Sodium Bicarbonate for Severe Metabolic Acidemia and Acute Kidney Injury
JAMA, 2025 · Multicenter randomized open-label controlled trial (627 analyzed patients)
Clinical question
In critically ill adults with severe metabolic acidemia and moderate-to-severe AKI, does sodium bicarbonate improve survival?
What the trial found
Bicarbonate did not improve 90-day, 28-day, or 180-day mortality in severe acidemia with moderate-to-severe AKI, but it reduced use of kidney replacement therapy.
Current guideline position
The 2026 Surviving Sepsis Campaign conditionally suggests bicarbonate for septic shock with pH <= 7.2 and AKIN 2-3, with very low certainty, while suggesting against bicarbonate solely to improve hemodynamics or reduce vasopressor requirements in hypoperfusion-induced lactic acidemia.
Clinical interpretation
Do not claim a mortality benefit from bicarbonate in severe acidemia with AKI. Selective use may still be reasonable to correct severe acidemia and may reduce kidney replacement therapy, balanced against sodium, volume, calcium, and alkalemia risks.
Differential diagnosis (GOLD MARK vs HARDCARP), toxic alcohol osmolar gaps, Urine Anion Gap, and current sodium bicarbonate evidence including BICAR-ICU and BICARICU-2.
Stepwise 6-step interpretation algorithm, compensation formulas, albumin-corrected anion gap, delta ratio, and Stewart physicochemical (SID) principles.
Sepsis-AKI microcirculatory decoupling, KDIGO staging, Furosemide Stress Test (FST), urine microscopy, and the AEIOU dialysis threshold framework.
The subset of sepsis with profound circulatory and cellular/metabolic abnormality — clinically identified by a vasopressor requirement to maintain MAP ≥ 65 mmHg plus lactate > 2 mmol/L despite adequate fluid resuscitation.