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PubMed1993

Evaluation of different criteria for the separation of pleural transudates from exudates.

OBJECTIVES: To determine the relative usefulness of different criteria for the separation of pleural transudates from exudates. DESIGN: Prospective evaluation of patients referred for thoracentesis. SETTING: Community teaching hospital. PATIENTS: Three hundred fifty-one consecutive patients with pleural effusions referred for thoracentesis. Fifty-four of these patients were excluded from the analysis. MEASUREMENTS: We recorded clinical characteristics and final diagnosis and measured pleural fluid and serum levels of total protein, lactate dehydrogenase, and cholesterol. All patients included were followed up until final diagnosis. MEAN RESULTS: Forty-four (15 percent) pleural effusions were transudates and 253 (85 percent) were exudates. The criteria of Light et al, with a sensitivity of 98 percent and a specificity of 77 percent for exudates, showed the best accuracy (95.2 percent). Moreover, when the cutoff used for the criteria of Light et al was modified according to our own laboratory results, specificity rose to 93 percent with almost a similar accuracy (94 percent). Protein pleural fluid/serum ratio > 0.5 and pleural fluid cholesterol > 60 mg/dl showed equal specificity (91 percent), but the former had better sensitivity for exudates (88 percent vs 81 percent). CONCLUSIONS: When the proportion of exudates included is 85 percent or more, as in the present series, the criteria of Light et al remain the method that offers the highest accuracy for segregating transudates from exudates.

Adolescent↗
PubMed1990

Pleural fluid to serum bilirubin concentration ratio for the separation of transudates from exudates.

Whether fluid accumulating in the pleural space is a transudate or an exudate is determined by the widely used criteria of the pleural fluid to serum LDH and protein concentration ratios. Such a distinction is important for limiting the extent of the differential diagnosis of possible causes for this condition. We have found that a pleural fluid to serum total bilirubin ratio can serve the same purpose. The correlation of a bilirubin concentration ratio of 0.6 or more with the presence of an exudate as determined by established criteria is statistically highly significant; and its sensitivity, specificity, positive predictive accuracy, and overall accuracy in relation to etiology and LDH or protein criteria (Light's criteria) are about 90 percent. Hence, the bilirubin criterion is statistically equivalent to the widely accepted LDH and protein criteria.

Bilirubin↗
PubMed1989

Evaluation of pleural and peritoneal effusions.

Certain diseases cause an increase in the amount of fluid present in the pleural and/or peritoneal cavity (an effusion). Uroperitoneum subsequent to kidney, ureter, bladder, or urethra rupture also can cause an increased amount of fluid in the abdomen. Evaluation of fluid samples often is helpful in identifying the mechanism causing the effusion and, occasionally, results in a specific diagnosis. The TP, TNCC, and general cytologic examination can be performed easily, quickly, and inexpensively in-house. The TP and TNCC are used to classify effusions as transudates, modified transudates, or exudates. Transudates usually are caused by hypoalbuminemia, but also can be caused by leakage of fluid from efferent intestinal lymphatics. Cytology and culture usually are not rewarding in the evaluation of transudates. Modified transudates usually are caused by increased vascular permeability or increased intrahepatic hydrostatic pressure. Cytologic and radiographic examinations often are helpful in evaluating patients with modified transudates, while cultures usually are unrewarding. The exudate class encompasses the inflammatory exudates (septic or nonseptic), neoplastic exudates, and chylous effusions. Inflammatory exudates have a high TP and predominantly contain inflammatory cells. They may be septic or nonseptic. When septic, degeneration neutrophils often, but not always, are found. Cultures often are needed to determine whether sepsis is present, to identify the specific organism, and to determine the best therapy. Neoplastic exudates may contain numerous neoplastic cells. If there is concern that the cells are dysplastic instead of neoplastic, the cytology preparation should be referred to a consultant. Chylous effusions usually contain many small lymphocytes with a variable number of neutrophils and macrophages. In chronic chylous effusions, however, neutrophils and/or macrophages may predominate. Chylous effusions usually are differentiated easily from pseudochylous effusions by cytology. Comparison of fluid and serum triglyceride and cholesterol concentrations can be used to differentiate chylous and pseudochylous effusions when differentiation cannot be accomplished by cytology.

