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PubMed1998

Ascitic fluid to serum bilirubin concentration ratio for the classification of transudates or exudates.

OBJECTIVE: We compared the ascitic fluid to serum bilirubin ratio with three other ways of classifying ascitic fluid to the categories of exudate or transudate: the serum-ascites albumin gradient, the total protein concentration of the fluid, and the adaptation of Light's criteria for the detection of pleural fluid exudate, i.e., fluid to serum protein or LDH ratio or fluid LDH concentration. (Recently it has been reported that the pleural fluid to serum bilirubin ratio is statistically equivalent to Light's criteria.) Also, we evaluated whether the addition of the bilirubin ratio to the other criteria increases their diagnostic accuracy. METHODS: Eighty-one specimens of ascitic fluid from 81 different patients were obtained. They were analyzed prospectively by SMA12, whereas the category of the fluid was determined according to the clinical diagnosis. The diagnostic accuracy of each criterion alone and in combination with the bilirubin ratio, with reference to the contended etiology, were evaluated. RESULTS: The best criterion is the albumin gradient (overall accuracy = 0.84). The bilirubin and LDH ratio criteria had equivalent overall accuracy (0.815 and 0.802, respectively). The addition of the bilirubin ratio to any criterion did not improve its predictive or overall accuracy. CONCLUSIONS: Ascitic fluid to serum bilirubin ratio is an additional marker for the distinction of transudate from exudate. A ratio > 0.6 has a statistically significant association with exudate.

Ascitic Fluid↗
PubMed1998

Evaluating diagnostic tests in the pleural space. Differentiating transudates from exudates as a model.

Physicians have a staggering variety of diagnostic tests available for directing their diagnostic and therapeutic decisions. Technologic advances in laboratory science have increased the sophistication of new tests and accelerated their rate of adoption into clinical practice. Unfortunately, studies that report the value of new diagnostic tests often fail to follow accepted methodologic standards for unbiased test assessment or provide clinicians with sufficient information for the intelligent evaluation of a test's performance and applicability. The following review of pleural fluid tests that discriminate between exudative and transudative effusions serves to highlight important methodologic considerations in the assessment of diagnostic tests.

Diagnosis, Differential↗
PubMed2005

HDL/LDL ratio: a useful parameter for separation of pleural transudates from exudates.

The first diagnostic step in pleural effusions is the separation of transudates from exudates. We aimed in present study to investigate the value of HDL/LDL ratio for distinguishing between pleural exudates and transudates. Pleural fluids (PF)from 121 patients, including 28 transudates and 93 exudates were analyzed. The levels of cholesterol, HDL cholesterol and LDL cholesterol in PF were measured. The HDL/LDL ratio was calculated. HDL/LDL ratio found significantly higher in transudates than exudates (p= 0.001). Receiver operating characteristic (ROC) curves were generated and the cut off points determined to the highest level of accuracy and precision. The HDL/LDL ratio was to maximize sensitivity over specificity in the diagnosis of a transudative effusion. The usefulness of HDL/LDL ratio for identifying transudates was evaluated in terms of sensitivity and specificity. The value of pleural HDL/LDL ratio that best differentiated between transudates and exudates was 0.6 (sensitivity 89%, and specificity of 79%). Measurement of HDL and LDL in PF and calculating of HDL/LDL ratio can be proposed to aid for differentiation between pleural exudates and transudates with advantage of not requiring serum levels.

Adult↗
PubMed1991

Cholesterol: a useful parameter for distinguishing between pleural exudates and transudates.

Previously established criteria were used to classify 253 pleural effusions as transudates (65 cases), neoplastic exudates (67 cases), tuberculous exudates (65 cases), or miscellaneous exudate (56 cases). The parameters pleural LDH (PLDH), pleural LDH/serum LDH ratio (P/SLDH), and pleural protein/serum protein ratio (P/SPROT) were compared with pleural cholesterol (PCHOL) and the pleural cholesterol/serum cholesterol ratio (P/SCHOL) with regard to their usefulness for distinguishing between pleural exudates and transudates. The PCHOL values determined were 28.5 +/- 12.8 mg/dl for transudates, 88.1 +/- 30 mg/dl for neoplastic exudates, 96.5 +/- 28 mg/dl for tuberculous exudates, and 88 +/- 35.9 mg/dl for the miscellaneous group; the differences between the transudate group and the others are statistically significant (p less than 0.001). The sensitivity and specificity of P/SPROT for diagnosis of exudates were both 89 percent; the sensitivity of PLDH was 67 percent and its specificity was 95 percent; the sensitivity and specificity of P/SLDH were both 84.6 percent. Using Light's three criteria as a battery, the sensitivity was 94.6 percent and its specificity was 78.4 percent. All the transudates and 17 (9 percent) of the 188 exudates had PCHOL values below 55 mg/dl, so that with this threshold, PCHOL had a sensitivity of 91 percent and a specificity of 100 percent for diagnosis of exudates. With a threshold of 0.3, P/SCHOL had a sensitivity of 92.5 percent and a specificity of 87.6 percent. The number of misclassifications by PCHOL was less than with any other of the parameters, with statistically significant differences with respect to PLDH (p less than 0.001) and P/SLDH (p less than 0.01). We conclude that determination of PCHOL and P/SCHOL is of great value for distinguishing between pleural exudates and transudates, and should be included in routine laboratory analysis of pleural effusions.

