ERJ open research · 2026
Revisiting Light's criteria: a validated blood-free triple combination matches diagnostic accuracy in over 7000 patients.
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Porcel José M, Porcel Laura, Palma Rosa, Bielsa Silvia
Аннотация
BACKGROUND: Light's criteria remain the standard for distinguishing exudative from transudative pleural effusions, but require serum sampling and lack specificity. We assessed whether a pleural fluid-only approach could match the diagnostic accuracy.
METHODS: We analysed 7280 diagnostic thoracenteses from a single centre, divided into derivation (n=5000) and validation (n=2280) cohorts. We compared Light's criteria with a triple (protein >3 g·dL-1, lactate dehydrogenase (LDH) >250 IU·L-1 or cholesterol >55 mg·dL-1) and a double (LDH >250 IU·L-1 or cholesterol >55 mg·dL-1) combination using sensitivity, specificity, likelihood ratios and area under the curve (AUC). AUCs were assessed using the DeLong method with multiple imputations from a mixed model. McNemar's test examined discordant classifications.
RESULTS: The triple combination showed no significant AUC difference versus Light's criteria in either cohort and had equivalent sensitivity (99% versus 98% in derivation; both 98% in validation). In the derivation cohort, McNemar's test showed a small but statistically significant excess of false negative exudates with the triple combination (p<0.001), whereas no significant difference was found in the validation cohort (p=0.241). The triple combination correctly reclassified 19-20% of transudates misclassified by Light's criteria, while the reverse occurred in 11-14%. The double combination yielded the highest AUCs but missed more exudates, limiting its clinical safety.
CONCLUSION: A pleural fluid-only triple combination matches Light's criteria in diagnostic accuracy, avoids serum sampling and improves specificity with minimal sensitivity loss in one cohort. This approach may be a practical alternative for the initial classification of pleural effusion when blood sampling is unavailable or undesirable.
METHODS: We analysed 7280 diagnostic thoracenteses from a single centre, divided into derivation (n=5000) and validation (n=2280) cohorts. We compared Light's criteria with a triple (protein >3 g·dL-1, lactate dehydrogenase (LDH) >250 IU·L-1 or cholesterol >55 mg·dL-1) and a double (LDH >250 IU·L-1 or cholesterol >55 mg·dL-1) combination using sensitivity, specificity, likelihood ratios and area under the curve (AUC). AUCs were assessed using the DeLong method with multiple imputations from a mixed model. McNemar's test examined discordant classifications.
RESULTS: The triple combination showed no significant AUC difference versus Light's criteria in either cohort and had equivalent sensitivity (99% versus 98% in derivation; both 98% in validation). In the derivation cohort, McNemar's test showed a small but statistically significant excess of false negative exudates with the triple combination (p<0.001), whereas no significant difference was found in the validation cohort (p=0.241). The triple combination correctly reclassified 19-20% of transudates misclassified by Light's criteria, while the reverse occurred in 11-14%. The double combination yielded the highest AUCs but missed more exudates, limiting its clinical safety.
CONCLUSION: A pleural fluid-only triple combination matches Light's criteria in diagnostic accuracy, avoids serum sampling and improves specificity with minimal sensitivity loss in one cohort. This approach may be a practical alternative for the initial classification of pleural effusion when blood sampling is unavailable or undesirable.