Diagnostic Utility of Pleural Fluid NT-proBNP in Reclassifying Cardiogenic Pleural Effusions Misclassified by Light's Criteria: A Prospective Observational Cross-Sectional Study

Ritwik Chakraborty; Sourabh Kumar; Mohammad Shoaib; Gyanendra Agrawal

doi:10.51168/1k9wm097

Autori

Ritwik Chakraborty Consultant, Department of Critical Care Medicine, Max Superspeciality Hospital Vaishali Ghaziabad, India
Sourabh Kumar Assistant Professor, Department of Critical Care Medicine, Himalayan Institute of Medical Sciences (HIMS), Swami Rama Himalayan University, Jollygrant, Dehradun, India
Mohammad Shoaib Department of Critical Care Medicine, Livasa Hospital, Khanna, Punjab, India
Gyanendra Agrawal Senior Director, Department of Critical Care, Max Super Speciality Hospital Sec-128, Noida, India

DOI:

https://doi.org/10.51168/1k9wm097

Cuvinte cheie:

Pleural effusion, NT-proBNP, Light’s criteria, cardiogenic effusion, biomarker

Rezumat

Background:

Light's criteria are widely used to differentiate transudative and exudative pleural effusions but may misclassify cardiogenic pleural effusions, particularly in patients receiving diuretic therapy. Pleural fluid N-terminal pro-brain natriuretic peptide (NT-proBNP) has emerged as a promising biomarker for improving diagnostic accuracy.

Objective:

To evaluate the diagnostic utility of pleural fluid NT-proBNP in reclassifying cardiogenic pleural effusions misclassified by Light's criteria.

Methods:

This prospective observational cross-sectional study was conducted over one year at a tertiary care hospital in North India. Ninety-three adults with pleural effusion undergoing diagnostic thoracocentesis were enrolled. Pleural fluid was analyzed using Light's criteria and NT-proBNP estimation. Final diagnoses were established using clinical, radiological, and echocardiographic findings. Receiver operating characteristic (ROC) curve analysis assessed diagnostic performance.

Results:

The study included 93 patients (mean age 58.3 ± 10.2 years; 52 (55.9%) males and 41 (44.1%) females). Cardiogenic pleural effusion was diagnosed in 35 (37.6%) patients. Light's criteria misclassified 8 (22.9%) cardiogenic effusions as exudates. Median pleural fluid NT-proBNP levels were significantly higher in cardiogenic than non-cardiogenic effusions (11,250 vs. 185 pg/mL; p < 0.001). At a cutoff of >1500 pg/mL, NT-proBNP demonstrated 97.1% sensitivity, 98.2% specificity, and an AUC of 0.995, correctly reclassifying all misclassified cases.

Conclusion:

Pleural fluid NT-proBNP is a highly accurate biomarker for identifying cardiogenic pleural effusions and effectively reclassifies cases misdiagnosed by Light's criteria.

Recommendation:

Routine measurement of pleural fluid NT-proBNP should be considered as an adjunct to Light's criteria, particularly in patients with suspected heart failure or receiving diuretic therapy.

Biografii autori

Ritwik Chakraborty, Consultant, Department of Critical Care Medicine, Max Superspeciality Hospital Vaishali Ghaziabad, India

is a Consultant in the Department of Critical Care Medicine at Max Super Speciality Hospital, Vaishali, Ghaziabad, India. His clinical and research interests include critical care medicine, respiratory disorders, sepsis, and biomarkers in critically ill patients.
Sourabh Kumar, Assistant Professor, Department of Critical Care Medicine, Himalayan Institute of Medical Sciences (HIMS), Swami Rama Himalayan University, Jollygrant, Dehradun, India

is an Assistant Professor in the Department of Critical Care Medicine at the Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, India. His research interests include critical care medicine, pulmonary diseases, and clinical epidemiology.
Mohammad Shoaib, Department of Critical Care Medicine, Livasa Hospital, Khanna, Punjab, India

is a Consultant in the Department of Critical Care Medicine at Livasa Hospital, Khanna, Punjab, India. His areas of interest include intensive care medicine, respiratory diseases, and emergency medicine.
Gyanendra Agrawal, Senior Director, Department of Critical Care, Max Super Speciality Hospital Sec-128, Noida, India

is the Senior Director of the Department of Critical Care at Max Super Speciality Hospital, Noida, India. His research focuses on critical care, sepsis, cardiopulmonary disorders, and evidence-based intensive care management.

