{"id":31769,"date":"2026-09-20T04:57:00","date_gmt":"2026-09-19T20:57:00","guid":{"rendered":"https:\/\/csccm.org.cn\/?p=31769"},"modified":"2026-09-20T06:08:31","modified_gmt":"2026-09-19T22:08:31","slug":"nejm%e5%8f%91%e8%a1%a8%e8%bf%b0%e8%af%84%ef%bc%9a%e9%87%8d%e7%97%87%e6%82%a3%e8%80%85%e7%9a%84%e7%a2%b3%e9%85%b8%e6%b0%a2%e9%92%a0%e6%b2%bb%e7%96%97%ef%bc%9a%e5%bc%80%e5%90%af%e6%96%b0%e7%9a%84","status":"publish","type":"post","link":"https:\/\/csccm.org.cn\/?p=31769","title":{"rendered":"[NEJM\u53d1\u8868\u8ff0\u8bc4]\uff1a\u91cd\u75c7\u60a3\u8005\u7684\u78b3\u9178\u6c22\u94a0\u6cbb\u7597\uff1a\u5f00\u542f\u65b0\u7684\u7bc7\u7ae0"},"content":{"rendered":"\n

EDITORIAL<\/a><\/p>\n\n\n\n

Sodium Bicarbonate in Critical Illness \u2014 A New Chapter for the Book<\/h1>\n\n\n\n

Marlies\u00a0Ostermann,\u00a0Deborah J.\u00a0Cook<\/h3>\n\n\n\n

N Engl J Med\u00a02026;395:1124-1127<\/h3>\n\n\n\n

DOI: 10.1056\/NEJMe2610218<\/h3>\n\n\n\n

Acute metabolic acidosis is common in hospitalized patients owing to conditions such as shock, kidney disease, and diabetic ketoacidosis. While the underlying cause is being treated, it may be tempting to use buffer solutions concurrently to try to raise extracellular pH, particularly in critically ill patients. Clinical approaches to this impaired homeostasis vary, given uncertainty about whether adjunctive sodium bicarbonate therapy improves patient-centered outcomes.1<\/a><\/sup><\/p>\n\n\n\n

In this issue of the Journal<\/em>, Serpa Neto and colleagues report the results of the SODa-BIC (Sodium Bicarbonate for Metabolic Acidosis in the ICU [intensive care unit]) trial,2<\/a><\/sup> a placebo-controlled evaluation of sodium bicarbonate infusion for up to 5 hours in adults with metabolic acidosis who were receiving vasopressor treatment. The investigators enrolled 500 patients with metabolic acidosis (pH, <7.30) who had been receiving vasopressor support for up to 48 hours in 55 ICUs in seven countries. Sodium bicarbonate treatment corrected acidosis more rapidly than control (placebo) and prevented recurrent metabolic acidosis. However, no significant between-group difference was observed in the risk of major adverse kidney events (defined as death, use of renal-replacement therapy, or persistent renal dysfunction) within 30 days,3<\/a><\/sup> nor did there appear to be substantial differences in the individual components of in-hospital death, receipt of renal-replacement therapy, or persistent renal dysfunction at day 30.<\/p>\n\n\n\n

This trial has several unique features contributing to the research renaissance on this topic. It was thoughtfully designed as blinded, and a heterogeneous population of patients was enrolled, 48% of whom had metabolic acidosis caused by sepsis or septic shock, and 46% of whom had acute kidney injury (AKI) before randomization. Although two large earlier trials of sodium bicarbonate therapy enrolled patients with a pH level of no more than 7.20,4,5<\/a><\/sup> the SODa-BIC trial focused on patients with less severe acidosis (pH, <7.30), with a median pH at enrollment of 7.26 (interquartile range, 7.22 to 7.28). Patients in seven countries received a treatment that is inexpensive and widely available, and clear biochemical separation between the groups was achieved.<\/p>\n\n\n\n

The occurrence of a major adverse kidney event within 30 days is a widely accepted patient-centered composite outcome in critical care and nephrology trials. With 500 patients, the SODa-BIC trial was powered to detect an absolute between-group difference of 14 percentage points in the risk of major adverse kidney events at 30 days, an effect size exceeding most treatment effects in trials that use this composite.6,7<\/a><\/sup><\/p>\n\n\n\n

