Original Investigation
Caring for the Critically Ill Patient
Sodium Bicarbonate for Severe Metabolic Acidemia and Acute Kidney Injury: The BICARICU-2 Randomized Clinical Trial
Boris Jung, Mathieu Jabaudon, Audrey De Jong, et al
JAMA Published Online: October 29, 2025
doi: 10.1001/jama.2025.20231
Key Points
Question For patients with severe metabolic acidosis and moderate to severe acute kidney injury, does sodium bicarbonate infusion decrease day 90 all-cause mortality?
Findings In this multicenter randomized clinical trial that included 640 patients, sodium bicarbonate infusion was not associated with lower day 90 all-cause mortality (195 of 314 patients in the bicarbonate group and 193 of 313 patients in the control group).
Meaning Sodium bicarbonate infusion does not improve day 90 all-cause mortality.
Abstract
Sodium Bicarbonate for Severe Metabolic Acidemia and Acute Kidney Injury
Visual Abstract.
Importance The effect of sodium bicarbonate infusion on outcome in patients with severe metabolic acidemia and moderate to severe acute kidney injury is unknown.
Objective To determine whether sodium bicarbonate infusion is associated with day 90 all-cause mortality in patients with severe metabolic acidemia and moderate to severe acute kidney injury.
Design, Setting, and Participants Randomized, open-label, clinical trial conducted with 640 patients in 43 French intensive care units from October 6, 2019, to December 19, 2023, with 90-day follow-up. The last date of follow-up was June 17, 2024. Adults with severe metabolic acidemia (defined as pH ≤7.20) and moderate to severe acute kidney injury were enrolled.
Intervention Patients were randomized 1:1 to receive either intravenous sodium bicarbonate infusion or no sodium bicarbonate to target an arterial pH of 7.30 or higher.
Main Outcomes and Measures The primary outcome was day 90 all-cause mortality. Secondary outcomes included day 28 and day 180 all-cause mortality; use of organ support therapy, vasopressors, or invasive mechanical ventilation; intensive care unit and hospital length of stay; intensive care unit–acquired infections; fluid balance; day-7 Sequential [Sepsis-related] Organ Failure Assessment score (6 organ systems’ function is evaluated and scored from 0 [no dysfunction] to 4 [failure]; total score ranges from 0 [normal] to 24 [maximum failure]); and major adverse kidney events on day 90.
Results Among 640 randomly assigned patients, 627 were analyzed (313 in the control group and 314 in the bicarbonate group). The median age was 67 years (IQR, 59-74 years); 194 of 314 patients (62%) in the bicarbonate group and 185 of 313 controls (59%) were male. In the primary analysis, day 90 all-cause mortality was 195 of 314 patients (62.1%) in the bicarbonate group and 193 of 313 (61.7%) in the control group (absolute difference, 0.4; 95% CI, −7.2 to 8.0; P = .91). There was no evidence of a group effect on day 28 or day 180 all-cause mortality. Among 18 secondary outcomes, kidney replacement therapy was used in 109 of 314 (35%) bicarbonate group patients and 157 of 313 (50%) controls (absolute difference, −15.5; 95% CI, −23.1 to −7.8). No evidence of a group effect was found on other secondary outcomes, including adverse events.
Conclusions and Relevance For patients with severe metabolic acidemia and moderate to severe acute kidney injury, intravenous sodium bicarbonate did not affect mortality.
Trial Registration ClinicalTrials.gov Identifier: NCT04010630
