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Crit Rev Clin Lab Sci, 2013; 50(4–5): 107–124

! 2013 Informa Healthcare USA, Inc. DOI: 10.3109/10408363.2013.844679

REVIEW ARTICLE

Body fluid analysis: Clinical utility and applicability of published studies

to guide interpretation of today’s laboratory testing in serous fluids*
Critical Reviews in Clinical Laboratory Sciences Downloaded from informahealthcare.com by Laurentian University on 10/26/13

Darci R. Block and Alicia Algeciras-Schimnich

Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA

Abstract Keywords
Requests for testing various analytes in serous fluids (e.g. pleural, peritoneal, pericardial Ascites, effusion, pericardial fluid, pleural fluid
effusions) are submitted daily to clinical laboratories. Testing of these fluids deviates from assay
manufacturers’ specifications, as most laboratory assays are optimized for testing blood or urine History
specimens. These requests add a burden to clinical laboratories, which need to validate assay
performance characteristics in these fluids to exclude matrix interferences (given the different Received 5 August 2013
composition of body fluids) while maintaining regulatory compliance. Body fluid testing for a Revised 3 September 2013
number of analytes has been reported in the literature; however, understanding the clinical Accepted 11 September 2013
utility of these analytes is critical because laboratories must address the analytic and clinical Published online 24 October 2013
validation requirements, while educating clinicians on proper test utilization. In this article, we
review the published data to evaluate the clinical utility of testing for numerous analytes in
For personal use only.

body fluid specimens. We also highlight the pre-analytic and analytic variables that need to be
considered when reviewing published studies in body fluid testing. Finally, we provide
guidance on how published studies might (or might not) guide interpretation of test results in
today’s clinical laboratories.

Abbreviations: ACCP: American College of Chest Physicians; AFP: a-fetoprotein; BNP: B-type
natriuretic peptide; BTS: British Thoracic Society; CA15-3: cancer antigen 15-3; CA125: cancer
antigen 125; CA19-9: cancer antigen 19-9; CEA: carcinoembryonic antigen; CYFRA
21-1: cytokeratin 19 fragment; LDH: lactate dehydrogenase; þLR: positive likelihood ratio;
LR: negative likelihood ratio; LR: likelihood ratio; NT-proBNP: N-terminal pro–B-type
natriuretic peptide; SAAG: serum ascites albumin gradient; SBP: spontaneous bacterial
peritonitis

Introduction validation can usually be applied to the alternate matrix

without creating issues for compliance. In addition, guiding
Laboratories routinely receive requests to perform testing on
interpretation of the test result poses challenges because
body fluids that are outside the specimen types validated by
particular assay manufacturers. Although this service might
laboratories might need to perform extensive and expensive 13
20
clinical validations to provide clinical decision limits and
be useful clinically, it poses a dilemma as the analytic assay
interpretive comments.
performance needs to be validated on these alternate speci-
This review aims to highlight the most relevant studies of
men types to maintain regulatory compliance. Validation
serous body fluids that can be used to provide interpretive
involves demonstrating acceptable accuracy, precision,
information on body fluid analytes. We also provide guidance
reportable range, reference range, sample stability, and
on how applicable these studies are in today’s clinical
analytic sensitivity and specificity. Very little guidance is
laboratories.
available to laboratories when performing an analytic valid-
ation, although the principles of a serum, plasma, or urine
Methods
Literature searches were conducted using PubMed or Scopus.
Search terms are listed in Table 1. We limited search results to
*Referee: Richard A. McPherson, MD, Director of Immunopathology English-language articles involving human subjects that had
Laboratory, Virginia Commonwealth University Medical Center.
been indexed between database inception and May, 2013.
Address for correspondence: Alicia Algeciras-Schimnich, PhD,
Titles were screened for pertinent studies of body fluid
Department of Laboratory Medicine and Pathology, Mayo Clinic,
200 First Street SW, Rochester, MN 55905, USA. E-mail: testing. Abstracts were reviewed to identify potential diag-
algecirasschimnich.alicia@mayo.edu nostic studies (defined as reporting sensitivity, specificity,
 108 D. R. Block & A. Algeciras-Schimnich Crit Rev Clin Lab Sci, 2013; 50(4–5): 107–124

Table 1. Initial search results for diagnostic serous fluid studies.

Titles or abstracts Full papers Included in

Search term reviewed, no. retrieved, no. analysis, no.
Serum-ascites albumin gradient 91 29 12
Pleural albumin gradient 43 23 13
Pancreatic ascites and amylase 222 37 11
Amylase and pleural effusions 250 8 2
Light’s criteria 250 39 22
Ascites and Light’s criteria 230 5 1
Biochemical composition of pericardial effusions 6 4 3
Ascitic fluid cholesterol 143 17 9
Pericardial fluid cholesterol 61 4 1
Pleural fluid and glucose 491 37 7
Ascitic fluid and glucose 378 28 6
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Pericardial fluid and glucose 76 2 2

Pleural fluid tumor markers 478 30 12
Peritoneal fluid tumor markers 724 35 9
Pericardial fluid tumor markers 96 9 3

accuracy, positive predictive value, negative predictive value,
or likelihood ratio [LR] in the results subheading of the
abstract) for all papers identified from each search. Papers
with abstracts meeting the search criteria were retrieved
for comprehensive review. Searches were further expanded
by including relevant papers referenced in the original or
in related articles. Papers were abstracted if they reported
sensitivity, specificity, or showed data allowing such
calculations.
For personal use only.
samples that require anaerobic handling and cold transport.
Most studies do not describe pre-analytic handling conditions
in detail, which confounds the interpretation of published
results, particularly for these sensitive analytes.
For analytes interpreted in conjunction with a serum
result, it is not well understood how close the collection time
of the serum should be to that of the body fluid. One study
of pleural and ascitic fluid suggested that categorization
by Light criteria and serum ascites albumin gradient

