 28-day or 180-day mortality. However, among secondary outcomes, the median time to initiate kidney replacement therapy was longer in the bicarbonate group (31 hours) compared with the control group (16 hours), suggesting that sodium bicarbonate may delay or potentially avoid initiation of kidney replacement therapy in some patients.
Bottom line: In patients with severe metabolic acidosis and moderate to severe acute kidney injury, sodium bicarbonate infusion does not reduce 90-day all-cause mortality.
Citation: Jung B, et al. Sodium bicarbonate for severe metabolic acidemia and acute kidney injury: the BICARICU-2 randomized clinical trial. JAMA. 2025;334(22):2000-2010. doi: 10.1001/jama.2025.20231.
View Dr. Merrill’s video review.
Dr. Merrill
Dr. Merrill is a hospitalist in the division of hospital medicine at Mount Sinai Hospital and an associate professor of medicine and medical education at the Icahn School of Medicine at Mount Sinai, both in New York.