LiverTREM-1: Hepatic TREM-1 Expression and Prognosis in Severe Alcoholic Hepatitis

Overview

Background \& Rationale Severe alcohol-related hepatitis (SAH) is a serious condition with a 3-month mortality rate of \~30%. Diagnosis and prognosis are complex due to non-specific and insensitive clinical, biological, and histological indicators. Corticosteroids-the only validated treatment-are only effective in 50% of cases and can worsen outcomes in non-responders by promoting infections. Liver transplantation remains a limited option due to organ scarcity and patient eligibility. TREM-1, a pro-inflammatory receptor, has shown promise in inflammatory liver diseases. Its expression in hepatocytes may serve as a biomarker to better classify patients, guide treatment, and improve outcomes. Objectives Primary Objective: Compare TREM-1 expression (via immunohistochemistry) between SAH patients and controls with other liver diseases (e.g., HCC, metastatic colon cancer, cholangiocarcinoma). Secondary Objectives: Determine optimal antibody dilution for TREM-1 staining. Assess diagnostic performance (sensitivity, specificity, PPV, NPV). Identify homogeneous SAH subgroups using clinical, histological, and biological data. Evaluate prognostic value of TREM-1 expression for: 2-month mortality Corticosteroid response (bilirubin regression at Day 7) Lille score \<0.45 at Day 7 Compare TREM-1's predictive power to standard scores (MELD, Maddrey, Lille, etc.). Methodology Population: Cases: Adults treated at CHRU de Nancy (2013-2023) for SAH, with archived liver biopsies. Controls: Adults with liver malignancies and archived biopsies. Sample Size: Phase I: 12 cases, 6 controls Phase II: 150 cases, 150 controls Data Sources: Medical records, archived pathology slides Statistical Tools: Logistic regression, survival analysis, ROC curves, clustering, SAS/R software Expected Outcomes \& Impact Improved prognostic stratification and therapeutic guidance for SAH patients Better targeting of corticosteroid therapy to reduce unnecessary risk Early referral for liver transplantation when appropriate Validation of TREM-1 as a diagnostic/prognostic biomarker Foundation for future TREM-1-targeted clinical trials Potential paradigm shift linking liver histology with real-time clinical decision-making Enhanced resource allocation and patient management

Study Title Official Title: Liver TREM-1: Hepatic Expression of TREM-1 in Severe Alcoholic Hepatitis Brief Summary (250 words max) Severe alcohol-associated hepatitis (sAH) is a life-threatening liver disease with a 3-month mortality rate of up to 30%. The only validated treatment-corticosteroids-fails in approximately 40% of patients, increases infection risk, and offers no survival benefit beyond 28 days. Therefore, there is an urgent need to identify prognostic biomarkers to guide therapy. TREM-1 (Triggering Receptor Expressed on Myeloid cells 1) is a pro-inflammatory receptor expressed on hepatic immune and endothelial cells. Preclinical murine studies suggest it plays a pivotal role in alcohol-induced liver injury. This observational study aims to assess the diagnostic and prognostic value of hepatic TREM-1 expression in patients with severe alcohol-associated hepatitis using archived liver biopsy samples. A total of 300 archived liver specimens (150 sAH cases, 150 controls with hepatic malignancies) will be analyzed via immunohistochemistry using a validated TREM-1 scoring system. Outcomes include TREM-1 expression levels, correlation with clinical parameters, mortality at 2 months, and response to corticosteroid therapy. Detailed Description The study will determine whether hepatic TREM-1 expression can serve as a biomarker to stratify sAH patients into prognostic subgroups. TREM-1 expression will be measured via immunostaining and categorized as high vs. low using a score developed by Duan et al. Secondary analyses include diagnostic accuracy, treatment response (based on jaundice regression and Lille score at Day 7), and survival at 2 months. Statistical models (logistic regression, survival analysis, ROC curves, clustering) will be used. This study complies with the Declaration of Helsinki, EU Regulation 536/2014, MR004 guidelines (CNIL), and French Public Health laws 2004-806, 2004-800, and 2016-41. Study Type Observational Observational Model: Cross-sectional Time Perspective: Retrospective Biospecimen Retention: Samples retained (Slides; No DNA) Primary Outcome Measure Hepatic TREM-1 Expression Type: Binary categorical variable (high vs. low) Time Frame: At the day of liver biopsy Method: Immunohistochemistry (Duan et al. score) Secondary Outcome Measures Diagnostic Accuracy of TREM-1 Sensitivity, specificity, PPV, NPV for sAH diagnosis Gold standard: multidisciplinary diagnosis Time Frame: at the day of liver biopsy Jaundice Resolution Binary variable: resolved/persistent at Day 7 Time Frame: 7 days after corticosteroid start Lille Score \< 0.45 Prognostic response to corticosteroids Time Frame: Day 7 Mortality at 2 Months Time Frame: 60 days post-diagnosis Analysis: Cox regression Cluster Analysis of sAH Subgroups Based on TREM-1 expression and clinico-biological profiles Comparison to Established Prognostic Scores MELD, AHHS, Glasgow, Maddrey, SALVE, Lille, Lille-MELD TREM-1 expression in RNAseq3' in SAH patients categorical variable (detected vs undetected) and quantitative variable (TREM expression as fragments per millions) Comparison of TREM-1 expression in RNAseq3' in SAH patients to prognostic scores and outcomes MELD, AHHS, Glasgow, Maddrey, SALVE, Lille, Lille-MELD Infection from day 3 to day 180 Mortality at M2, M3 and M6 Overall Mortality Response to steroids Enrollment Estimated Enrollment: 300 Sampling Method: Non-probability sample Eligibility Criteria Inclusion Criteria (Cases): Adults (≥18) with biopsy-proven severe alcohol-associated hepatitis (2013-2024) Available liver biopsy slides at CHRU Nancy Non-opposition documented Inclusion Criteria (Controls): Adults (≥18) with hepatic resection for colorectal metastases, cholangiocarcinoma, or HCC Archived liver samples available Non-opposition documented Exclusion Criteria: No histologic diagnosis of sAH Depleted paraffin blocks unsuitable for staining Study Dates Start Date: Upon ethics approval Primary Completion Date: \~9 months after start Study Completion Date: \~15 months after start Locations CHRU Nancy, France Lead Pathology and Hepatology Units Collaborating Site: Hôpital Henri Mondor (AP-HP) Sponsor and Contacts Sponsor: CHRU Nancy Scientific PI: Dr. Vincent Haghnejad Email: v.haghnejad@chru-nancy.fr Phone: +33 625150180 Regulatory Compliance This study adheres to the following regulations and ethical standards: Declaration of Helsinki EU Regulation (EU) 536/2014 French Public Health Law: 2004-806, 2004-800, 2016-41 Bioethics Law and GDPR (EU 2016/679) CNIL MR004 framework for retrospective, non-interventional data use Statistical Methods Primary Objective: Logistic regression (univariate p\<0.2 threshold, stepwise multivariate model) to compare TREM-1 expression between cases and controls. Secondary Objectives: ROC curve analysis to determine optimal antibody dilution (AUC, Youden index). Diagnostic accuracy metrics (sensitivity, specificity, PPV, NPV). Clustering (Multiple Correspondence Analysis + Ward's Hierarchical Clustering) for subgroup discovery. Cox model for 2-month mortality. Logistic regression for treatment response (Day 7 jaundice, Lille score \<0.45). Comparative model performance vs. MELD, Maddrey, etc. Software: SAS 9.4 or R Significance Level: 5% (two-sided)