The information abstracted from the full paper included
disease assessed, total population tested, number of positive
cases, sensitivity, specificity, analytic method (including
serum reference interval), specimen collection container,
time from collection to analysis, and the time between
collection of serous fluid and serum. The positive LR (þLR)
and negative LR (LR) were calculated (if not reported) as
[sensitivity/(1  specificity)] and [(1  sensitivity)/specifi-
city], respectively, except for studies with cut-off values
chosen to achieve 100% specificity for tumor markers. þLRs
410 and LRs50.1 are considered strong evidence supporting
or excluding diagnoses, respectively, in most circumstances1.
Pre-analytic and analytic considerations for body
fluid testing
Body fluid specimens are collected for diagnostic or thera-
peutic reasons (or both) by ultrasound-guided procedures.
Examples include amniocentesis (to collect amniotic fluid),
thoracentesis (pleural fluid), paracentesis (peritoneal or
ascitic fluid), pericardiocentesis (pericardial fluid), and
arthrocentesis (synovial fluid). The collection container and
the conditions under which the specimen is transported to
the laboratory are dictated by the tests ordered. Most samples
for chemistry tests are collected in tubes that mirror the
specimen type validated in the laboratory, i.e. plain tubes
if serum is used for comparison or anticoagulant tubes if
plasma is preferred. Generally, glucose should be collected
in glycolysis-inhibitor tubes, although many laboratories
would not reject samples on this basis.
Some tests are particularly sensitive to sample-handling
conditions; one notable example is measurement of pH for
(SAAG), respectively, was not affected by timing when
comparing samples collected within 2 hours and samples
not formally paired (mean, 26 hours; range, 3 hours to
6 days)2.
Most laboratories use serum or urine assays with their
associated calibrations or quality control methods for routine
testing of body fluid specimens. In 2009–2010, the College of
American Pathologists explicitly defined the need to validate
body fluids as though they were laboratory-developed tests.
Before this, little, if any, additional work was typically done
by laboratories to verify whether a body fluid matrix should
be performed in a similar manner as for the manufacturer-
validated specimen type or that it would produce accurate
results. A few cases of inaccurate results obtained from
alternate specimen types are reported, but no systematic
investigations have been performed3. The analytic validation
of body fluids is outside the scope of this work.
One aspect of maintaining compliance is providing clinical
decision limits and interpretive information with each result.
To accomplish this, laboratories must perform clinical
validation studies or rely on the available literature to abstract
this information. Clinical validation studies can be cumber-
some, cost-prohibitive, and not always feasible, given the
rarity of some fluid types and disease conditions. Performing
literature reviews is similarly time consuming and presents
several limitations. Many published studies do not describe
the analytic methods in enough detail to assess the transfer-
ability of the study results to today’s methods. For example, it
is not well known what, if any, bias may exist between
methods used in a 1973 study measuring glucose in pleural
fluids versus methods that align with today’s standards. In
addition, unless stated otherwise, body fluid studies published
 DOI: 10.3109/10408363.2013.844679
before 2010 may have used methods that have not been
validated according to present standards for these alternate
specimen types. The unknown effect of matrix interferences
in these methods makes reliance on published data
challenging.
Serous fluids
Serous fluid is a plasma filtrate contained in the pleural,
peritoneal, and pericardial spaces. Each cavity is lined by
the mesothelium of the visceral and parietal membranes
of their respective spaces. Serous fluid serves to lubricate
the surfaces of the membranes to reduce friction4.
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Each pleural space contains a mean (SD) fluid volume
of 8.4 (4.3) mL5. The peritoneal space normally contains
550 mL of fluid and the pericardial space contains 10 to
50 mL of fluid4.
Pathogenesis of increased body fluid accumulation
Formation of excessive fluid(s) occurs pathologically for
various reasons. Extravascular fluid contained in serous
cavities is continually being produced at low levels (1% of
plasma) as the fluid is filtered by capillaries and either
reabsorbed locally or transported back into the circulation by
lymphatic drainage. Pathologic increases in extravascular
fluid volume are due to increased production of fluid or
reduced rates of fluid absorption. Congestive heart failure and
For personal use only.
kidney disease are common causes of increased intravascular
hydrostatic pressure. Malnutrition, severe burns, nephrotic
syndrome, and liver cirrhosis are the primary causes of
decreased oncotic pressure. Inflammation, infection, burns,
nephritis, and trauma are common causes of increased
capillary permeability. Any of these conditions may lead to
a pathologic increase in fluid production. Lymphatic obstruc-
tion decreases fluid absorption (e.g. in malignancy) or impairs
drainage (e.g. from elevated systemic venous pressures in
congestive heart failure).
The most common causes of pleural effusion in adults are
heart failure, malignancy, pneumonia, tuberculosis, and
pulmonary embolism6. Pneumonia is the leading cause in
children. Depending on the underlying cause, signs, and
symptoms of an effusion may include dyspnea, cough, and
chest pain. Chest radiography usually confirms the presence
of a pleural effusion; however, ultrasound or computed
tomography are not definitive and are incapable of detecting
small effusions. Loculated effusions occur in association with
intense pleural inflammation such as that seen in empyema,
hemothorax, or tuberculosis. Heart failure is the most
common cause of bilateral pleural effusion. Patients who
present with non-specific symptoms of infection and an
effusion (regardless of fluid type) typically undergo diagnos-
tic fluid collection to exclude infection and identify the cause
of the increased fluid volume. Thoracentesis may not be
necessary for patients with obvious heart failure and no signs
of infection6. Approximately 20% of pleural effusions are due
to a malignancy; among these, 50% are from lung cancer.
The gross appearance of a pleural fluid may be suggestive
of its origin, e.g. turbidity may be caused by cells (empyema)
or lipids (chylothorax). Blood may be present because of
Laboratory testing of serous body fluids 109
malignancy, trauma, pulmonary embolism, or pneumonia.
Hemothorax is diagnosed if the hematocrit exceeds half the
peripheral blood hematocrit.
Ascites is the pathologic accumulation of fluid within
the peritoneal cavity. The most common causes of ascites
in the United States include liver cirrhosis (81%, majority are
alcohol related), malignancy (10%), heart failure (3%), and
tuberculosis, dialysis, and pancreatic disease (6% combined)7.
Symptoms and comorbidities of ascites include abdominal
distension, respiratory distress, hernias, worsening nutritional
status, coagulopathies, and increased susceptibility to infec-
tions8. Symptoms of ascites are typically not apparent until at
least 500 mL of fluid accumulates9. Diagnostic assessment of
a patient with ascites aims to identify the presence, severity,
cause, and complications of ascites, which can include
infection, spontaneous bacterial peritonitis (SBP), and renal
failure8.
Pericardial effusions are usually attributable to injury or
insult to the pericardium (e.g. pericarditis). Transudative
fluids result from obstruction of drainage; exudative fluids
occur because of inflammatory, infectious, malignant, or
autoimmune processes within the pericardium10. In two-thirds
of patients presenting with pericardial effusion, the cause is
related to a known medical condition such as renal failure
and autoimmune disease4. Malignant pericardial effusions
account for a very small fraction of cases (2%–4% of the
general population, 7%–12% of patients with cancer)11.
Pericardiocentesis is recommended for undiagnosed pericar-
dial effusions or when patients have symptoms of hemo-
dynamic instability or cardiac tamponade12. The most
common causes of pericardial effusion requiring diagnostic
pericardiocentesis include inflammation due to infection and
malignancy4.
Analytes measured in serous fluids
Classic light criteria
Differentiation of pleural fluid transudates and exudates
aids in the identification of the underlying mechanism of
fluid formation. Transudates are typically bilateral and form
because of systemic imbalances in hydrostatic and oncotic
forces, most commonly caused by cirrhosis and heart
failure. Exudates are often unilateral and form because of
localized inflammatory disease, which increases vascular
permeability or interferes with lymphatic reabsorption of
fluid4.
The classic Light criteria for differentiating transudate
from exudate were established in the 1970s for patients with
pleural effusions13. Light criteria include the measurement
of total protein and lactate dehydrogenase (LDH) in pleural
fluid and serum. Exudates are defined as meeting one of the
following criteria: (1) pleural fluid-to-serum protein ratio
40.5, (2) a pleural fluid LDH 42/3 the upper limit of normal
serum LDH, or (3) a pleural fluid-to-serum LDH ratio 40.6.
The pleural fluid-to-serum protein ratio is an indicator of
capillary permeability. The pleural fluid LDH activity is an
indicator of the extent of inflammation in the pleural space.
In principle, they measure different characteristics of the
pleural space; however, they are in fact related because an
 110 D. R. Block & A. Algeciras-Schimnich
inflammatory process in the pleural space most likely
increases permeability in the pleura14.
Numerous studies since 1972 have confirmed the clinical
utility of the algorithm. Nevertheless, most have þLRs that
are relatively low (range, 2.3–15.2) and only three studies
have reported a þLR410; in contrast, Light’s seminal study13
had a þLR of 49.5. The poorer performance in these studies
is often attributed to the inclusion of patients receiving
diuretics (misclassified transudates)15.
Most pleural fluid studies published since 1972 have been
performed using Boehringer Mannheim reagents and Roche
or Hitachi instruments (Table 2). Many of these studies cite
the serum normal range for LDH in the methods description;
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this is a key piece of information that helps laboratories
determine transferability of decision limits from the literature
without conducting large trials. Alternately, use of fluid-
to-serum ratios of analytes collected at similar time points
diminishes the need for reporting the study normal serum
range31,32. Laboratories should be cautious regarding the
time and temperature stability of requested analytes, particu-
larly LDH, which can be unstable at refrigerated and
frozen temperatures because of the instability of isoenzymes
4 and 533.
The routine analysis of many biochemical analytes,
particularly the application of Light criteria when evaluating
pericardial fluid, is generally not helpful. Ben-Horin et al.34
found that 98% of pericardial effusions were classified as
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exudates by traditional Light criteria and that no single
parameter or set of parameters differentiated one cause of
effusion from another. Furthermore, the cohort was divided
into neoplastic or bacterial (exudative) versus immune or
idiopathic (transudative) causes of pericardial effusion, and
the area under the receiver operating characteristic curve
ranged from 0.55 to 0.69 when applying the Light criteria
established for pleural fluid. In addition, LDH (total and
ratio), total protein (total and ratio), glucose, cholesterol, and
albumin showed significant overlap between the two groups,
suggesting these analytes are not useful for differentiating
transudative and exudative causes of pericardial effusion.
The methods for both blood and fluid analysis were
performed using standard laboratory techniques, with no
further description of pre-analytic handling or analytic
methods. Despite limited evidence, the European Society
of Cardiology guidelines for the diagnosis and management
of patients with pericardial disease mention that specific
gravity (41.015), protein (43.0 g/dL, fluid-to-serum ratio
40.5), LDH (4200 mg/dL, fluid-to-serum ratio 40.6), and
glucose can separate exudates from transudates but are not
directly diagnostic (class IIIb, usefulness or efficacy is
less well established by evidence or opinion)35. The utility
of measuring protein and LDH in pericardial fluid is
therefore considered limited and should not be performed
routinely.
Ascitic fluid LDH has not been routinely measured or
reported, particularly for the purpose of differentiating
exudate from transudate, nor have traditional Light criteria
been applied. The measurement of albumin in ascitic fluid as
a surrogate marker of portal hypertension has largely replaced
the transudate–exudate concept in the evaluation of ascitic
fluid origin36. The measurement and interpretation of classic
Crit Rev Clin Lab Sci, 2013; 50(4–5): 107–124
Light criteria to differentiate transudative and exudative
causes of ascitic fluid is not useful36, although measurement
of individual components of Light criteria may be (discussed
below).
Albumin and total protein gradients
Serum albumin is measured to assess nutritional status, liver
function, and kidney function. Serous fluid albumin is often
used in conjunction with serum albumin to assess oncotic
pressure gradients, which can aid in the differential diagnosis
of serous effusions.
The pleural fluid albumin gradient (serum albumin minus
pleural fluid albumin) and pleural fluid-to-serum albumin
ratio have been studied as adjunct biomarkers in patients who
clinically present with transudative pleural effusions mis-
classified as exudates by Light criteria14. Misclassification
most often occurs in patients receiving diuretic therapy or in
patients with congestive heart failure. The median þLR to
identify exudates using an albumin gradient 41.2 g/dL is 6.3
(mean, 14; range, 1.4 to 495; n ¼ 12), whereas the median
þLR for an albumin ratio is 10.8 using cut-offs that varied
between 40.59 and 40.68 g/dL (mean, 31.7; range, 6.2 to
478; n ¼ 3)17,20,23,31,32,37–44. The albumin methods used in
these studies primarily employed bromcresol green on
multiple instruments or nephelometry. Several more studies
used Hitachi or Roche modular instruments; however, the
method (bromcresol green versus bromcresol purple) is not
stated. It is unclear whether the bromcresol green method
demonstrates a similar bias in pleural fluid as has been
observed in ascitic fluid (discussed below) (Table 3)47.
The total protein gradient (calculated as serum total
protein minus pleural fluid total protein) has been proposed
as an alternative to measure and calculate the albumin
gradient because total protein is routinely measured in pleural
fluid and serum to evaluate Light criteria. A protein gradient
43.1 g/dL indicates an exudate, with median þLR of 7.0
(mean, 7.1; range, 5.1–9.3; n ¼ 3)23,37,39. These three studies
used the biuret method on Hitachi or Roche modular
instrumentation. Light14 recommends applying classic Light
criteria to the initial classification of pleural fluids and then
calculating a protein gradient for cases in which transudates
are clinically unlikely.
Pericardial fluid protein and albumin quantitation have not
been extensively studied or reported. Two studies describe
non-significant elevation of protein (fluid-to-serum ratio
40.5) in patients with malignancy48 and exudative causes of
effusion49. In ‘‘normal’’ transudative pericardial fluids,
collected during open heart surgery for coronary or valvular
disease, the mean fluid-to-serum total protein ratio was 0.6
(99% CI, 0.5–0.7), and LDH ratio was 2.4 (99% CI, 1.3–
3.5)50. Based on this, they would be misclassified as
exudative by pleural fluid standards. Thus, the utility of
such analyses is questionable. The mean albumin ratio of 0.7
(99% CI, 0.6–0.8) also suggests that the pericardial fluid is
exudative when using pleural fluid cut-offs. The fluid and
blood samples in the study were collected simultaneously, but
no other pre-analytic or analytic details were provided.
Overall, the measurement of protein, LDH, and albumin
gradient in pericardial fluid has limited utility.
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Table 2. Protein and LDH methods used to determine the diagnostic performance of classic Light criteria for differentiating exudative from transudative pleural effusionsa.
DOI: 10.3109/10408363.2013.844679