Animals↗
PubMed1996

[Differential diagnosis between exudate and transudate in pleural effusion].

The objective was 1) to determine the usefulness of different criteria in the differential diagnosis between exudate and transudate in pleural effusion, 2) to evaluate albumin gradient changes in pleural effusion fluids characterized as transudates in patients who do and do not receive diuretic therapy, 3) to define the specificity of pleural effusions of neoplastic etiology. All patients with pleural effusion admitted to the hospital between January 15 and August 15 1994 were evaluated consecutively. Serum and pleural effusion, total protein, LDH, albumin and cholesterol levels were measured and the etiologic diagnosis of the pleural effusion (gold standard) was established. Out of the total of 112 evaluated patients, 7 were excluded because it was impossible to reach a final diagnosis. Based on the etiologic diagnosis, 47 patients (44.8%), average age of 69.6 +/- 12.07, had pleural effusions defined as transudate and 58 patients (55.2%), average age of 66.5 +/- 14.26, had pleural effusions defined as exudate. Sixty-six percent of the transudates were secondary to heart failure, while 40% of the exudates were of neoplastic origin. Using the criteria of Light et al, we obtained a diagnostic accuracy (DA) of 82.7% (CI 95% 73.1-90.0)%. However, when the cut-off point was modified according to Valdez and the value of cholesterol in pleural effusion and its relation to serum cholesterol was added, the DA rose to 90.2 (83.2-96.0)% (p < 0.05). The effusion-serum cholesterol ratio demonstrated 100 (85.1-100)% sensitivity for neoplastic effusions, whereas for non-neoplastic exudative effusions the sensitivity was 89 (73.2-96.8)%. The tests, however, showed only 17.4 (6.56-33.6)% specificity. The albumin gradient (the difference between serum and pleural effusion albumin) did no vary in patients with transudates who received diuretics, allowing a correct diagnosis of transudate in 93 (82.4-97.8)% of the cases. However, in patients who were taking diuretics, the classic criteria of protein index defined correctly only 66 (53.4-82.1)% of the cases (p < 0.05). It can be concluded that the variation of cut-off points originally established by Light et al. and the addition of cholesterol determination in pleural effusion and its relation to the serum cholesterol level allowed us to increase the DA. This appears to be the best way to differentiate a transudate from an exudate. The relation between pleural effusion and serum cholesterol levels showed a very low specificity for the differentiation of neoplastic and non-neoplastic exudative pleural effusions. Unlike the pleural effusion-serum total protein ratio, the albumin gradient allowed us to establish the correct diagnosis of transudate even in patients taking diuretics.

Adult↗
PubMed2002

[Biological criteria for distinguishing exudative and transudative pleural effusions. Usefulness in a general hospital].

The first step in the diagnosis of a pleural effusion is to determine the exudative or transudative nature of the fluid. The purpose of this work was to compare different biological criteria commonly used in clinical practice. Among 118 pleural effusion fluids studied, 24.6% were exudates and 75.6% were transudates. The different parameters studied were Light criteria, Costa criteria, protein content, cholesterol content, and lactate dehydrogenase activity in the pleural fluid. The results showed that the Light criteria enabled classing all the fluids as exudates or transudates. We were also able to demonstrate that simple assay of lactate dehydrogenase activity in the pleural fluid gave comparable results, avoiding the need for further blood samples.

Aged↗
PubMed1998

Pharmacokinetic studies of flunixin meglumine and phenylbutazone in plasma, exudate and transudate in sheep.

