Bicarbonate in AKI and acidemia to reduce mortality and need for kidney replacement therapy

Severe metabolic acidemia (arterial pH 7.20) in the setting of acute kidney injury (AKI) remains a major clinical challenge in the intensive care unit (ICU) 1 .Acidemia may impair cardiac contractility, worsen kidney perfusion, and contribute to multi-organ dysfunction. 2The BICARICU-2 investigators conducted a pragmatic multicenter, open-label, randomized trial to determine whether intravenous sodium bicarbonate (target pH 7.30), compared with usual care without bicarbonate, would improve outcomes in adults with severe acidemia and KDIGO stage 2-3 AKI 1,3 .The study enrolled 640 patients from 43 French ICUs between October 2019 and December 2023.A total of 627 patients (314 assigned to bicarbonate, 313 to control) were included in the intention-totreat analysis.Baseline characteristics were well balanced: median age 67 years, predominantly septic septic schock, median arterial pH around 7.15, serum bicarbonate 12-13 mEq/L, and a high proportion required vasopressor support (~80%) or mechanical ventilation (~75%).