No. Evaluated
(No. Positive Sensitivity, Specificity, Time between serum and
Study Disease for Disease) % % þLR LR Method pleural fluid collection
Light et al.13 Exudate 150 (103) 99 98 49.5 0.01 Boehringer Mannheim kit (procedure of Wroblewski 530 minb
and Ladue16); serum reference limit 5300 IU
Metintas et al.17 Exudate 93 (72) 100 81 5.3 0.00 Boehringer Mannheim kits (Hitachi 747-100) Simultaneous to 24 hc
Gazquez et al.18 Exudate 193 (155) 97 71 3.3 0.04 Hitachi 717 524 h
Hamm et al.19 Exudate 62 (31) 100 70 3.3 0.00 Boehringer Mannheim kit; serum reference limit Usually same day, shortly
5240 IU after admission
Leers et al.20 Exudate 408 (300) 100 73 3.7 0.00 UV lactate to pyruvate (Roche modular); serum 524 h
reference limit 5480 U/L
Porcel et al.21 Exudate 171 (NR) 98 74 3.8 0.03 Standard methodology (Hitachi 917) Simultaneous
Romero et al.22 Exudate 243 (182) 99 85 6.6 0.01 Biuret, kinetic UV (Hitachi 747); serum reference Simultaneous
limit 5460 IU/L
Romero-Candeira et al.23 Exudate with 72 (31) 100 71 3.4 0.00 Biuret, kinetic UV (Hitachi 747); serum reference Simultaneous
diuretic therapy limit 5460 IU/L
Romero-Candeira et al.23 Exudate 249 (185) 100 75 4.0 0.01 Biuret, kinetic UV (Hitachi 747); serum reference Simultaneous
limit 5460 IU/L
Gil Suay et al.24 Exudate 204 (156) 100 65 2.8 0.00 SMAC Technicom, enzymatic (200 IU/L high 524 h
normal)
25
Vives et al. Exudate 230 (156) 99 78 4.4 0.02 Biuret, kinetic UV (Boehringer Mannheim, Hitachi Simultaneous
717); serum reference limit 5456 IU/L
Garcia-Pachon et al.26 Exudate 153 (118) 97 74 3.8 0.03 Unspecified autoanalyzer Simultaneous
Kalayci et al.27 Exudate in children 60 (40) 100 90 10.0 0.00 Biuret, timed end point (Boehringer Mannheim, 52 h, fasting
age 3–23 y Hitachi 717)
Meisel et al.28 Exudate 46 (23) 90 82 5.0 0.12 SMA 12 51 h
Valdes et al.29 Exudate 253 (188) 95 78 4.4 0.07 Biuret—no serum blank, kinetic UV (Genesis 21-IL) Simultaneous, fasting
Costa et al.30 Exudate 180 (131) 98 82 5.4 0.02 Biuret; UV spectrophotometry at 37  C, 340 nm NA
(Boehringer Mannheim)

Abbreviations: IU, international unit; LDH, lactate dehydrogenase; þLR, positive likelihood ratio; LR, negative likelihood ratio; NA, not applicable; NR, not reported.
a
All studies defined exudates as being positive for 1 of 3 parameters: (1) protein ratio40.5, (2) LDH ratio40.6, or (3) LDH42/3 serum reference limit or4200 U/L if the serum range was unspecified. Specimen
collection containers and handling conditions from collection to analysis were not specified unless noted.
b
Specimens were immediately centrifuged and tested within 48 hours.
c
Specimens were centrifuged at 3000 rpm for 10 min and stored at 20  C until assayed.
Laboratory testing of serous body fluids
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112

Table 3. Albumin method used to determine the diagnostic performance of pleural fluid albumin gradient and pleural fluid albumin ratio in the differentiation of transudates and exudatesa.

No. Evaluated Time between

(No. Positive Sensitivity, Specificity, serum and pleural
Study Disease for disease) Cut-off % % þLR LR Method fluid collection
37
Bielsa et al. Transudate (heart 364 (133) Ratio 50.6 94 NR NA NA Hitachi 717, 911, or Roche 524 hb
failure) Modular DP
Bielsa et al.37 Transudate (hepatic 102 (76) Ratio 50.6 95 NR NA NA Hitachi 717, 911, or Roche 524 hb
hydrothorax) Modular DP
D. R. Block & A. Algeciras-Schimnich

Gonlugur and Gonlugur32 Exudate 285 (NR) Ratio 40.6 82 92 10.8 0.20 Bromcresol green (SYNCHRON NR
LX27)
17
Metintas et al. Exudate 93 (72) Gradient 41.2 g/dL 63 81 3.3 0.46 Boehringer Mannheim kit (Hitachi Simultaneous
747-100) or 524 hc
Atalay et al.39 Exudate 359 (246) Gradient 41.2 g/dL 89 80 4.3 0.15 Bromcresol green (ILAB 1800) Simultaneous
Leers et al.20 Exudate 408 (300) Gradient 41.2 g/dL 44 89 4.0 0.63 Bromcresol green (Roche 524 h
modular)
Romero-Candeira et al.23 Exudate 249 (185) Gradient 41.2 g/dL 88 86 6.3 0.14 Nephelometric array protein Simultaneous
(Beckman Instruments)
Romero-Candeira et al.23 Exudate with diur- 72 (31) Gradient 41.2 g/dL 87 88 7.3 0.15 Nephelometric array protein Simultaneous
etic therapy (Beckman Instruments)
Das and Baruah41 Exudate 40 (26) Gradient 41.2 g/dL 96 93 13.7 0.04 Manual method of Doumas et al.45, NR
modified by Spencer and
Price46
Gonlugur and Gonlugur32 Exudate 285 (NR) Gradient 51.2 g/dL 69 92 9.1 0.33 Bromcresol green (SYNCHRON NR
LX27)
42
Mangaraj et al. Exudate 60 (40) Gradient 41.2 g/dL 92 85 6.1 0.09 Bromcresol green (Technicon NR
RA-1000)

