Background: An important part of the investigation of pleural effusion is the identification of markers that help separate exudate from transudate. Objectives: The purposes of this study were to compare the accuracy of published and new sets of criteria to distinguish between exudative and transudative pleural effusions, and to determine whether serum biochemical analysis is necessary. Methods: An externally validated cohort study was performed. Pleural effusions were determined to be transudative or exudative on the basis of an assessment of the medical record by two clinicians blinded to biochemical results. Sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and area under the receiver operating characteristic curve were determined for each proposed combination of criteria. Results: Pleural fluid analysis was available for 311 thoracenteses in the main cohort and for 112 thoracenteses in the validation cohort. The best sensitivity (97% [95% CI 94–99]) and negative likelihood ratio (0.04 [95% CI 0.02–0.08]) for identifying exudative effusions were observed with criteria combining pleural fluid lactate dehydrogenase greater than 0.6 the upper limit of normal serum lactate dehydrogenase and pleural fluid cholesterol greater than 1.04 mmol/L (40 mg/dL). The overall diagnostic accuracy was similar to Light’s criteria. Findings were similar in the validation cohort. Conclusions: Our proposed criteria using simultaneously pleural fluid lactate dehydrogenase and pleural fluid cholesterol can identify an exudate with a sensitivity and an overall diagnostic accuracy similar to Light’s criteria. It avoids simultaneous blood sampling, thus reducing patient discomfort and potential costs.

1.
Light
RW
,
Macgregor
MI
,
Luchsinger
PC
,
Ball
WC
 Jr
.
Pleural effusions: the diagnostic separation of transudates and exudates
.
Ann Intern Med
.
1972
Oct
;
77
(
4
):
507
13
.
[PubMed]
0003-4819
2.
l disease
.
N Engl J Med
.
2018
;
378
(
8
):
740
51
.
[PubMed]
0028-4793
3.
Beaudoin
S
,
Gonzalez
AV
.
Evaluation of the patient with pleural effusion
.
CMAJ
.
2018
Mar
;
190
(
10
):
E291
5
.
[PubMed]
0820-3946
4.
Froudarakis
ME
.
Diagnostic work-up of pleural effusions
.
Respiration
.
2008
;
75
(
1
):
4
13
.
[PubMed]
1423-0356
5.
Hamm
H
,
Brohan
U
,
Bohmer
R
,
Missmahl
HP
.
Cholesterol in pleural effusions. A diagnostic aid
.
Chest
.
1987
Aug
;
92
(
2
):
296
302
.
[PubMed]
0012-3692
6.
Light
RW
,
Lee
YC
.
Textbook of pleural diseases.
Third edition. ed. Boca Raton: CRC Press, Taylor & Francis Group;
2016
.
7.
Hillerdal
G
.
Chyliform (cholesterol) pleural effusion
.
Chest
.
1985
Sep
;
88
(
3
):
426
8
.
[PubMed]
0012-3692
8.
Wilcox
ME
,
Chong
CA
,
Stanbrook
MB
,
Tricco
AC
,
Wong
C
,
Straus
SE
.
Does this patient have an exudative pleural effusion? The Rational Clinical Examination systematic review
.
JAMA
.
2014
Jun
;
311
(
23
):
2422
31
.
[PubMed]
0098-7484
9.
Costa
M
,
Quiroga
T
,
Cruz
E
.
Measurement of pleural fluid cholesterol and lactate dehydrogenase. A simple and accurate set of indicators for separating exudates from transudates
.
Chest
.
1995
Nov
;
108
(
5
):
1260
3
.
[PubMed]
0012-3692
10.
Romero
S
,
Candela
A
,
Arriero
JM
.
Keep testing the waters
.
Chest
.
1996
Jul
;
110
(
1
):
299
300
.
[PubMed]
0012-3692
11.
Soliano
JS
,
Jorge
MC
. Compairing Pleural Fluid Cholesterol and Lactate Dehydrogenase (Costa’s Criteria) and Light’s Criteria in Separating Exudates From Transudates. CHEST Journal.
2008
;134(4_MeetingAbstracts):p57002-p57002.
12.
Imazio
M
,
Hoit
BD
.
