DISCUSSION

i n the evaluation of a pleural effusion the first step is to differentiate the

transudates & exudates. It bears its implication in arriving at an etiological
diagnosis as the diagnostic and the therapeutic strategies for the transudates
and exudates are different. An exudative effusion requires extensive
sometimes invasive procedures for its etiological diagnosis, on the other hand
a transudative pleural effusion requires treatment directed only towards the
primary disease process. Histopathological examinations are confirmatory, but
it has its limitations ions as the specimen yield is very low, sometimes up to
30% [Escudero et al 1990] and being an invasive technique it has its
hazards.The laboratory parameters such as Light’s criteria [Light et al 1972],
pleural fluid protein value has variable results in the differential diagnosis as
reported by many workers.

Keeping all these factors in mind the present study was

undertaken to study the significance of serum–effusion albumin gradient in
differential diagnosis of pleural effusion and compare with the already
established Light’s criteria.

The present study comprised of 40 cases of pleural effusion in

which the etiology was established by clinical examination, Radiological
investigations, pleural fluid cytology, special laboratory methods and
histopathological examination of pleural biopsy specimen in selected cases. In the
present series 75% were male and 25% cases were females belonged to age group
of 13–83 years. Among 40 cases of transudates and exudates, 50% had right sided
pleural effusion, 30% had left sided and 20% had bilateral pleural effusions.

Differential Diagnosis of Transudates and Exudates:

Classically pleural effusion are divided into transudates and

exudates. In the present study of 40 cases of pleural effusion 65% were
established as exudates and 35% as transudates.
  DI S CUSS I ON  76

Pleural Fluid Proteins in Differential Diagnosis of Pleural

Effusion:

In the present study of 40 cases of pleural 55% of exudates &

45% of transudates were differentiated by a pleural fluid protein value of 3
g/dl. The sensitivity and specificity of these parameters is 80% & 70%
respectively. Total misclassification of 25% occurred with this parameter ie
23.07% misclassified exudates and 28.52% of treansudates.

In a study, Carr & Power [1958] showed that a pleural fluid

protein value of 3 g/dl could differentiate 64% of exudates & 50% of
transudates with total misclassification of 21%.

In a study by K.B. Gupta et al showed that pleural fluid protein

value of 3 g/dl misclassified 25% of exudates and 18.7% of transudate with
sensitivity and specificity of 83.3% and 75% with total misclassification of
20%.

Pleural Fluid to Serum Protein in Differential Diagnosis of

Pleural Effusion:

In the present study of 40 cases of pleural effusion pleural fluid

to serum protein ratio of.5 separated 57.5% as exudates & 42.5% as
transudates with sensitivity and specificity of 85% & 73.7% with total
misclassification rate of 20%. This parameter correctly classified 81% of
exudates and 85% of transudates. Misclassification rate for transudates
21.42% and for exudates is 1.9%.

Light et al [1972]; in their study reported that a pleural fluid to

serum protein ratio of >0.5 correctly classified 92% of transudates & 90% of
exudates.

Valdes et al [1991] also found in their study that this parameter

correctly classified 89% of transudates and 84% of exudates.
  DI S CUSS I ON  77

Ram et al [1995] also reported that the pleural fluid protein to

serum protein ratio of 0.5 correctly classified 81.5% of transudates and all
exudates with a misclassification rate of 15%.

K.B. et al found a sensitivity and specificity of 85% and 66.6%

with this parameter and are total misclassification of 18%.

From the above results by the above results by the other workers
it is found that results obtained in the present study are comparable. The
misclassification rate is higher in the present study.

Pleural Fluid Protein and Pleural Fluid to Serum Protein

Ratio in Differential Diagnosis of Pleural Effusion:

In the present study of 40 cases of pleural effusion pleural fluid

protein of 3 g/dl and p/s of.5 separated 55% as exudates and 45% as
transudates with true classification rate of 82% as exudates and 83.3% as
transudates. Total misclassification rate of 17.5% occurred.

Pleural Fluid LDH in Differential Diagnosis of Pleural

Effusion:

In the present study of 40 cases of pleural effusion pleural fluid

LDH of 200 U/L separated 60% as exudates and 40% as transudate. True
classification was 87% for exudates and 82% for transudates. Total
misclassification of 17.5% occurred. The sensitivity and specificity of this
parameter is 86% & 77%.