Adult↗
PubMed2002

[Comparative analysis of Light's criteria and other biochemical parameters to distinguish exudates from transudates].

Light's criteria have classically been used to differentiate exudates from transudates. Nevertheless, a number of studies have attempted to identify more efficient parameters. The objective of our study was to determine the usefulness of biochemical parameters to differentiate transudates from exudates, and to compare them with the so far best studied criteria: the Light's criteria. We prospectively analysed 850 non selected cases of pleural effusion, with closed final diagnosis after its confirmation, therapeutic response and follow-up, collected consecutively at the Pleura Unit of our hospital. The parameters evaluated as potentially discriminatory between transudates and exudates included: glucose, proteins, albumin, lactate-dehydrogenase (LDH), cholesterol, triglycerides, bilirubin, alkaline phosphatase and adenosin-deaminase (ADA), both separately and in combination to obtain the highest yield. The highest diagnostic yield was observed with the combination of pleural cholesterol, pleural LDH, and the pleural fluid/serum protein ratio, but without significant differences between combinations of pleural cholesterol and LDH, pleaural LDH and pleural proteins, Light's criteria or modified Light's criteria. We recommend the use of pleural cholesterol higher than 47 mg/dl and pleural LDH higher than 222 IU/l to offer the same yield as the combination of three parameters, due to its lower cost and because the necessity of serum determinations is avoided.

Aged↗
PubMed2001

Is the pleural fluid transudate or exudate? A revisit of the diagnostic criteria.

BACKGROUND: Pleural effusions are classified into transudates and exudates based on criteria developed in the 1970s. However, their accuracy has not been evaluated. We compared the performance of the pleural fluid absolute lactic dehydrogenase level (FLDH), fluid to serum ratio of LDH (LDHR), and fluid to serum ratio of total protein (TPR). TPR has been used instead of the absolute value of fluid protein based on the observation that fluid protein is influenced by changes in the serum protein concentration. However, the rationale for using LDHR remains unexplored. METHODS: Of 212 consecutive patients with pleural effusions, four with multiple causes and eight with an uncertain diagnosis were excluded. ROC curves were generated using sensitivity and 1-specificity values for TPR, FLDH, and LDHR and positive likelihood ratios (LR+ve) were computed using the optimum cut off values. The correlation between pleural fluid and serum concentrations of total protein and LDH was also estimated. RESULTS: Of 200 effusions studied, 156 were exudates and 44 were transudates. The optimum cut off levels were: FLDH 163 IU/l, TPR 0.5, LDHR 0.6, and the FLDH-TPR combination 163 and 0.4, respectively. The area under the curve (AUC) with 95% confidence interval (CI) was: 0.89 (0.86 to 0.96) for FLDH, 0.86 (0.80 to 0.91) for TPR, 0.82 (0.77 to 0.89) for LDHR, and 0.90 (0.86 to 95) for FLDH-TPR. A significant correlation was observed between serum and pleural fluid protein levels in transudates and exudates (r=0.5 and 0.6, respectively), but the correlation between serum and pleural fluid LDH levels was insignificant. CONCLUSION: FLDH is the most accurate marker for the diagnostic separation of transudates and exudates and LDHR has no role in this process. Combining TPR with FLDH appears to improve the diagnostic accuracy slightly.

Adolescent↗
PubMed1998

Cytologically proved malignant pleural effusions: distribution of transudates and exudates.

PURPOSE: This study attempts to determine the distribution of transudates vs exudates in pathologically proved malignant pleural effusions and the necessity for cytologic studies in patients with a transudative effusion. MATERIALS AND METHODS: A retrospective review of all cytologically positive malignant pleural effusions was performed at Duke University Medical Center over an 18-month period. All effusions were characterized as a transudate or an exudate based on standard criteria, including lactate dehydrogenase and protein values. RESULTS: Ninety-eight patients with a mean age of 62 years were identified as having a cytologically positive malignant pleural effusion and blood chemistry values available to distinguish an exudate from transudate. Ninety-seven patients (99%, 95% confidence interval; 0.94 to 0.99) had criteria for an exudative effusion. One patient (1%) with diffuse metastatic lung cancer had a borderline transudate and was in congestive heart failure at the time of thoracentesis. CONCLUSIONS: Cytologically positive pleural effusions for malignancy are almost always exudates. Cytologic evaluation for malignant cells of a transudative pleural effusion is not recommended.

