TOPLINE:

In critically ill patients with severe metabolic acidaemia (defined as pH ≤ 7.20) and moderate-to-severe acute kidney injury (AKI), intravenous sodium bicarbonate infusion did not reduce all-cause mortality at 90 days but was associated with a lower need for kidney replacement therapy.

METHODOLOGY:

• Researchers in France conducted a clinical trial to evaluate the effect of sodium bicarbonate infusion on mortality outcomes in critically ill patients with severe metabolic acidaemia and moderate-to-severe AKI.
• Patients were required to have a total Sequential [Sepsis-related] Organ Failure Assessment score greater than 4 or an arterial lactate concentration greater than or equal to 2 mmol/L within 48 hours after ICU admission.
• The analysis included 627 patients (median age, 67 years; 59%-62% men) who were randomly assigned to receive either intravenous 4.2% sodium bicarbonate (targeting an arterial pH ≥ 7.30 for up to 28 days or until ICU discharge) or no sodium bicarbonate (control group) within 48 hours of ICU admission.
• The primary outcome was all-cause mortality at day 90. Secondary outcomes included all-cause mortality at days 28 and 180; use of organ support therapy, vasopressors, or invasive mechanical ventilation; ICU stays; ICU-acquired bloodstream infections; and major adverse kidney events on day 90.

TAKEAWAY:

• At day 90, all-cause mortality showed no significant difference between bicarbonate and control groups (62.1% vs 61.7%; absolute difference, 0.4; P = .91).
• By day 28, kidney replacement therapy was required less frequently in the bicarbonate group than in the control group (35% vs 50%), with an absolute difference of -15.5% (95% CI, -23.1% to -7.8%).
• The risk for the initiation of kidney replacement therapy during the first 28 days was nearly 40% lower in the bicarbonate group than in the control group (hazard ratio, 0.59; 95% CI, 0.46-0.75), with a median time to initiation of 31 vs 16 hours.
• ICU-acquired bloodstream infections occurred in 4% of patients in the bicarbonate group vs 9% of those in the control group.

IN PRACTICE:

"Clinicians can choose to use short-term IV [intravenous] sodium bicarbonate therapy to manage severe acidemia complications of AKI, knowing that this may avert KRT [kidney replacement therapy] in select patients and that it does not appear to portend greater risk of adverse events," experts wrote in an accompanying editorial.

SOURCE:

This study was led by Boris Jung, MD, PhD, Medical ICU, Lapeyronie University Hospital, Montpellier University, Montpellier, France. It was published online on October 29, 2025, in JAMA.

LIMITATIONS:

The open-label design of the trial was a key limitation. Additionally, the sodium bicarbonate dose was not computed on the basis of laboratory tests or patient weight but was instead individualised to target a pH of 7.30 or higher. Sodium bicarbonate's pH‑raising action may have led to later kidney replacement therapy in the bicarbonate group by lessening the influence of low pH on the decision to start therapy.

DISCLOSURES:

This trial was funded by the French Ministry of Health and sponsored by the Montpellier University Hospital. Some authors reported receiving consulting fees, speaker or lecturer fees, and reimbursement of travel and accommodation expenses for attending scientific meetings and having other ties with various pharmaceutical companies.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.