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1 From the Department of Medicine, St. Joseph's Hospital and Medical Center, Phoenix, and the University of Arizona Health Sciences Center, Tucson, Arizona
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.
Key Words: diagnosis • pleural disease • pleural effusion • receiver operating characteristic
Submitted on August 30, 1996
Accepted on November 11, 2007
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