Abbreviations: NA, not applicable; NR, not reported; rpm, rotations per minute.
a
Specimen collection containers and handling conditions from collection to analysis were not specified unless noted.
b
Specimens were collected in 5-mL sterile heparinized tubes.
c
Specimens were centrifuged at 3000 rpm for 10 min and stored 20  C until assayed.
Crit Rev Clin Lab Sci, 2013; 50(4–5): 107–124
 DOI: 10.3109/10408363.2013.844679
Albumin is measured in ascitic fluid for the purpose of
determining the SAAG, which is calculated as serum albumin
minus ascitic fluid albumin36. Early studies soon recognized
the poor performance of protein and LDH to differentiate
exudates (including malignancy and non-portal hypertension)
compared with SAAG. However, total protein measurement
alone misclassifies up to 20% of infectious- and malignancy-
related ascites as transudates (protein 52.5–3.0 g/dL) and cir-
rhosis or heart failure cases as exudates (42.5–3.0 g/dL)36,51.
This is because of the complex dependence of ascitic fluid
total protein concentration on serum total protein concentra-
tion and portal pressure. Conversely, SAAG has a direct
relationship with portal pressure and has fewer external
Critical Reviews in Clinical Laboratory Sciences Downloaded from informahealthcare.com by Laurentian University on 10/26/13
influences52. High gradients (SAAG 1.1 g/dL) are asso-
ciated with hepatic metastases, hepatocellular carcinoma,
cirrhosis, and congestive heart failure9,36. Low gradients
(SAAG51.1 g/dL) are associated with peritoneal malignancy,
tuberculosis, and pancreatitis.
Studies have shown that SAAG is superior to total protein
analysis. SAAG has a median þLR of 16.3 (mean, 25.8;
range, 2.8 to 487.8; n ¼ 6), whereas total protein 42.5 to
3.5 g/dL has a median þLR of 1.6 (mean, 1.5; range, 0.4–2.5;
n ¼ 4), and total protein ratio 40.5 has a median þLR of 4.0
(mean, 4.0; range, 3.4–4.5; n ¼ 2)36,53–58. The diagnostic
utility of the protein gradient is not expected to rival the
albumin gradient; however, to our knowledge, they have not
been directly compared.
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Among the studies that aimed to differentiate malignancy-
related ascites from non-malignant causes (primarily cirrho-
sis), the median þLR was 20.1 for SAAG 51.1 g/dL (mean,
22.7; range, 2.8–56.5; n ¼ 8), whereas the median þLR was
5.7 for protein 42.5 to 3.5 g/dL (mean, 10.3; range, 2.3–33.8;
n ¼ 8), and for protein ratio40.5, it was 3.8 (mean, 7.3; range,
2.5–15.7; n ¼ 3)59–67 (Table 4). This supports the conclusion
that SAAG is superior to total protein for differentiating
malignancy-related from non-malignant ascites. Total protein
may be used in limited cases to differentiate causes of high-
gradient portal hypertension, including peritoneal metastasis
(low protein 52.5 g/dL)62 and cardiac ascites (high protein
42.5 g/dL)36.
Various methods have been used in ascitic fluid studies
to quantitate albumin, including nephelometry, bromcresol
green, electrophoresis, and radial immunodiffusion, despite
the fact that all use the same cut-off. Protein concentrations
were measured using the biuret method (without specifying
the instrument or manufacturer), electrophoresis, the Lowry
method, or did not specify. It is difficult to know whether any
of the assays have been reformulated or had any other
appreciable shifts since these studies were performed.
However, the assay should be acceptable if it is free of
matrix interferences in ascitic fluid and a gradient is
calculated.
A method comparison study published in 1995 demon-
strates good agreement (Passing & Bablok regression,
y ¼ 1.02x  0.3, 58 samples) between an automated total
protein method (Chem-1, Bayer-Technicon) and a manual
biuret reference method in ascitic fluid47. However, albumin
was compared between a bromcresol green method on the
same analyzer and a nephelometric assay (Beckman Array)
and demonstrated a positive bias (Passing & Bablok
Laboratory testing of serous body fluids 113
regression, y ¼ 1.32x  1.3, 58 samples). Both albumin
methods were calibrated using human plasma international
reference preparations, with assigned values established by
radial immunodiffusion, nephelometry, and turbidimetry.
The positive bias was attributed to the lack of specificity of
bromcresol green for albumin and matrix differences between
serum and ascitic fluid. The authors recommended avoiding
the bromcresol green albumin method for ascitic fluid47.
However, they did not demonstrate or discuss acceptable
correlation between methods using serum or plasma speci-
mens, so it is difficult to determine whether the observed bias
was in fact due to matrix differences, the method, or both.
Cholesterol
Serum cholesterol is measured to determine the concentration
of circulating lipoprotein particles when screening for
cardiovascular disease. The concentration is affected by
genetic and lifestyle factors. Cholesterol concentrations in
serous effusion may become elevated by various mechanisms
related to malignancy or other exudative processes9,68. The
cholesterol may originate from cell lysis, increased vascular
permeability, increased cholesterol synthesis, and is released
from neoplastic cells and obstructed lymphatic drainage.
Pleural fluid cholesterol has been one of the more popular
analytes proposed to modify or replace classic Light criteria
to improve specificity for differentiating exudates and tran-
sudates29. The performance of pleural fluid cholesterol-
to-serum cholesterol ratio (ranging from 0.3 to 0.4) is similar
to Light criteria, with most studies having þLR 44 and
3 studies showing þLR 41017–22,24,26,27,29,30–32,40. Pleural
fluid cholesterol absolute concentration cut-offs (ranging
from 445 mg/dL to 465 mg/dL) have been proposed for
exudates. These cut-offs perform considerably better, with
þLRs 410 in 11 of 14 diagnostic studies. Most of these
studies concluded that cholesterol performs as well as Light
criteria but does not add much value beyond that. Light14
recommends that protein and LDH be measured to differen-
tiate exudates, using protein (or albumin) gradients when
there is suspicion of transudate misclassification.
Cholesterol testing in these studies utilized cholesterol
oxidase methods on autoanalyzers. Cholesterol standardiza-
tion efforts began more than 50 years ago, suggesting that
these methods, irrespective of the manufacturer, are compar-
able to today’s methods. However, performance characteris-
tics for cholesterol in body fluid matrices is not well
established69.
Pleural fluid cholesterol is also used in conjunction
with triglyceride measurement to aid in the diagnosis of
chylothorax and pseudochylothorax. Chylothorax occurs
when the thoracic duct is disrupted and chyle accumulates
in the pleural space; it is due primarily to malignancy (50%)
and trauma (25%)70. Pseudochylous effusions, also known
as cholesterol pleurisy, may result from chronic pleural
effusions in which cholesterol crystals accumulate primarily
from rheumatoid pleurisy and tuberculosis. Triglyceride
levels 4110 mg/dL and cholesterol 5200 mg/dL is diagnostic
of chylothorax71, whereas cholesterol 4200 mg/dL and
triglyceride 550 mg/dL is diagnostic of pseudochylothorax.
When triglyceride concentrations are indeterminate
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For personal use only.
114

Table 4. Albumin and protein methods used to determine diagnostic performance for identification of malignancy-related ascitesa.

No. Evaluated Time between serum and

Study (No. With Malignancy) Cut-off Sensitvity, % Specificity, % þLR LR Method ascitic fluid collection
Bansal et al.59 60 (13) SAAG 51.1 g/dL 77 72 2.8 0.3 Biuret NA
Chen et al.61 123 (29) SAAG 51.1 g/dL 62 99 56.5 0.4 Nephelometric on array (Beckman, USA) Simultaneous, fasting
D. R. Block & A. Algeciras-Schimnich

Gupta et al.66 76 (43) SAAG 51.1 g/dL 91 94 15.2 0.1 Commercial kits for Photometer Simultaneous, fasting
4010 (Boehringer Mannheim)
Lee et al.60 103 (22) SAAG 51.5 g/dL 100 96 25.0 0.0 Electrophoresis (Gelman) Simultaneous, 524 h of admission
Prieto et al.62 69 (15) SAAG 51.1 g/dL 80 98 40.0 0.2 SMA-C Technion autoanalyzer Simultaneous, 524 h of admission
Rana et al.63 50 (25) SAAG 51.1 g/dL 88 84 5.5 0.1 Bromcresol green (Boehringer Mannheim) NA
Villamil et al.64 82 (42) SAAG 51.1 g/dL 67 98 33.5 0.3 Bromcresol green Simultaneous, 524 h of admission
Gerbes et al.65 48 (20) SAAG 51.1 g/100 mL 85 71 2.9 0.2 Radial immunodiffusion on Simultaneous
Nor-partigen plates (Behring)
Bansal et al.59 60 (13) Protein 43 g/dL 77 66 2.3 0.3 Biuret NA
Bansal et al.59 60 (13) Protein ratio 40.5 85 66 2.5 0.2 Biuret NA
Gupta et al.66 76 (43) Protein 42.5 g/dL 100 76 4.2 0.0 Biuret Simultaneous, fasting
Gupta et al.66 76 (43) Protein ratio 40.5 94 94 15.7 0.1 Biuret Simultaneous, fasting
Lee et al.60 103 (22) Protein 42.5 g/dL 95 97 33.8 0.1 Electrophoresis (Gelman) Simultaneous, 524 h after admission
Prieto et al.62 69 (15) Protein 42.5 g/dL 87 94 14.5 0.1 Lowry method Simultaneous, 524 h after admission
Gerbes et al.65 48 (20) Protein 42.5 g/100 mL 90 68 2.8 0.1 Biuret (Merck) Simultaneous
Gerbes et al.65 48 (20) Protein ratio 40.5 80 79 3.8 0.3 Biuret (Merck) Simultaneous
Castaldo et al.67 94 (21) Protein 43.5 g/dL 95 93 13.6 0.1 Hitachi 705, Boehringer Mannheim NRb