Referințe

1. Light RW. Pleural diseases. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2013.

2. Porcel JM. Pleural effusions. Lancet. 2016;387(10028):165-175.

3. Light RW, Macgregor MI, Luchsinger PC, Ball WC Jr. Pleural effusions: the diagnostic separation of transudates and exudates. Ann Intern Med. 1972;77(4):507-513. https://doi.org/10.7326/0003-4819-77-4-507

4. Romero-Candeira S, Hernández L, Romero-Brufao S, Orts D, Fernández C, Martín C. Misleading criteria for separating transudates and exudates in patients with pleural effusion. Chest. 2002;122(5):1524-1529. https://doi.org/10.1378/chest.122.5.1524

5. Chakko S, Caldwell SH, Sforza PP. Treatment of congestive heart failure: its effect on pleural fluid chemistry. Am J Med. 1989;86(6):665-668.

6. Bielsa S, Porcel JM, Castellote J, Mas E, Esquerda A, Light RW. Solving Light's criteria misclassification of cardiac and hepatic transudates. Respirology. 2012;17(4):721-726. https://doi.org/10.1111/j.1440-1843.2012.02155.x

7. Maisel AS, Krishnaswamy P, Nowak RM, McCord J, Hollander JE, Duc P, et al. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med. 2002;347(3):161-167. https://doi.org/10.1056/NEJMoa020233

8. Januzzi JL Jr, Camargo CA, Anwaruddin S, Baggish AL, Chen AA, Krauser DG, et al. The N-terminal Pro-BNP investigation of dyspnea in the emergency department (PRIDE) study. Circulation. 2005;112(12):1806-1812.

9. Porcel JM, Vives M, Cao G, Bielsa S, Ruiz-González A, Esquerda A. Measurement of pro-brain natriuretic peptide in pleural fluid for the diagnosis of pleural effusions due to heart failure. Chest. 2004;126(2):452-458.

https://doi.org/10.1016/j.amjmed.2003.11.008

10. Tomcsányi J, Nagy E, Somlói M, Moldvay J, Bezzegh A, Benczúr B. NT-proBNP levels in pleural fluid distinguish between pleural transudates and exudates. Eur J Heart Fail. 2004;6(6):753-756. https://doi.org/10.1016/j.ejheart.2003.11.017

11. Kolditz M, Halank M, Schulte-Hubbert B, Höffken G. ProBNP in pleural fluid: a diagnostic marker for cardiac effusions. Respiration. 2006;73(6):739-744.

12. Han CH, Lee OJ, Kim HJ, Kim YD, Kim SH, Lee JH. Clinical utility of pleural fluid NT-proBNP in patients with pleural effusion. Am J Med Sci. 2008;336(1):45-49.

13. Porcel JM. Biomarkers in the diagnosis of pleural diseases: a 2018 update. Respirology. 2018;23(6):556-564.

https://doi.org/10.1177/1753466618808660

14. Li H, Xu X, Wang L, Zhang Y, Wang X. Diagnostic value of NT-proBNP in pleural effusions: a meta-analysis. BMC Pulm Med. 2014;14:43.

15. Hanley JA, McNeil BJ. The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology. 1982;143(1):29-36. https://doi.org/10.1148/radiology.143.1.7063747

16. Heffner JE, Brown LK, Barbieri CA. Diagnostic value of tests distinguishing exudative and transudative pleural effusions. Chest. 1997;111(4):970-980. https://doi.org/10.1378/chest.111.4.970

17. Burgess LJ, Maritz FJ, Le Roux I, Taljaard JJ. Combined use of pleural fluid cholesterol and LDH in distinguishing transudates and exudates. Chest. 1995;107(6):1604-1609. https://doi.org/10.1378/chest.107.6.1604

18. Roth BJ, O'Meara TF, Cragun WH. The serum-effusion albumin gradient in evaluating pleural effusions. Chest. 1990;98(3):546-549. https://doi.org/10.1378/chest.98.3.546

19. Valdés L, Alvarez D, Valle JM, Pose A, San José E. Etiology of pleural effusions in an area with high tuberculosis prevalence. Chest. 1996;109(1):158-162. https://doi.org/10.1378/chest.109.1.158

20. McGrath EE, Anderson PB. Diagnosis of pleural effusion: a systematic approach. Clin Med (Lond). 2011;11(6):610-613.

21. Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, et al. 2013 ACCF/AHA guideline for the management of heart failure. Circulation. 2013;128(16):e240-e327. https://doi.org/10.1161/CIR.0b013e31829e8776

22. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, et al. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2016;37(27):2129-2200. https://doi.org/10.1093/eurheartj/ehw128

23. Porcel JM, Esquerda A, Bielsa S. Diagnostic performance of pleural fluid NT-proBNP for identifying pleural effusions due to heart failure: a systematic review and meta-analysis. Eur J Heart Fail. 2011;13(6):659-667.