Tocilizumab vs CRRT in Management of Cytokine Release Syndrome (CRS) in COVID-19

Study Overview
=================
Brief Summary
-----------------
Some patients infected with the COVID-19 can develop uncontrolled immune response, leading to potentially life-threatening damage to lung tissue. Tocilizumab was first approved by the U.S. FDA in 2010 for rheumatoid arthritis and might now be used to treat serious COVID-19 patients with lung damage, according to China's National Health Commission updated its treatment guidelines in 7th version.Continuous Renal Replacement Therapy (CRRT) was recommended by China's National Health Commission treatment guidelines in 1st-7th version to control sever COVID-19 patients.

Detailed Description
-----------------
Tocilizumab doesn't directly kill the novel coronavirus. It's known as an inhibitor of the receptor of interleukin 6 (IL-6), a pro-inflammatory cytokine. In the disease COVID-19, the body may respond to the pathogen by overproducing immune cells and their signaling molecules in a dangerous phenomenon called cytokine release storm.It has been recently speculated that IL-6 as a main culprit in that immune over activation among COVID-19 patients, hence the Tocilizumab clinical trial was initiated. In 2017, the FDA also approved Tocilizumab to treat cytokine release syndrome (CRS), a form of cytokine storm caused by CAR-T treatment. The investigator's hypothesis was that Tocilizumab would be associated with better clinical outcomes, such as decreased systemic inflammation, improved survival rate, better hemodynamic and improved of respiratory distress.Systemic inflammatory response syndrome was one of the main indications for treatment with CRRT. So it is clinically significant to compare the efficacy and safety of Tocilizumab and CRRT in management of CRS triggered by COVID-19.

Official Title
-----------------
A Retrospective Study of Evaluating Safety and Efficacy of Tocilizumab Compared to Continuous Renal Replacement Therapy in Controlling CRS Triggered by COVID-19

Conditions
-----------------
Covid-19, SARS, Cytokine Storm, Cytokine Release Syndrome, Tocilizumab

Intervention / Treatment
-----------------
* Drug: Tocilizumab
* Other: Standard of care
* Procedure: Continuous renal replacement therapy


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: Agrees to the collection of oropharyngeal or anal swabs and venous blood per protocol. Male or non-pregnant female adult ≥18 years of age at time of enrollment. Has laboratory-confirmed novel coronavirus infection as determined by polymerase chain reaction (PCR), or other commercial or public health assay in oropharyngeal or anal specimen within 72 hours prior to hospitalization. Illness of any duration, and at least one of the following: Radiographic infiltrates by imaging (chest x-ray, CT scan, etc.), OR Clinical assessment (evidence of rales/crackles on physical examination) AND SpO2 ≤93% on room air, OR Requiring mechanical ventilation and/or supplemental oxygen, OR Sustained fever in the past 24 hours and unresponsive to NSAID or steroid Serum IL-6 ≥3 times the upper limit of normal Exclusion Criteria: Alanine transaminase/aspartate transaminase (ALT/AST) > 5 times the upper limit of normal. Stage 4 severe chronic kidney disease or requiring dialysis (i.e. estimated glomerular filtration rate (eGFR) < 30 ml /min/1.73 m^2) Hemoglobin<80 g/L Leukocytes<2.0×10^9 Platelets<50×10^9 Pregnancy or breast feeding. Anticipated transfer to another hospital which is not a study site within 72 hours. Expected life span does not exceed 7 days. Allergy to any study medication.

Ages Eligible for Study
-----------------
Minimum Age: 18 Years
Maximum Age: 80 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
No

Study Plan
=================
How is the study designed?
-----------------

Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Tocilizumab<br>Subjects received 8 mg/kg (body weight) Tocilizumab once in 100 ml 0.9% saline solution and administered intravenously within no less than 60 minutes. Tocilizumab was administered according to the local label. | Drug: Tocilizumab<br>* Administered as an intravenous infusion.<br>* Other names: Actemra;Other: Standard of care<br>* Standard of care therapy per local written policies or guidelines and includes balancing of electrolytes and acid-base, the provision of enteral or parenteral nutrients support, antibiotics therapy, oxygen therapy and noninvasive ventilation.<br>|
| Continuous Renal Replacement Therapy<br>Femoral vein catheterization was performed to complete continuous renal replacement therapy for consecutive 3 times or more. | Other: Standard of care<br>* Standard of care therapy per local written policies or guidelines and includes balancing of electrolytes and acid-base, the provision of enteral or parenteral nutrients support, antibiotics therapy, oxygen therapy and noninvasive ventilation.<br>Procedure: Continuous renal replacement therapy<br>* Catheter insertion site is femoral vein.<br>|
| Standard care<br>Standard of care therapy per local written policies or guidelines. | Other: Standard of care<br>* Standard of care therapy per local written policies or guidelines and includes balancing of electrolytes and acid-base, the provision of enteral or parenteral nutrients support, antibiotics therapy, oxygen therapy and noninvasive ventilation.<br>|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Proportion of Participants With Normalization of Fever and Oxygen Saturation Through Day 14 | This is a composite outcome measure. Criteria for fever normalization: Temperature < 36.6 °C armpit, < 37.2 °C oral sustained for at least 72 hours and criteria for oxygen normalization: peripheral capillary oxygen saturation (Sp02) > 94% sustained for at least 72 hours. | First dose date up to 14 days | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Duration of hospitalization | Measured in days | Up to 28 days | 
| Proportion of Participants With Normalization of Fever Through Day 14 | Criteria for: Temperature < 36.6 °C armpit, < 37.2 °C oral, or < 37.8 °C rectal sustained for at least 72 hours. | First dose date up to 14 days | 
| Change from baseline in white blood cell and differential count | Blood routine test | Day 1 through Day 28 | 
| Time to first negative in 2019 novel Corona virus RT-PCR test | Oropharyngeal or anal swabs | Up to 28 days | 
| All-cause mortality | Date and cause of death (if applicable). | up to 12 weeks | 
| Change from baseline in hsCRP | Serum hsCRP | Day 1 through Day 28 | 
| Change from baseline in cytokines IL-1β, IL-10, sIL-2R, IL-6, IL-8 and TNF-α | Serum inflammatory cytokines | Day 1 through Day 28 | 
| Change from baseline in proportion of CD4+CD3/CD8+CD3 T cells | Flow cytometry for peripheral whole blood | Day 1 through Day 28 (if applicable) |