Abbreviation: NA, not applicable; NR, not reported; SAAG, serum ascites albumin gradient.
a
Specimen collection containers and handling conditions from collection to analysis were not specified unless noted.
b
Blood and ascitic fluid were tested within 3 hours of collection.
Crit Rev Clin Lab Sci, 2013; 50(4–5): 107–124
 DOI: 10.3109/10408363.2013.844679
(50–110 mg/dL), these studies suggest that the laboratory
investigate the presence of chylomicrons.
Pericardial cholesterol has been used to differentiate
exudates from transudates in one study, but when using
multiple different cut-offs and fluid-to-serum ratios, all þLR
were 5572. The study had several limitations; the pre-analytic
and analytic methods were not described, and most patients
were diagnosed with tuberculous effusions (rare in first-world
countries). Overall, only limited evidence suggests that
cholesterol measurement in pericardial fluid is clinically
useful.
Ascitic fluid cholesterol has been used predominantly for
the differential diagnosis of malignant ascites. Elevated
Critical Reviews in Clinical Laboratory Sciences Downloaded from informahealthcare.com by Laurentian University on 10/26/13
cholesterol concentrations have been described in malignant
versus non-malignant ascites. These elevations have been
attributed to multiple causes, including increased vascular
permeability73, release from neoplastic cells74, and lymphatic
obstruction leading to lymphatic rupture75. For studies in
which cytology and cholesterol measurement were evaluated
simultaneously, cholesterol was superior to cytology for the
identification of malignant ascites. At 100% specificity,
cytology sensitivities ranged from 47% to 64%; reported
sensitivities for cholesterol ranged from 88% to 100%, with
specificities of 80% to 100%63,67,76,77. At cut-offs between
32 to 70 mg/dL, the median þLR was 15.7 (mean, 24.7;
range, 2.2 to488; n ¼ 9) and the median LR was 0.1 (mean,
0.15; range, 0.0–0.3; n ¼ 9)59,62,63,65,67,77,78. Based on the LR
For personal use only.
data, analysis of cholesterol for differentiation of malignant
ascites might be clinically useful, but the use of ascitic fluid
cholesterol in routine clinical practice is controversial79,80.
Bilirubin
Serum bilirubin is used to aid in the differential diagnosis
of jaundice and assessment of liver function. The most useful
documented report in serous fluid testing describes detection
of biliary leaks in Jackson–Pratt drain fluid, in which a drain
fluid-to-serum ratio 45 is 100% sensitive and 100% spe-
cific81. Another documented use for serous fluid bilirubin
measurement is for the differentiation of transudates and
exudates, owing to increased capillary permeability in
inflammatory conditions.
A pleural fluid-to-serum bilirubin ratio 40.6 has been
proposed to improve the performance of Light criteria, but
in four studies, the þLR was 5617,28,32,40. Consequently,
bilirubin is not considered a useful analyte for differentiating
transudates from exudates alone or in combination with
classic Light criteria. The pre-analytic and analytic methods
are not well described in these four studies, but paired serum
was analyzed within 24 hours in three of four studies. This
makes the interpretation translatable to bilirubin methods
used today, assuming no matrix interferences. Laboratories
should exercise some caution, however, because the utility in
pleural fluid is limited and does not add more beyond what
evaluations of Light criteria, protein gradient, and possibly
cholesterol have to offer.
Pericardial fluid bilirubin has been investigated to differ-
entiate exudate from transudate using a fluid-to-serum ratio
40.5. The þLR was 2.6 and was not shown to be more useful
than the serum effusion albumin gradient72.
Laboratory testing of serous body fluids 115
Ascitic fluid bilirubin may be useful in detecting leakage
of bile into the peritoneal cavity (i.e. choleperitoneum) caused
by gallbladder rupture82. These patients present with symp-
toms similar to SBP, and differentiating them clinically is
often difficult. The right diagnosis is critical because surgery
is life-saving for choleperitoneum but life-threatening for
SBP. All patients in a small case series (n ¼ 6) with confirmed
gallbladder rupture had ascitic fluid bilirubin exceeding
6 mg/dL and fluid-to-serum ratios 41 compared with ascitic
fluid controls (n ¼ 84)82. A Technicon autoanalyzer was used
to measure total bilirubin. It is unclear how that method
compares to today’s methods; therefore, the laboratory should
demonstrate that their serum bilirubin method is free of bias
when testing an ascitic fluid matrix and use the serum ratio
decision limit for interpretation.
Enzymes
Enzymes measured in serum are used as biomarkers of
leakage from specific organs (e.g. pancreatic lipase, creatine
kinase). Enzymes such as LDH, however, are not tissue
specific. Enzymes can be found in serous body fluid
compartments due to localized leakage from nearby tissues
or non-specific inflammatory processes that allow larger-
molecular-weight molecules to passively diffuse.
Measurement of pleural fluid LDH is a well-established
piece of Light criteria, but a limited number of studies have
quantitated other enzymes in pleural fluid to determine if
there is an improvement in differentiation of transudates.
Creatine kinase17, alkaline phosphatase17,21, adenosine dea-
minase39, pseudocholinesterase83, and cholinesterase21,22
have a median þLR of 4.7 (mean, 6.4; range, 1.5–17.5;
n ¼ 6) using fluid-to-serum ratios of 0.15 to 0.66 compared
with LDH alone, which has a median þLR of 5.9 using a
fluid-to-serum ratio of 40.6 (mean, 10.5; range, 2.4–43;
n ¼ 17)13,17–22,24,25,27,29,31,32,41,42,84,85. All studies reported
the analytic platform used, but fewer specified the reagents
and only two of the assays indicated the serum range. The
fluid-to-serum ratios give the most reliable cut-offs in these
studies, but the overall conclusion is that the performance of
these enzymes is not improved over LDH, particularly when
used in the application of Light criteria. One exception is
pleural fluid adenosine deaminase in regions of the world
where mycobacteria tuberculosis infection is prevalent. The
þLR was 9.0 (95% CI, 7.2–11.3) and LR was 0.10 (95% CI,
0.07–0.14) in a meta-analysis of 63 studies for the identifi-
cation of tuberculous pleurisy86. Two-thirds of the studies
reported using the Giusti method and a cut-off of 440 IU/L.
Ascitic fluid LDH was measured in a few studies to aid in
the differentiation of malignancy-related ascites. The median
þLR was 11.5 (mean, 29.1; range, 3.3–90; n ¼ 4) using
absolute cut-offs for LDH, but each study used a different
cut-off and none specified the serum normal range; therefore,
interpretation and application of these results to today’s
practice is difficult59,60,62,67. Using an LDH fluid-to-serum
ratio of 40.6, for which the lack of analytic method
description has less of an impact, the median þLR is 3.4
(mean, 3.4; range, 2.2–4.5; n ¼ 2), but these studies indicate
that the LDH ratio does not have great discriminatory power
for identifying exudates or malignancy-related ascites53,59.
 116 D. R. Block & A. Algeciras-Schimnich
Given this evidence, the routine measurement of Light criteria
for differentiating ascitic fluid exudates or measurement of
LDH to identify malignancy-related ascites is not recom-
mended. One notable exception is measurement of LDH in
combination with glucose and protein to aid in the diagnosis
of SBP (discussed below).
Ascitic fluid a-1-antitrypsin, a major serum protease
inhibitor, has been shown to aid in the differentiation of
malignant versus cirrhotic ascites64. It has a þLR of 19.2
using an a-1-antitrypsin cut-off 4120 mg/dL and a þLR of
33.3 using a fluid-to-serum ratio of 0.4, suggesting clinical
utility. However, the study also shows significant correlation
between serum and ascitic fluid concentrations of a-1-
Critical Reviews in Clinical Laboratory Sciences Downloaded from informahealthcare.com by Laurentian University on 10/26/13
antitrypsin in patients with malignancy, which diminishes
the utility of the test outside of serum.
Amylase
Serum amylase is measured to aid in the diagnosis of
pancreatitis; concentrations 43 times the upper normal serum
limit are considered positive for the diagnosis87. Amylase-rich
pleural effusions are usually caused by exudative conditions
associated with pancreatitis, esophageal rupture, malignancy,
pneumonia, and liver cirrhosis10,87,88. Measurement of amyl-
ase in pleural fluid should not be performed routinely89.
The prevalence of amylase-rich pleural effusions (defined as
pleural fluid–to-serum amylase ratios 41) has been reported
to be from 5% to 15%88,90. Studies demonstrated the pleural
For personal use only.
fluid-to-serum ratio is higher in effusions caused by pancre-
atic disease (mean [SD], 18 [6.3]) versus non-pancreatic
disease (4.8 [1.3])88. Amylase isoenzyme analysis in these
effusions revealed pancreatic amylase isoforms in conjunction
with acute or chronic pancreatitis, pancreatic fistulas, and
pancreatic pseudocysts. Salivary amylase isoforms are
observed in esophageal rupture and in conjunction with
effusions caused by malignancy10. Measurement of serous
fluid amylase can be conducted in conjunction with serum to
aid in the interpretation of results91.
pH
pH is measured in whole blood, serum, and plasma to assess
acid–base balance. pH is often measured in body fluids to aid
in the diagnosis and treatment decisions relating to infection
because body fluid pH typically decreases from the action of
increased neutrophil count92. Patients who present with
non-specific symptoms of infection and an effusion (regard-
less of fluid type) typically undergo diagnostic fluid collec-
tion to exclude infection and identify the cause of the
increased fluid volume. The American College of Chest
Physicians (ACCP) and the British Thoracic Society (BTS)
recommend that pleural fluid specimens should be collected
in heparinized blood gas syringes, capped, and sent to the
blood gas laboratory immediately after aspiration93,94. Pleural
fluid pH below 7.20 or low glucose (560 mg/dL in ACCP
and 540 mg/dL in BTS guidelines) are strong indicators
of complicated parapneumonic effusion and drainage is
recommended.