Post-cardiac injury syndromes. An emerging cause of pericardial diseases
.
Int J Cardiol
.
2013
Sep
;
168
(
2
):
648
52
.
[PubMed]
0167-5273
13.
Singh
A
,
Bajwa
A
,
Shujaat
A
.
Evidence-based review of the management of hepatic hydrothorax
.
Respiration
.
2013
;
86
(
2
):
155
73
.
[PubMed]
1423-0356
14.
Koegelenberg
CF
,
Diacon
AH
,
Bolliger
CT
.
Parapneumonic pleural effusion and empyema
.
Respiration
.
2008
;
75
(
3
):
241
50
.
[PubMed]
1423-0356
15.
Maldonado
F
,
Hawkins
FJ
,
Daniels
CE
,
Doerr
CH
,
Decker
PA
,
Ryu
JH
.
Pleural fluid characteristics of chylothorax
.
Mayo Clin Proc
.
2009
Feb
;
84
(
2
):
129
33
.
[PubMed]
0025-6196
16.
Epler
GR
,
McLoud
TC
,
Gaensler
EA
.
Prevalence and incidence of benign asbestos pleural effusion in a working population
.
JAMA
.
1982
Feb
;
247
(
5
):
617
22
.
[PubMed]
0098-7484
17.
Samman
PD
,
White
WF
.
The “Yellow Nail” Syndrome
.
Br J Dermatol
.
1964
Apr
;
76
(
4
):
153
7
.
[PubMed]
0007-0963
18.
Valdés
L
,
Pose
A
,
Suàrez
J
,
Gonzalez-Juanatey
JR
,
Sarandeses
A
,
San José
E
, et al
Cholesterol: a useful parameter for distinguishing between pleural exudates and transudates
.
Chest
.
1991
May
;
99
(
5
):
1097
102
.
[PubMed]
0012-3692
19.
Shen
Y
,
Zhu
H
,
Wan
C
,
Chen
L
,
Wang
T
,
Yang
T
, et al
Can cholesterol be used to distinguish pleural exudates from transudates? evidence from a bivariate meta-analysis
.
BMC Pulm Med
.
2014
Apr
;
14
(
1
):
61
.
[PubMed]
1471-2466
20.
DeLong
ER
,
DeLong
DM
,
Clarke-Pearson
DL
.
Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach
.
Biometrics
.
1988
Sep
;
44
(
3
):
837
45
.
[PubMed]
0006-341X
21.
Hooper
C
,
Lee
YC
,
Maskell
N
;
BTS Pleural Guideline Group
.
Investigation of a unilateral pleural effusion in adults: British Thoracic Society Pleural Disease Guideline 2010
.
Thorax
.
2010
Aug
;
65
Suppl 2
:
ii4
17
.
[PubMed]
0040-6376
22.
Wilcox
M
,
Chong
CY
,
Stanbrook
MB
,
Tricco
AC
,
Wong
C
,
Straus
SE
.
Supplementary Online Content: does this patient have an exudative pleural effusion? The rational clinical examination systematic review
.
JAMA
.
•••
;
3112014
:
2422
31
.0098-7484
23.
Porcel
JM
,
Vives
M
,
Vicente de Vera
MC
,
Cao
G
,
Rubio
M
,
Rivas
MC
.
Useful tests on pleural fluid that distinguish transudates from exudates
.
Ann Clin Biochem
.
2001
Nov
;
38
(
Pt 6
):
671
5
.
[PubMed]
0004-5632
24.
Heffner
JE
,
Brown
LK
,
Barbieri
CA
,
Investigators
PS
;
Primary Study Investigators
.
Diagnostic value of tests that discriminate between exudative and transudative pleural effusions
.
Chest
.
1997
Apr
;
111
(
4
):
970
80
.
[PubMed]
0012-3692
25.
Eaton
KP
,
Levy
K
,
Soong
C
,
Pahwa
AK
,
Petrilli
C
,
Ziemba
JB
, et al
Evidence-Based Guidelines to Eliminate Repetitive Laboratory Testing
.
JAMA Intern Med
.
2017
Dec
;
177
(
12
):
1833
9
.
[PubMed]
2168-6106
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.