X. Wu (2026). Therapeutic effectiveness of sodium bicarbonate in diabetic ketoacidosis: A retrospective cohort analysis using the marginal structural Cox model. Medicine, 105(5), e47529. https://doi.org/10.1097/MD.0000000000047529

PubMed 41630327

[Abstract]
The treatment effect of sodium bicarbonate in diabetic ketoacidosis (DKA) remains controversial, as clinical guidelines recommend its use only in extreme acidemia (pH < 6.9) owing to inconsistent evidence and concerns over potential risks such as paradoxical central nervous system acidosis, delayed ketone clearance, and electrolyte imbalance. This study aimed to evaluate the real-world effectiveness and safety of sodium bicarbonate therapy in critically ill patients with DKA in a large clinical database. This is a retrospective cohort study following the STROBE guidelines on the MIMIC-IV database. The propensity score matching was used to balance the baseline difference. The primary outcome was the risk of multiple organ dysfunction syndrome (MODS). Secondary outcomes were the risk of renal function worsening, and neurological worsening. Adverse events included mortality, hospital readmission, and the occurrence of posttreatment supplementation of potassium or calcium. The Cox regression along with the marginal structural Cox model was employed to analyze the internal time-varying covariates. A total of 482 patients after propensity score matching was included. The Cox regression reveals that sodium bicarbonate (NaHCO3) use was associated with a lower risk of MODS, renal worsening, and neural worsening, while marginal structural Cox model also proved a lower risk in the creatinine exceeding (hazards ratio: 0.36, 95% confidence interval: 0.25-0.52, P < .05) and Glasgow Coma Scale worsening (hazards ratio: 0.36, 95% confidence interval: 0.18-0.75, P < .05). No statistically significant association was found between NaHCO3 use and mortality, readmission, or posttreatment of potassium or calcium, but potential adverse effect of NaHCO3 use on MODS or readmission was detected in the severe subgroups. Sodium bicarbonate showed a potential protective association with MODS, neurological function protection, and was associated with modest protection in renal function among patients with DKA. Its use did not appear to significantly increase the risk of mortality, readmission, or posttreatment electrolyte supplementation. However, a possible adverse association with MODS and readmission was observed in the most severe subgroups. In all, NaHCO3 in DKA patients still need cautious patient selection and close monitoring of fluid and biochemical status during therapy.