Flunixin meglumine (FM, 1.1 mg/kg) and phenylbutazone (PBZ, 4.4 mg/kg) were administered intravenously (i.v.) as a single dose to eight sheep prepared with subcutaneous (s.c.) tissue-cages in which an acute inflammatory reaction was stimulated with carrageenan. Pharmacokinetics of FM, PBZ and its active metabolite oxyphenbutazone (OPBZ) in plasma, exudate and transudate were investigated. Plasma kinetics showed that FM had an elimination half-life (t1/2beta) of 2.48 +/- 0.12 h and an area under the concentration - time curve (AUC) of 30.61 +/- 3.41 Lg/mL x h. Elimination of PBZ from plasma was slow (t1/2beta = 17.92 +/- 1.74 h, AUC = 968.04 +/- microg/mL x h). Both FM and PBZ distributed well into exudate and transudate although penetration was slow, indicated by maximal drug concentration (Cmax) for FM of 1.82 +/- 0.22 microg/mL at 5.50 +/- 0.73 h (exudate) and 1.58 +/- 0.30 microg/mL at 8.00 h (transudate), and Cmax for PBZ of 22.32 +/- 1.29 microg/mL at 9.50 +/- 0.73 h (exudate) and 22.07 +/- 1.57 microg/mL at 11.50 +/- 1.92 h (transudate), and a high mean tissue-cage fluids:plasma AUClast ratio obtained in the FM and PBZ groups (80-98%). These values are higher than previous reports in horses and calves using the same or higher dose rates. Elimination of FM and PBZ from exudate and transudate was slower than from plasma. Consequently the drug concentrations in plasma were initially higher and subsequently lower than in exudate and transudate.

Animals↗
PubMed1995

Pleural cholesterol in differentiating transudates and exudates. A prospective study of 232 cases.

Two hundred and four patients with pleural effusion were studied to investigate the utility of Light's criteria and pleural fluid cholesterol level (pCHOL) in the identification of exudative pleural effusion (EPE) and transudative pleural effusion (TPE). There were 48 TPE, 56 tumor, 47 tuberculous, 30 metapneumonic and 23 miscellaneous patients. A value > or = 54 mg/dl for pCHOL and > or = 0.32 for the pleura/serum cholesterol ratio (p/sCHOL) showed sensitivity (S) and specificity (Sp) of 95.5% and 91.6% for pCHOL, and 97.4% and 91.6% for p/sCHOL, respectively. Combined pCHOL and/or p/sCHOL showed a S of 98.7% and Sp of 89.5%. Light's criteria achieved a S of 100% and Sp of 64.5%. Combined pCHOL and p/sCHOL revealed a similar accuracy to Light's criteria in EPE diagnosis but was found to be more exact in TPE diagnosis.

Adult↗
PubMed1991

[Cytologic, biochemical and immunologic parameters of pleural effusions. I. Criteria for differentiating transudates and exudates].

In 158 patients with pleural effusions the authors assessed 7 cytological, 26 biochemical and 6 immunological parameters in the pleural fluid. Using Light's criteria in 22 patients the fluid was a transudate, in 136 an exudate. The differences between the mean values of studied parameters were analysed. Basing on this the most characteristic cut of values were calculated. Each parameter was calculated for its sensitivity, specificity and diagnostic accuracy in differentiating the nature of the pleural fluid. The authors found the cytological parameters and protein levels in pleural fluid differentiate best exudates from transudates.

Adult↗
PubMed2005

Pleural adenosine deaminase in the separation of transudative and exudative pleural effusions.