K.B. Gupta et al found a sensitivity and specificity of 80% &

75% with this parameter with total misclassification of 21.6% occurred.

From the above results by other workers it is found that results

found in the present study are comparable. The misclassification rate in the
present study is 17.5% ie low compared to the above study.
  DI S CUSS I ON  78

Pleural Fluid LDH to Serum LDH of 0.6 in Differential

Diagnosis of Pleural Effusion:

In the present study of 40 cases of pleural effusion pleural fluid

LDH to serum LDh of.6 separated 67.5% as exudates and 32.5% as
transudates with true classification of 88.8% as exudates & 84.6% as
transudates. The sensitivity & specificity of this parameter is 92% & 73.3%
with total misclassification of 12.5%.

Light et al found a total misclassification of 10% with this

parameter.

K.B. Gupta et al found a total misclassification of 15.4% with

this parameter.

From the results found by other workers they are quite similar
but the misclassification rate in the present study is 12.5%.

Pleural Fluid LDH of 200 U/L & P/S LDH of.6 in Differential
Diagnosis of Pleural Effusion:

In the present study of 40 cases of pleural effusion pleural fluid

LDH of 200U/L & P/S LDH of.6 separated 70% as exudates & 30% as
transudates with true classification of 93% for exudates & 88% for
transudates with total misclassification of 10%. The sensitivity & specificity
of this parameter is 90.4% & 82.6%.

Serum–Effusion Albumin Gradient of 1.2g/dl in Differential

Diagnosis of Pleural Effusion:

In the present study of 40 cases of pleural effusion serum

effusion albumin gradient of 1.2g/dl separated 65% as exudates & 35% as
transudates with true classification rate of 96.15% for exudates & 94% for
treansudates with total misclassification of only 5%. The sensitivity and
specificity of this parameter is 96.1% & 93%.
  DI S CUSS I ON  79

Roth et al in a series of 59 patients used serum effusion albumin

gradient of 1.2g/dl & classified all the transudates correctly & only 2 exudates
were miss classified with total misclassification rate of 3.3%. The sensitivity
& the specificity of the parameter used was 90% & 92%.

E Razi et al attained a sensitivity & specificity of 91.5% &

92.86% respectively.

K.B. Gupta et al attained a sensitivity & specificity of 97.9% &

100% with total misclassification rate of 2%.

M.C. Dhar et al obtained a sensitivity & specificity of 100% &

94% with this parameter.

From the results obtained by the above workers, they are quite
similar to the present study. Misclassification rate obtained in the present
study is 5%.

Comparative Analysis of the Parameters Used In the Study of 40

Cases of Pleural Effusion:

EXUDATE TRANSUDATES MIS–

CLASSIFIED CLASSIFIED CLASSIFICATION
PARAMETER
CORRECTLY CORRECTLY RATE
[%] [%] [%]
PF Protein [3gm/dl] 72.70 77.70 25.00
P/S Protein [0.5] 78.26 82.35 20.00
PF Protein + P/S Protein 81.80 83.30 17.50
PF LDH [2001U/L] 83.30 81.25 17.50
P/S LDH [0.6] 88.80 84.60 12.50
PF LDH + P/S LDH 92.80 83.30 10.00
SEAG of 1.2 gm/dl 96.15 93.60 5.00

The parameters of protein, LDH & Serum–Effusion Albumin

gradient were studied in the 40 cases of pleural effusion & compared with the
established diagnosis of pleural effusion in the present study. The study
  DI S CUSS I ON  80

revealed that even though the parameter of pleural fluid protein of 3 gm/dl,
pleural fluid to serum protein ratio of.5, pleural fluid LDH level of 200 U/L &
pleural fluid LDH to Serum LDH ratio of.6 are useful in differentiating the
exudates & transudates. The greater differential value is found with the SEAG
value of 1.2 gm/dl which correctly classified 96.15% of exudates & 93.6% of
transudates with a total misclassification of only 5% & with a sensitivity &
specificity of 96.1% & 93%.

Therefore the present study shows that Serum–Effusion Albumin

gradient of 1.2 gm/dl is a useful parameter in differential diagnosis of pleural
effusion which can be tried as a first step in the evaluation of cases of pleural
effusion.

The graphical representation of the misclassification rate of

various parameters showed in the above table is given in Fig–13.

usu