Diagnosis, Differential↗
PubMed2001

Cholesterol in the separation of transudates and exudates.

The Light criteria represent the most acceptable method to separate transudates and exudates. However, approximately 10% of patients with transudates, especially those with congestive heart disease, are misdiagnosed with these criteria. To improve diagnostic accuracy, many biochemical markers have been proposed as alternatives to differentiate transudates and exudates. Cholesterol has raised particular interest because only pleural fluid is needed, which makes blood samples unnecessary and simplifies the procedure. In most clinical studies, cholesterol has been shown to be as sensitive as the Light criteria, although it is less specific. Other randomized studies are necessary to determine the real potential value of pleural-fluid cholesterol measurements. Studies of pleural-fluid cholesterol are aimed at better understanding the mechanisms by which cholesterol enters the pleural cavity and its role in diseases. The ideal cutoff point of cholesterol to differentiate transudates and exudates is still unknown. Recently, aspects of the cholesterol turnover in diseases have raised great interest. Cholesterol generated great interest after it was related to coronary artery diseases. The involvement of cholesterol in the atherosclerotic process is well known, although its importance in body cavities is still unclear.

Cholesterol↗
PubMed2003

Do we need all three criteria for the diagnostic separation of pleural fluid into transudates and exudates? An appraisal of the traditional criteria.

BACKGROUND: Classification of pleural effusions into transudates and exudates is based on pleural fluid absolute lactic dehydrogenase value (FLDH), fluid to serum ratio of LDH (LDHR) and fluid to serum ratio of total protein (TPR) used in a parallel combination strategy. Combining multiple tests in a parallel strategy to improve diagnostic accuracy is useful only if the pair-wise correlation of the individual tests is less than 0.75. So far, this concept has not been tested in patients with pleural effusions. MATERIAL/METHODS: Biochemical data from our 200-patient series with a known cause of pleural effusion were included in this study. Correlation between the three possible combinations of tests was determined. RESULTS: There were 116 males and 84 females. The mean age was 62+/-1.1 years (mean+/-SEM). Of the 200 effusions, 156 were exudates and 44 were transudates. There was a significant correlation between FLDH and LDHR (r=0.93, p<0.00). However, the correlation between FLDH and TPR (r=0.27) and TPR and LDHR (r=0.22) was not significant. CONCLUSIONS: The operative mechanism for LDHR and FLDH used in the classification of transudate and exudates appears to be similar, and therefore unsuitable for a parallel combination strategy in the diagnostic separation of pleural effusion. FLDH and TPR have a dissimilar operating mechanism, and can therefore be combined in this process. Therefore, the diagnostic separation of pleural effusion can be done cost effectively by utilizing FLDH and TPR alone, as the cost for estimating serum LDH is eliminated in this approach.

Aged↗
PubMed2002

Is it meaningful to use biochemical parameters to discriminate between transudative and exudative pleural effusions?

OBJECTIVES: The usefulness of biochemical criteria to separate pleural transudates from exudates is controversial, and the limitations of Light's criteria in patients receiving diuretic therapy is of general concern. We evaluated the added value of biochemical criteria to clinical judgment for separating transudates from exudates. SETTING: A community teaching hospital. DESIGN: A prospective, observational study for the evaluation of diagnostic tests. PATIENTS AND MEASUREMENTS: In 249 consecutive patients referred for diagnostic thoracentesis, two physicians classified the pleural effusion as transudate or exudate based on all available information just before performing the thoracentesis. The sensitivity, specificity, and accuracy of the clinical presumption were compared with those of Light's criteria, and serum-pleural fluid albumin and protein gradients. The combined accuracy of biochemical and clinical criteria was also assessed. RESULTS: The accuracy of Light's criteria (93%) was significantly higher than that showed by the initial clinical presumption (84%; p < 0.01) and that of the alternative biochemical criteria: serum-pleural fluid albumin gradient (87%; p < 0.03) and serum-pleural fluid protein gradient (86%; p < 0.01). In patients receiving diuretic therapy, the accuracy of Light's criteria was 83% (60 of 72 cases), neither different to that of the albumin gradient (88%; 63 of 72 cases) nor to that of the protein gradient (86%; 62 of 72 cases). When these alternative biochemical criteria were applied exclusively to patients receiving diuretics who were thought to have a transudative effusion by clinical criteria, but having fluid identified as exudative by Light's criteria, the results did not improve significantly. Using a multiparametric model for the population receiving diuretics, the accuracy was greater (93%; 67 of 72 cases) than that of Light's criteria but without reaching statistical significance (p = 0.12). CONCLUSIONS: Light's criteria are significantly superior to the clinical presumption to separate pleural transudates from exudates. In patients receiving diuretics, Light's criteria lose accuracy, which is similar to that showed by the use of alternative biochemical criteria alone or combined with clinical judgment.