The utility of pleural fluid pH was established using blood
gas analyzers95,96 on specimens collected anaerobically in
heparinized syringes to minimize exposure to air before
Crit Rev Clin Lab Sci, 2013; 50(4–5): 107–124
analysis97–100. The use of indicator paper or a dipstick results
in a consistent and clinically significant positive bias of 0.15
to 0.81 pH units compared with the blood gas analyzer,
whereas a pH meter demonstrated a positive bias of 0.15 to
0.30 units101,102. Exposure of pleural fluid to an air bubble
(2:1 ratio) to simulate aerobic conditions led to a clinically
significant mean bias of þ0.08 units (95% CI, 0.06–0.09)
and 71% clinical discordance (in a study of 92 patients)99. The
measurement of pleural fluid pH is one of few examples
in which the pre-analytic method (anaerobic collection and
handling) and analytic method (measurement by blood gas
analyzer rather than by pH meter or indicator strip) have been
established in the literature and are endorsed by international
clinical guidelines.
Few studies have reported the diagnostic utility of
measuring pH in pericardial fluid. Kindig and Goodman103
demonstrated a significant difference in pericardial pH
between patients with inflammatory causes (mean [SD],
7.06 [0.07]) and those with non-inflammatory causes (7.42
[0.06]) in a cohort of 13 patients103. Specimens for this study
were collected anaerobically and pH was measured on a blood
gas analyzer, mirroring the requirements for pleural fluid pH
analysis. One study showed that pericardial fluid pH was a
poor discriminator of exudates, with 56% sensitivity and 40%
specificity49. The pre-analytic and analytic methods were not
described and potentially may have contributed to the
unfavorable results. The clinical utility is unclear; neverthe-
less, if such studies are pursued in the future, careful attention
should be paid to pre-analytic handling and choice of analytic
method.
The measurement of pH in peritoneal fluid is often
performed to aid in the diagnosis of SBP. SBP occurs in up to
27% of hospitalized patients with cirrhosis. The mortality rate
of SBP in the 1970s exceeded 90%, but with improved
diagnosis and treatment, it is now about 30%104. Four studies
used blood gas analyzers to measure pH on samples collected
anaerobically and analyzed in 515 minutes in a manner
similar to how pleural fluid pH studies were conducted. The
median þLR was 4.9 using a pH cut-off of 57.31 to 7.35
(mean, 23; range, 2.1–80.1; n ¼ 4), whereas studies that were
not as rigorous in their design had similar results, with median
þLR of 5.3 (mean, 7.7; range, 3.3–16.8; n ¼ 4)59,92,105–109.
The 1982 Gitlin study105 (þLR of 80.1) performed much
better than any subsequent studies, but consistent attention to
pre-analytic details is lacking, suggesting that the utility of
ascitic fluid pH is questionable at best. Instead, neutrophil
count, clinical judgment, and bedside inoculation of ascitic
fluid cultures are the preferred methods for making a
diagnosis of SBP92.
Glucose
Blood glucose is measured to assess the glycemic state of
a patient. Fasting plasma glucose is used as a screening
and diagnostic test for diabetes mellitus. Serous fluid glucose
is routinely measured to aid in the diagnosis of infection
and possibly malignancy because of the increased cellularity
and metabolic rate of cells contained in the body fluid space.
Low pleural fluid glucose concentrations (540–60 mg/dL)
indicate a complicated parapneumonic or malignant
 DOI: 10.3109/10408363.2013.844679
effusion110. However, low glucose is not specific for infection
or malignancy and may be attributed to hemothorax, tuber-
culosis, or rheumatoid or lupus pleuritis, among other
diseases. Heffner et al.111 published a meta-analysis to
determine the predictive ability of pH, glucose, and LDH to
identify complicated parapneumonic effusions. The authors
concluded that pH had better diagnostic accuracy than
glucose or LDH when identifying patients with complicated
parapneumonic effusions requiring drainage (area under the
curve: 0.92 for pH, 0.84 for glucose, and 0.82 for LDH). The
glucose methods were not defined in any of the studies
beyond standard techniques95,112–114.
Pericardial fluid glucose has been investigated on a limited
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basis. In presumed normal specimens collected during
surgery, pericardial fluid-to-serum ratio for glucose was 1.0
(95% CI, 0.8–1.2)50. A subsequent study of 105 patients
undergoing diagnostic pericardiocentesis with glucose ana-
lysis had fluid-to-serum ratios of approximately 1.0 (or with a
95% CI that included 1.0); indications for pericardiocentesis
included neoplasms (n ¼ 43), acute pericarditis (n ¼ 17),
idiopathic pericarditis (n ¼ 22), trauma (n ¼ 5), radiation
(n ¼ 1), heart failure (n ¼ 1), and indeterminate causes
(n ¼ 10)34. The only groups with ratios 51.0 were patients
with bacterial infection (ratio, 0.3; 95% CI, 0–0.6; four
patients) and tuberculosis (ratio, 0.7; 95% CI, 0.6–0.9; two
patients). The methods were not described, but glucose
in pericardial fluid may have limited utility and should be
For personal use only.
interpreted in conjunction with serum concentrations for the
purpose of identifying bacterial infection.
Ascitic fluid glucose may be helpful in differentiating SBP
from secondary peritonitis caused by bowel perforation115.
The distinction, although difficult to make in some cases, is
critical because the treatment for bowel perforation is surgery.
Secondary peritonitis is likely if two of the three following
criteria are met: (1) total protein41 g/dL; (2) LDH4225 IU/L
(or greater than the upper limit of normal for serum);
(3) glucose 550 mg/dL116. Beyond this particular use, ascitic
fluid glucose should be interpreted in conjunction with serum
glucose measurement. In a cohort of non-infected patients
with alcohol-related cirrhosis, the mean (SD) ascitic fluid-to-
serum glucose ratio was 1.04 (0.25)117. Low ascitic fluid
glucose has been observed in patients with peritoneal
malignancy and tuberculous peritonitis, with a glucose
ratio 51.059,63.
Tumor markers
Measurement of tumor markers in serous effusions has been
investigated for differentiating between malignant and non-
malignant causes of fluid accumulation. Cytologic examin-
ation for the presence of malignant cells has high specificity
for the evaluation of malignancy on serous effusions, but it
has a low sensitivity due to the lack of cell exfoliation in some
malignancies. Multiple tumor markers, including carcinoem-
bryonic antigen (CEA), cancer antigen 19-9 (CA19-9), cancer
antigen 125 (CA125), cytokeratin 19 fragment (CYFRA 21-1),
a-fetoprotein (AFP), cancer antigen 15-3 (CA15-3), neuron-
specific enolase, cancer antigen 72-4, and squamous cell
carcinoma antigen have been analyzed, alone or in combin-
ation, as adjuncts to cytology to identify the origin of effusions.
Laboratory testing of serous body fluids 117
Measurement of tumor markers in serous effusions has
proven controversial given the wide ranges of published
sensitivities and specificities that arise in part from the use of
different testing methods, different cut-offs for interpretation,
and heterogeneity in the types of malignancies included in the
studies. Tumor markers are typically measured with immuno-
assays. Assays from different manufacturers could influence
the interpretation cut-offs, given the different antibodies used
for analyte detection and the varying standardizations of
assays. For tumor marker studies, the selected cut-off will
have a marked effect on sensitivity and specificity outcomes.
For studies in which receiver operator curves are used to
select a cut-off that achieves 100% specificity, the þLR and
LR are not useful when interpreting the study outcomes
because of the various cut-offs selected. For studies in which
a cut-off that is similar to the level found in serum is used,
þLR and LR are useful in interpreting results. Therefore, in
this section, LRs are described only when applicable.
The origin of the effusions included in studies needs to be
considered when interpreting study outcomes. The types of
non-malignant effusions and the origin and histologic type
of malignant effusions might bias assay performance. For
example, mesotheliomas and hematologic malignancies are
known to secrete low levels of CEA and CA19-9; when the
above-mentioned malignancies are included in studies of
these tumor markers at a higher frequency, they can be
expected to lower sensitivity. In contrast, gastrointestinal
malignancies are commonly known to secrete high levels of
CEA and CA19-9; if these malignancies are included at a
higher frequency, the sensitivity tends to be higher. This
section will summarize the data for the most frequently
studied or requested tumor markers in serous effusion.
Carcinoembryonic antigen
CEA, an oncofetal protein first described the 1960s, is a
glycoprotein overexpressed in a number of adenocarcin-
omas118,119. In blood, CEA concentrations are elevated in
colorectal, breast, lung, gastric, and pancreatic cancer120.
Today, CEA is the most widely used tumor marker in the
management of patients with colorectal malignancies and
other CEA-secreting cancers120. Mild elevations in CEA
concentrations are seen in non-malignant conditions such as
peptic ulcer disease, inflammatory bowel disease, pancrea-
titis, hypothyroidism, biliary obstruction, and cirrhosis120.
Smoking has also been associated with mild elevations of
CEA120. Because of its low specificity, serum CEA is not
useful in screening for colorectal cancer or other
malignancies.
In serous effusions, CEA is the most useful tumor marker
to differentiate between malignant and non-malignant causes
of fluid accumulation. In pleural fluid, sensitivities range
from 29% to 72% and specificities from 90% to 100%121–130.
In studies using a CEA cut-off similar to the serum
concentration (3–6 ng/mL), median sensitivity was 64%
(mean, 62%; range, 52%–72%; n ¼ 7), median specificity
was 92% (mean, 91%; range, 77%–98%; n ¼ 7), median þLR
was 9 (mean, 11; range, 2–32; n ¼ 7), and median LR was
0.42 (mean, 0.44; range, 0.30–0.62; n ¼ 7)121,123,126,128–131.
Studies that used higher CEA cut-off values (40–50 ng/mL) to
 118 D. R. Block & A. Algeciras-Schimnich Crit Rev Clin Lab Sci, 2013; 50(4–5): 107–124

