Clinical Information

Total protein results of 3.0 g/dL or greater, historically used to classify ascites fluid as transudate or exudate, has a reported accuracy of only 55% in identifying exudates and has been largely replaced with measurement of the serum-ascites albumin gradient (SAAG), calculated as serum albumin concentration minus ascites albumin concentration.

SAAG has been shown to correlate directly with portal pressure and SAAG results of 1.1 g/dL or greater are 97% accurate at identifying portal hypertension. Conditions associated with high SAAG include cirrhosis, acute liver failure, fatty liver disease, alcoholic hepatitis, portal vein thrombosis, hepatic malignancy, and veno-occlusive disease. Cardiac ascitic fluid caused by congestive heart failure has both a high SAAG result (≥1.1 g/dL) and total protein concentration greater than 2.5 g/dL. Conditions associated with low SAAG measurement (<1.1 g/dL) include peritoneal malignancy, tuberculosis, pancreatitis, connective tissue disease, and nephrotic syndrome.

Pleural fluid:

Pleural fluid is normally present within the pleural cavity surrounding the lungs, serving as a lubricant between the lungs and inner chest wall. Pleural effusion develops when the pleural cavity experiences an overproduction of fluid due to increased capillary hydrostatic and osmotic pressure that exceeds the ability of the lymphatic or venous system to return the fluid to circulation. Laboratory-based criteria are often used to classify pleural effusions as either exudative or transudative. Exudative effusions form due to infection or inflammation of the capillary membranes allowing excess fluid into the pleural cavity. Patients with these conditions benefit from further investigation and treatment of the local cause of inflammation. Transudative effusions form due to systemic conditions such as volume overload, end-stage renal disease, and heart failure that can lead to excess fluid accumulation in the pleural cavity. Patients with transudative effusions benefit from treatment of the underlying condition.(1) Dr. Richard Light derived criteria in the 1970s for patients with pleural effusions that are still used today.(2) Dr. Light's criteria were designed to be sensitive for detecting exudates at the expense of specificity.(3) Heart failure and recent diuretic use contribute to most misclassifications by Dr. Light's criteria (transudates falsely categorized as exudates). Serum-to-fluid protein or albumin gradient (serum protein or albumin minus fluid protein or albumin) may be calculated in these cases and when more than 3.1 g/dL (protein) or 1.2 g/dL (albumin) suggests the patient has a transudative effusion.