The interpretation of composite end points can be challenging. Each component of the composite of major adverse kidney events within 30 days (death, use of renal-replacement therapy, or persistent renal dysfunction within 30 days) is modifiable by many factors, independent of sodium bicarbonate therapy.6,8<\/a><\/sup> The renal-replacement therapy component is affected by initiation thresholds within and across centers, which were not protocolized in the SODa-BIC trial, in contrast to other trials (Table 1<\/a>).4,5<\/a><\/sup> The persistent renal dysfunction component requires previous creatinine results for accurate identification. When data are unavailable, an assumption of normal preexisting kidney function, as was made in this trial, may not influence the between-group difference but may increase the overall incidence of events by misclassifying patients with unknown chronic kidney disease as having new persistent renal dysfunction. A multidisciplinary consensus conference with patient engagement could harmonize approaches to these definitional complexities. Methodologic research may enhance the reproducibility of renal outcomes in future trials.6<\/a><\/sup><\/p>\n\n\n\n

TABLE 1<\/p>\n\n\n\n

\"\"<\/a><\/figure>\n\n\n\n

The rigorous SODa-BIC trial adds to the growing evidence about sodium bicarbonate treatment. The BICAR-ICU (Sodium Bicarbonate to Treat Severe Acidosis in the Critically Ill) trial, which evaluated sodium bicarbonate administration for up to 30 days in patients with a pH level of no more than 7.20, showed no difference in the primary composite end point, death from any cause at 28 days or at least one organ failure at day 7 (absolute difference estimate, \u22125.5 percentage points; 95% confidence interval [CI], \u221215.2 to 4.2).4<\/a><\/sup> However, 28-day mortality appeared to be lower in the subgroup of patients with moderate or severe AKI than in the subgroup of patients with mild or no AKI (P value for interaction, 0.03). The BICAR-ICU 2 (Sodium Bicarbonate for the Treatment of Severe Metabolic Acidosis with Moderate or Severe Acute Kidney Injury in ICU) trial evaluated sodium bicarbonate therapy in patients with moderate-to-severe AKI and a pH level of no more than 7.20 and showed 90-day mortality of 62.1% in the sodium bicarbonate group and 61.7% in the control group (absolute difference, 0.4 percentage points; 95% CI, \u22127.2 to 8.0).5<\/a><\/sup><\/p>\n\n\n\n

A meta-analysis of individual-level patient data from both trials, which included 1016 adults, showed that 90-day mortality was not lower with sodium bicarbonate than with control (58.3% and 60.6%, respectively; risk ratio, 0.96; 95% CI, 0.86 to 1.07).9<\/a><\/sup> However, in subgroup analyses, 90-day mortality appeared to be lower with sodium bicarbonate than with no treatment among patients with a pH level of no more than 7.10 (risk ratio, 0.80; 95% CI, 0.68 to 0.93) but not among patients with a pH level of more than 7.10 (risk ratio, 1.05; 95% CI, 0.92 to 1.21) (P value for interaction, 0.006). Sodium bicarbonate therapy also led to a lower risk of renal-replacement therapy initiation than control (34.8% vs. 50.7%; risk ratio, 0.69; 95% CI, 0.60 to 0.79) and increased the number of days free from dialysis (incidence rate ratio, 1.10; 95% CI, 1.06 to 1.14).9<\/a><\/sup> A recent meta-analysis of four trials including 1111 patients with metabolic acidosis had similar conclusions: sodium bicarbonate therapy led to a lower risk of renal-replacement therapy initiation than control (risk ratio, 0.69; 95% CI, 0.61 to 0.78) but not to lower mortality (risk ratio, 0.84; 95% CI, 0.55 to 1.30).10<\/a><\/sup> Bayesian analyses estimated a posterior probability of 0.90 of any lower risk of death. However, on the basis of the specified parameters, trial sequential analysis indicated that the cumulative trial data remain far below the required information size.10<\/a><\/sup><\/p>\n\n\n\n

Whether, when, and in whom sodium bicarbonate therapy confers benefit for patients with metabolic acidosis remains under active investigation. For example, in critically ill adults with metabolic acidosis and AKI, the MOSAICC (Multicenter Evaluation of Sodium Bicarbonate in Acute Kidney Injury in Critical Care) trial (ISRCTN Registry number, ISRCTN14027629<\/a>) is evaluating the effect of 8.4% sodium bicarbonate on 90-day mortality, quality-adjusted life-years, and economic outcomes. As clinical evidence about the role of sodium bicarbonate therapy for metabolic acidosis evolves, the SODa-BIC trial adds a compelling new chapter to the latest book. The full story is not yet written.<\/p>\n","protected":false},"excerpt":{"rendered":"

EDITORIAL Sodium Bicarbonate in Critical Illness \u2014 A Ne […]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":[],"categories":[24,23],"tags":[],"_links":{"self":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/31769"}],"collection":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=31769"}],"version-history":[{"count":1,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/31769\/revisions"}],"predecessor-version":[{"id":31771,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/31769\/revisions\/31771"}],"wp:attachment":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=31769"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=31769"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=31769"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}