CEA þ Cytology
achieve 100% specificity reported much lower sensitivities

Sensitivity, %
(29% and 45%)122,127. Although selection of a cut-off with

80
85
88
82
72
59
63
75
88
59
100% specificity is ideal when using a tumor marker, the use
of high cut-offs markedly reduces the sensitivity for detection
of malignant effusions.
Malignancies for which CEA has been evaluated in pleural

CEA LR
fluid include lung, breast, ovarian, and colorectal cancers,

0.55
0.48
0.07
0.50
0.78
0.51
0.57
0.55
0.50
0.65
mesotheliomas, and lymphomas. Measurement of CEA in
pleural fluid is not a sensitive marker for non-epithelial

Abbreviations: CEA, carcinoembryonic antigen; þLR, positive likelihood ratio; LR, negative likelihood ratio; NC, not calculated; RIA, radioimmunoassay; NR, not reported.
tumors (e.g. mesotheliomas, lymphomas, sarcomas)122,125,129,

CEA þLRa
which express very low levels of CEA that are insufficient to

NC

NC

NC
NC

NC
3
11
23
13

13
elevate CEA in serum. Therefore, studies that include a large
number of these malignancies tend to show a lower overall
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sensitivity of CEA for malignancy detection. For example, in

a study by Alatas et al.121 45% of cases were malignant

CEA specificity, %
pleural mesotheliomas and the reported +LR was 2. The
highest CEA performance (þLR 410) was reported for

95
97
96

99

96
100

100

100
100

100
pleural effusions caused by lung cancer and other cancers
associated with increased serum concentrations of

Table 5. Diagnostic performance of CEA and cytology (separately and in combination) for the differentiation of malignancy-related effusions.
CEA129,131.
In ascitic fluid, CEA has high specificity but low

CEA sensitivity, %
sensitivity for differentiating between malignant and non-
malignant causes of ascites. Reported sensitivities range from
32% to 51% to identify malignant ascites due to gastric, colon,

45
54
51
52
29
64
43
45
52
35
ovarian, pancreatic, and breast cancer65,68,132–135. In the
studies using a CEA cut-off similar to the serum concentra-
tion (3–6 ng/mL), median sensitivity was 50% (mean, 48%;
For personal use only.

range, 38%–54%; n ¼ 5), median specificity was 97% (mean,

sensitivity, %
97%; range, 95%–100%; n ¼ 5), median þLR was 13 (mean, Cytology

70
58
77
58
54
27
43
58
78
35
14; range, 10–19; n ¼ 5), and median LR was 0.52 (mean,
0.53; range, 0.48–0.63; n ¼ 5)65,68,132,133,135. Few studies have
compared the performance of CEA in ascitic fluid versus
serum. Some investigators suggest that measurement of CEA
Cut-off, ng/mL

in serum is as informative as measurement in ascites134,

2.5

3.5

6.5
3.5
NR

whereas others suggest that a CEA fluid-to-serum ratio 42 is

11

50

40

40
5
superior to measurement of the marker in either fluid alone65.
Most recently, measurement of CEA in peritoneal fluid from
patients with known malignancies has been evaluated.
Not specified

Peritoneal fluid CEA levels were associated with peritoneal

Method

For some studies, þLR was not calculated because of 100% specificity.
Beckman

Beckman
Immulite

metastasis in patients with colorectal cancer with negative

Abbott

Roche

Bayer

cytology136. In patients with gastric cancer, low CEA levels

RIA

RIA

RIA

(55 ng/mL) in the ascitic fluid showed a greater association

with longer survival (7.4 months) compared to elevated CEA
(No. with malignancy)

(45 ng/mL; survival, 2.3 months)137. However, this study

No. of Patients

showed a similar trend when the serum was analyzed,

(166)

(100)
(101)
(54)
(75)
(80)
(54)

(44)
(65)
(40)

suggesting that ascitic fluid CEA is not superior to serum

CEA as a prognostic marker.
121
130
130
137
339
116
207
124
198
252

The use of CEA and other tumor markers in serous

effusions is intended to improve diagnostic sensitivity when
used jointly with cytologic examination. A limited number
of publications have compared the performance of cytology
Fluid type
Peritoneal
Peritoneal
Peritoneal
Peritoneal

in combination with the tumor markers in pleural and

Pleural
Pleural
Pleural
Pleural
Pleural
Pleural

peritoneal effusions. The reported sensitivity for cytologic

classification of malignancy ranges from 50% to 60% in
pleural fluid138 and 40% to 70% in peritoneal fluid139,140.
Hackbarth et al.129
Torresini et al.132

Table 5 shows the diagnostic performance of CEA alone,

Villena et al.125

Villena et al.141
Gaspar et al.127
Kaleta et al.135
Porcel et al.122
Shitrit et al.124
Gerbes et al.65

