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)

Inclusion Criteria:

Cases:

• Individuals who received full information about the study and did not object to the use of their data within this research.
• Patients managed in one of the intensive care or hepatogastroenterology departments at CHRU de Nancy for severe alcohol-related hepatitis between January 1, 2013, and December 31, 2023.
• Archived liver biopsy slides available at CHRU de Nancy.
• Adult patients at the time of diagnosis.

Controls:

• Individuals who received full information about the study and did not object to the use of their data within this research.
• Patients treated and operated on at CHRU de Nancy for hepatocellular carcinoma, colorectal cancer liver metastasis, or cholangiocarcinoma between January 1, 2013, and December 31, 2023.
• Archived liver biopsy slides available at CHRU de Nancy.
• Adult patients at the time of diagnosis.

Exclusion Criteria:

• None

Case:

Adult patient managed in one of the intensive care or hepatogastroenterology departments at CHRU de Nancy for severe alcohol-related hepatitis between January 1, 2013, and December 31, 2023, inclusive.

Control:

Adult patient managed and operated on at CHRU de Nancy for hepatocellular carcinoma, colorectal cancer liver metastasis, or cholangiocarcinoma between January 1, 2013, and December 31, 2023, inclusive.