Adolescent↗
PubMed1990

[A method of differentiating transudate and exudate].

A diagnostic value of pleural fluid alkaline phosphatase (AP) for transudate and exudate differentiation is shown. AP below and above 0.5 mumol/(ml.h) are characteristic of transudate and exudate, respectively.

Alkaline Phosphatase↗
PubMed2006

Discriminating between transudates and exudates.

The dichotomous classification of pleural fluid as a transudate or an exudate simplifies diagnostic efforts in determining the cause of pleural effusions. Multiple pleural fluid tests are available to discriminate between these two classes of effusions. Tests commonly used in clinical practice depend on the detection in pleural fluid of large-molecular-weight chemicals that enter the pleural space to greater degrees in conditions associated with exudative compared with transudative effusions. Considerable misclassifications can occur with all available testing strategies, so clinicians benefit from adopting a nondichotomous, bayesian approach for interpreting test results.

Bayes Theorem↗
PubMed1992

Lipoproteins and apolipoproteins in human pleural effusions.

We investigated the lipoproteins and apoproteins in human serum and pleural effusions of different origin: transudates, inflammatory exudates, and malignant exudates. Transudates had a low cholesterol content of 35 +/- 12 mg/dl (mean +/- SD) because of low levels of low-density lipoprotein (LDL) cholesterol--representing 16% of serum levels--whereas inflammatory exudates (cholesterol 92 +/- 26 mg/dl) and malignant exudates (cholesterol 86 +/- 6 mg/dl) exhibited high levels of LDL, with 67% and 69% of serum levels. Apolipoprotein (apo) B level corresponded with LDL and presented with multiple split-products in sodium dodecyl sulfate-polyacrylamide gel electrophoresis in exudative effusions. LDL levels in effusions correlated with serum levels in exudates but did not correlate with those in transudates. In contrast, lipoprotein(a) appeared in all effusions from patients with detectable serum levels. The isoforms were similar as demonstrated by immunoblotting. Differences were found in the composition of the high-density lipoprotein (HDL) fraction: transudates had cholesterol-rich HDL when compared with serum. HDL particles of malignant exudates were poor in cholesterol, and isoelectric focusing demonstrated more sialized apolipoprotein E. A strongly abnormal HDL level with accumulation of cholesterol was found in a long-standing tuberculous effusion. In conclusion, cholesterol in acute effusions is bound to lipoproteins and derived from the blood. The difference in total cholesterol levels between transudates and exudates is based on the lack of LDL in transudates. Transudates show the lipoprotein characteristics of interstitial fluid. Alterations of lipoproteins occur in chronic inflammation and in malignancy with possible de novo synthesis of apolipoprotein E by tumor cells. Lipoprotein(a) accumulates independently from LDL in the pleural space, a finding that supports the view that the physiologic function of lipoprotein(a) is located in the interstitial space.

Aged↗
PubMed1996

Pleural fluid to serum cholinesterase ratio for the separation of transudates and exudates.

STUDY OBJECTIVE: To evaluate the usefulness of two new parameters for separating pleural transudates and exudates: pleural fluid cholinesterase level and pleural fluid to serum cholinesterase ratio, and to compare the results with the other well-established criteria. DESIGN: Prospective evaluation of the patients referred for diagnostic thoracentesis. SETTING: Pulmonary sections of a community hospital and a university hospital. PATIENTS: One hundred ninety-three consecutive patients. Forty were excluded for different reasons. MEASUREMENTS: The following criteria for separating the pleural effusions in transudates and exudates were analyzed: Light's criteria, the pleural fluid cholesterol level, the pleural fluid to serum cholesterol ratio, the pleural fluid cholinesterase level, and the pleural fluid to serum cholinesterase ratio. RESULTS: One hundred fifty-three patients had conditions diagnosed. Thirty-five were classified as having transudates and 118 as exudates. The percentage of effusions misclassified by each parameter was as follows: Light's criteria, 7.8%; pleural fluid cholesterol, 7.8%; pleural fluid to serum cholesterol ratio, 6.5%; pleural fluid cholinesterase, 8.5%; and pleural fluid to serum cholinesterase ratio, 1.3%. CONCLUSIONS: The pleural fluid to serum cholinesterase ratio is the most accurate criterion for separating pleural transudates and exudates. If further studies confirm our results, the cholinesterase ratio could be used as the first step in the diagnosis of pleural effusions.

Cholesterol↗