OBJECTIVE: The purpose of this study was to evaluate the usefulness of a new parameter, pleural adenosine deaminase (PADA), for separating transudative pleural effusion from exudative pleural effusion, and to compare the results with other tests (albumin gradient and protein gradient). METHODS: From November 2001 to January 2003, 359 consecutive patients with pleural effusion who underwent a diagnostic thoracentesis were included in the study. Effusions were individually classified as transudates or exudates after the careful evaluation of all clinical data and biochemical parameters of pleural fluid and serum of patients on the basis of Light's criteria. The means and standard deviations of PADA, pleural/serum ADA (P/S ADA) ratio, albumin gradient and protein gradient were evaluated for transudative and exudative effusions. The best cut-off values for each test were identified by using the receiver operating characteristic (ROC) curve. The optimum cut-off level was determined by selecting points of test values that provided the greatest sum of sensitivity and specificity. RESULTS: There were 113 transudates and 246 exudates. For each test, differences in mean value between the transudate group and the exudate group were statistically significant (t test, P<0.001). The optimum cut-off levels for PADA and P/S ADA were 15.3 U/L and 0.66 U/L, respectively. ROC analysis confirmed previous recommendations for albumin gradient (12 g/L) and protein gradient (31 g/L). For detecting exudates, the PADA test yielded a sensitivity and specificity of 85.8% and 82.3%, respectively. Sensitivity and specificity of the albumin gradient were found to be 88.5% and 79.3%, and of the protein gradient 85% and 83.2%, respectively. The areas under the curve (AUC) data and accuracy demonstrated similar discriminative properties in the examined tests. CONCLUSIONS: The measurement of PADA is suggested as a reliable test in the separation of pleural exudates from transudates with accuracy similar to that of the albumin gradient and protein gradient.

Adenosine Deaminase↗
PubMed1994

Pleural exudates and transudates: diagnosis with contrast-enhanced CT.

PURPOSE: To determine the accuracy of computed tomography (CT) in enabling differentiation of pleural exudates from transudates. MATERIALS AND METHODS: Eighty consecutive patients (86 effusions) underwent contrast-enhanced CT. Thoracentesis was performed to measure pleural and serum total protein and lactate dehydrogenase (LDH) values. Effusions were classified as exudates with accepted criteria. CT scans were evaluated for the presence and appearance of parietal pleural and extrapleural fat thickening. RESULTS: Fifty-nine effusions were exudates and 27 were transudates. Thirty-six of the 59 exudates (61%) were associated with parietal pleural thickening. All cases of empyema and 56% of the parapneumonic exudative effusions had pleural thickening. The specificity of this finding in diagnosing the presence of an exudate is 96%. CONCLUSION: Parietal pleural thickening at contrast-enhanced CT almost always indicates the presence of a pleural exudate. A pleural exudate in the absence of pleural thickening occurs most frequently in patients with malignancy or uncomplicated parapneumonic effusion.

Adolescent↗
PubMed1997

Diagnostic value of tests that discriminate between exudative and transudative pleural effusions. Primary Study Investigators.

STUDY OBJECTIVE: To (1) determine appropriate decision thresholds and diagnostic accuracies for pleural fluid (PF) tests that discriminate between exudative and transudative pleural effusions, and (2) evaluate the quality of the primary investigations. DESIGN: Formal meta-analysis of studies that report the diagnostic value of pleural fluid tests. SETTING: Data collected from international academic medical centers. PATIENTS: Hospitalized patients undergoing thoracentesis for pleural effusions. INTERVENTIONS: Primary investigators were requested to transmit original data from patients described in their studies. MEASUREMENTS AND RESULTS: Eight primary studies described 1,448 patients with one or more of the following tests: protein (P)-PF, P-PF/serum ratio (R), bilirubin (BILI)-R, lactate dehydrogenase (LDH)-PF, LDH-R, cholesterol (C)-PF, C-R, and albumin gradient. We found that all eight tests had similar diagnostic accuracies when evaluated by receiver operating characteristic (ROC) analysis except for BILI-R, which was less diagnostically accurate. Decision thresholds determined by ROC analysis differed from previously reported values for LDH-PF (>0.45 upper limits of normal) and C-PF (>45 mg/dL). Paired and triplet test combinations tended to have higher diagnostic accuracies compared with individual tests, but examination of the odds ratios with 95% confidence intervals did not identify a clearly superior test combination. Limitations of the primary studies presented a high likelihood of bias affecting their results. CONCLUSIONS: Several strategies exist for clinicians in utilizing PF tests to classify effusions as exudates or transudates but accurate interpretations of these test results will require better designed studies.

Albumins↗