Gulyas et al.68

cytology alone, and both in combination for the detection of

malignancy in pleural and peritoneal effusions. In most cases,
Study

cytology examination shows superior sensitivity to CEA for

the classification of malignant effusions, but combining the
a
 DOI: 10.3109/10408363.2013.844679
marker with examination results in an increase in correct
classification of malignant effusions by an average of 21%.
Numerous studies have shown that inclusion of additional
tumor markers could further improve sensitivity in combin-
ation with cytology124,126,129. However, testing multiple
tumor markers might not be cost-effective because an
elevated tumor marker in the effusion is not diagnostic
and additional invasive testing is still necessary to confirm a
suspected malignancy.
In contrast to pleural and peritoneal effusions, measure-
ment of CEA in pericardial effusions has limited utility. For
the assessment of malignant pericardial effusions, CEA
sensitivity ranges from 72% to 86% and specificity ranges
Critical Reviews in Clinical Laboratory Sciences Downloaded from informahealthcare.com by Laurentian University on 10/26/13
from 90% to 100%142–144. In these studies, cytology perform-
ance was evaluated in parallel and it was found that
measurement of CEA did not provide additional sensitivity
beyond that obtained by cytology. Therefore, current evidence
is not sufficient to support routine measurement of pericardial
fluid CEA in the evaluation of suspected malignant pericar-
dial effusions.
Cancer antigen 19-9
CA19-9, or sialylated Lewis (a) antigen concentrations, are
increased in patients with pancreatic or biliary tract can-
cers120. Non-malignant conditions such as cirrhosis, choles-
tasis, cholangitis, and pancreatitis also display elevated
For personal use only.
serum CA19-9 concentrations, although values are usually
51000 U/mL145. Measurement of CA19-9 in serum or plasma
is used to monitor disease status in patients with pancreatic
cancer. One caveat with CA19-9 is that individuals who are
Lewis negative (5%–7% of the population) do not express
CA19-9 because of the lack of the fucosyltransferase
enzyme145. Similar to CEA, CA19-9 may be measured in
serous effusions to distinguish between non-malignant and
malignant causes of fluid accumulation. In both fluid types,
CA19-9 has lower sensitivity and a lower þLR for detection
of malignancy when compared with CEA.
Sensitivities between 20% and 40% and specificities
between 70% and 100% have been reported for CA19-9 in
pleural fluid121,123–125,127,129,141,146. For studies in which a
CA19-9 cut-off similar to the concentration found in serum
was used (20–37 U/mL), median sensitivity was 37% (mean,
38%; range, 35%–39%; n ¼ 4), median specificity was 78%
(mean, 80%; range, 67%–95%; n ¼ 4), median þLR was
2 (mean, 3; range, 1–7; n ¼ 4), and median LR was 0.80
(mean, 0.80; range, 0.68–0.93; n ¼ 4)123,124,129,146. For studies
using a very high CA19-9 cut-off (103 or 580 U/mL) to
achieve 100% specificity, the sensitivity was 20% and
25%125,127.
Data on the diagnostic performance of CA19-9 in
peritoneal fluid are very limited, with a reported sensitivity
of approximately 30% and a specificity ranging from 22% to
95%133–135,147. The low specificity is a result of the increased
concentrations of CA19-9 in peritoneal fluids that have been
reported in non-malignant conditions of ascites formation
(e.g. cirrhosis, cholestasis, cholangitis, pancreatitis), which
decreases the specificity and utility of CA19-9 in peritoneal
fluid. Similar to CEA, measurement of CA19-9 for the
evaluation of serous effusion accumulation as a consequence
Laboratory testing of serous body fluids 119
of non-epithelial tumors (e.g. mesotheliomas, lymphomas,
sarcomas) is not informative because these tumors do not
usually secrete CA19-9 in serum and consequently will not be
present in body fluids. Use of this tumor marker in the
evaluation of serous effusions is limited by the low specificity
and the fact that a fraction of the population does not express
CA19-9.
Cancer antigen 125
CA125 is a glycoprotein normally expressed in tissues derived
from coelomic epithelia (e.g. ovary, fallopian tube, periton-
eum, pleura, pericardium, colon, kidney, stomach). Serum
CA125 is used to monitor recurrence or disease progression in
patients with epithelial ovarian cancer120. Numerous non-
malignant conditions also display elevated serum CA125,
including endometriosis, uterine fibroids, pelvic inflamma-
tory disease, heart failure, and liver and renal disease, which
limits the specificity of CA125 as a tumor marker120.
In serous fluids, a number of non-malignant conditions
are associated with elevated levels of CA125 due to
production by mesothelial cells148. In pleural fluid, numerous
reports have examined the utility of CA125 to distinguish
malignant cases of pleural effusions, with discrepant
results122,124,128,130,146. In two series of patients with adeno-
carcinoma, squamous cell carcinoma, lymphoma, and
mesothelioma, and using a very high cut-off for CA125
(41700 IU/mL), specificities were 94% and 100% and
sensitivities were 17% and 36%122,130. In these studies, non-
malignant conditions included mostly patients with heart
failure, pneumonia, or tuberculosis. When using a cut-off of
435 IU/mL (similar to the serum reference range) in a series
of patients with lung, breast, or colorectal cancers, the
specificity was only 6%, the sensitivity was 98%, and
accuracy for malignancy detection was only 41% (þLR, 1;
LR, 0.33)124,146. Similar performance has been published
for CA125 in peritoneal fluid, with some studies excluding
the analyte from further analysis up-front because of the lack
of specificity (i.e. from elevation in cases of ascites due to
cirrhosis, acute pancreatitis, peritonitis, endometriosis, and
pelvic inflammatory disease)127,134. Therefore, elevations of
CA125 in serous effusions are neither specific nor helping in
differentiating between malignant or non-malignant causes of
fluid accumulation.
Cytokeratin 19 fragment
CYFRA 21-1 is a fragment of cytokeratin 19, which is
expressed in various types of epithelial cells and tumor cells
of epithelial origin149. Serum CYFRA 21-1 is the most
sensitive tumor marker for non–small-cell lung cancer.
However, CYFRA 21-1 may also be elevated in benign
respiratory disease and other malignancies such as urologic,
gastrointestinal, and gynecologic cancers.
In pleural fluid, CYFRA 21-1 measurements might be
useful in differentiating malignant effusion due to lung
cancer. In a series of patients with lung cancer, using a cut-off
of 450 ng/mL, sensitivity and specificity were 70% and 92%,
respectively150. When the histologic type was considered, the
highest sensitivity was reported in squamous cell lung cancer
(90%), followed by adenocarcinoma cell lung cancer (74%),
 120 D. R. Block & A. Algeciras-Schimnich
non-lung cancer (i.e. metastatic cancer; 54%), and small-cell
lung cancer (25%)150. CYFRA 21-1 was reported to have
superior sensitivity (480%) and specificity (490%) when
compared with other tumor markers in patients with lung
cancer and mesothelioma121,146. These studies used cut-offs
of 3.3 ng/mL and 8 ng/mL. In the detection of malignant
mesothelioma, a CYFRA 21-1–to-CEA ratio of 19.1 had a
sensitivity and specificity of 85% and 80%, respectively151. A
combination of high-level pleural fluid CYFRA 21-1
(100 ng/mL) and CA125 (1000 U/mL) correlates with
poor survival in patients with adenocarcinomatous or squa-
mous malignant effusions152. Additional studies are needed to
determine if measurement of CYFRA 21-1 in pleural fluid is
Critical Reviews in Clinical Laboratory Sciences Downloaded from informahealthcare.com by Laurentian University on 10/26/13
a useful prognostic marker.
Cancer antigen 15-3
CA15-3 is a transmembrane glycoprotein and the most widely
used serum marker for breast cancer. Serum elevation of
CA15-3 is not specific; elevations have been reported in
colon, lung, pancreatic and ovarian cancers, in benign liver
and kidney diseases, and in ovarian cysts153. In serous fluids,
CA15-3 has been mostly evaluated in pleural effusions from
lung, breast, and bronchial cancers and malignant mesotheli-
oma121,123–127,146. In three studies of patients with effusions
due to lung and breast cancer that used a cut-off similar to
what is found in serum (22–30 U/mL), the median sensitivity
was 63% (mean, 60%; range, 51%–67%; n ¼ 3), median
For personal use only.
specificity was 75% (mean, 79%; range, 73%–90%; n ¼ 3),
and þLR was 2 (mean, 4; range, 2–7; n ¼ 3)123,126,146. In a
study that evaluated pleural effusions due to bronchial
cancer and malignant mesothelioma, the þLR was 11 and
the LR was 0.22121. Overall, the current literature does not
support routine use of CA15-3 in the evaluation of serous
effusions.
-Fetoprotein
AFP is a glycoprotein produced in early fetal life by the yolk
sac, liver and intestine. AFP levels decrease soon after birth
and remain low through adulthood120. In adults, increased
serum AFP levels are observed during pregnancy and in
several benign and malignant diseases. Increased serum AFP
concentrations are seen in hepatocellular carcinoma, germ-
cell tumors arising from the ovaries, non-seminomatous
germ-cell tumors of the testes, testicular teratocarcinomas,
and primary germ-cell tumors arising within the central
nervous system120. In peritoneal fluid, AFP measurements
have very limited utility. AFP elevation in ascitic fluid has
been observed in hepatocellular carcinoma cases in which the
cytology was negative for malignancy135,154. However, peri-
toneal fluid AFP concentrations may be lower than serum
levels in patients with malignant ascites134,154. Furthermore,
serum and ascites AFP, when compared in the same
study, have identical diagnostic accuracy for hepatic
malignancies134,154,155.
Overall, the literature describing use of tumor markers for
the identification of malignant effusions is controversial.
Nevertheless, laboratories commonly receive requests for
such determinations in fluids obtained during surgical or
other invasive procedures. Analysis of tumor markers in
Crit Rev Clin Lab Sci, 2013; 50(4–5): 107–124
serous fluids, however, should not replace cytologic examin-
ation because routine analysis has limited value. In the
context of negative cytology and a positive tumor marker
level, invasive procedures to obtain a biopsy sample are still
needed for diagnosis and management decisions. In contrast, a
negative tumor marker result does not exclude a malignancy
because the cause of the effusion and additional investigation
still might be necessary.
Other analytes
Various alternate analytes have also been investigated for their
utility in differentiating transudates from exudates in pleural
fluid. Interleukin-1 b is a cytokine thought to mediate
inflammatory responses16. The þLR was 52 using a pleural
fluid cut-off of418.2 fmol/mL and fluid-to-serum ratio40.71
to differentiate exudates. The performance was similar in
a cohort of patients with malignant effusions compared
with malignant and inflammatory effusions and did not add
clinical value to the assessment.
Malondialdehyde is a hypothetical marker of oxidative
status in exudative pleural diseases. One study42 reported a
þLR of 19.4, but the classic Light criteria plus an albumin or
protein gradient performs just as well or better and is more
readily available.
Uric acid is a low-molecular-weight molecule produced in
the metabolism of purines. It may be found at increased
concentrations in transudates because of increased capillary
permeability and passive diffusion17, and it may be associated
with hypoxic states85. Neither of the above studies showed
utility beyond Light criteria for differentiating exudates from
transudates.
b2-Microglobulin is a low-molecular-weight protein
thought to be produced locally by lymphocytes. In a cohort
of children, a fluid-to-serum ratio 41.3 had a þLR of 15.4
for differentiating exudative causes of pleural effusion. The
authors concluded that the increased concentration was due to
local disease and did not reflect serum concentrations27.
Natriuretic peptides are neurohormones secreted by
cardiomyocytes in response to increased pressure in the
heart. They become elevated and measureable as B-type
natriuretic peptide (BNP) and N-terminal pro–B-type natri-
uretic peptide (NT-proBNP) in serum or plasma, aiding in the
diagnosis and staging of heart failure. BNP and NT-proBNP
have been investigated in transudative pleural effusions to
differentiate cardiac causes156. Multiple studies have been
conducted using the generally accepted cut-off for NT-
proBNP of 41500 ng/dL. Studies that measure NT-proBNP
in both serum and pleural fluid have consistently shown
a significant correlation between both measurements and
equivalent diagnostic accuracy157. Given that measurement of
BNP or NT-proBNP in pleural fluid does not offer any
advantage over serum NT-proBNP, laboratories should
discourage this practice and should not perform additional
analytic and clinical validations for an alternate specimen
type.
Conclusion
Body fluid analysis might be valuable to clinicians for the
identification of the cause and management of serous
 DOI: 10.3109/10408363.2013.844679 Laboratory testing of serous body fluids 121
Table 6. Clinical utility of various analytes in serous effusionsa.

Pleural fluid Peritoneal fluid Pericardial fluid

Not Limited Not Limited Not Limited
Analyte Useful useful utility Useful useful utility Useful useful utility
Light criteria X X X
Lactate dehydrogenase X X O
Total protein X X O
Cholesterol X X O
Bilirubin X X X
Enzymesb X X X
a-1-Antitrypsin O X O
Adenosine deaminase X O O
Serum effusion albumin gradient X X O
Total protein gradient X
Critical Reviews in Clinical Laboratory Sciences Downloaded from informahealthcare.com by Laurentian University on 10/26/13

Amylase X X X
pH X O O
Glucose X X X
Carcinoembryonic antigen X X X
Cancer antigen 19-9 X X O
Cancer antigen 125 X X O
CYFRA 21-1 (fragment of cytokeratin 19) O O O
Cancer antigen 15-3 X X O
a-Fetoprotein O X O
a
Xs indicate that diagnostic utility has been studied in well-controlled studies. Os indicate the lack of sufficient evidence to make a determination about
diagnostic utility.
b
Enzymes other than lactate dehydrogenase, amylase, and adenosine deaminase.

effusions. However, the available literature needs to be 3. Schoenicke G, Grabensee B, Plum J. Dialysis with icodextrin
interferes with measurement of serum alpha-amylase activity.
critically analyzed because published studies might not be Nephrol Dial Transplant 2002;17:1988–92.
For personal use only.

transferable to today’s clinical laboratory testing. Clinical
laboratories are responsible for encouraging appropriate
testing of body fluid specimens, especially as cost-
containment efforts in health care increase.
Evaluation of the current literature pertinent to biochemical
testing of serous fluids indicates that most studies were
conducted in the 1970s through 1990s. Few reports discuss
pre-analytic methods (e.g. specimen collection), transport, and
analytic measurements, but these details are critical when
trying to replicate or verify those findings. Consequently, it is
difficult to ascertain whether the reported sensitivity and
specificity from such studies correlate with today’s pre-
analytic and analytic methods. Using data on sensitivity,
specificity, and LRs, we categorized various analytes as useful
(diagnostic utility for routine use), not useful (diagnostic utility
is unfounded by well-controlled studies or lacks sufficient
evidence to make a determination), and limited utility (diag-
nostic utility demonstrated for a subset of patients or condi-
tions) in body fluids (Table 6). The information in this review
is of value to clinical laboratories when considering which
body fluid tests to offer in their practice and to clinicians when
ordering and interpreting body fluids tests.
Declaration of interest
The authors report no declarations of interest regarding the
publication of this review.
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