Academic Respiratory Unit, University of Bristol, Bristol, United Kingdom.
North Bristol NHS Trust, Southmead Hospital, Bristol, United Kingdom; and.
Am J Respir Crit Care Med. 2020 Jun 15;201(12):1545-1553. doi: 10.1164/rccm.201911-2169OC.
Parapneumonic effusions have a wide clinical spectrum. The majority settle with conservative management but some progress to complex collections requiring intervention. For decades, physicians have relied on pleural fluid pH to determine the need for chest tube drainage despite a lack of prospective validation and no ability to predict the requirement for fibrinolytics or thoracic surgery. To study the ability of suPAR (soluble urokinase plasminogen activator receptor), a potential biomarker of pleural fluid loculation, to predict the need for invasive management compared with conventional fluid biomarkers (pH, glucose, and lactate dehydrogenase) in parapneumonic effusions. Patients presenting with pleural effusions were prospectively recruited to an observational study with biological samples stored at presentation. Pleural fluid and serum suPAR levels were measured using the suPARnostic double-monoclonal antibody sandwich ELISA on 93 patients with parapneumonic effusions and 47 control subjects (benign and malignant effusions). Pleural suPAR levels were significantly higher in effusions that were loculated versus nonloculated parapneumonic effusions (median, 132 ng/ml vs. 22 ng/ml; < 0.001). Pleural suPAR could more accurately predict the subsequent insertion of a chest tube with an area under the curve (AUC) of 0.93 (95% confidence interval, 0.89-0.98) compared with pleural pH (AUC 0.82; 95% confidence interval, 0.73-0.90). suPAR was superior to the combination of conventional pleural biomarkers (pH, glucose, and lactate dehydrogenase) when predicting the referral for intrapleural fibrinolysis or thoracic surgery (AUC 0.92 vs. 0.76). Raised pleural suPAR was predictive of patients receiving more invasive management of parapneumonic effusions and added value to conventional biomarkers. These results need validation in a prospective multicenter trial.
脓胸性胸腔积液具有广泛的临床特征。大多数胸腔积液经保守治疗即可痊愈，但也有一些进展为需要介入治疗的复杂积液。几十年来，尽管缺乏前瞻性验证，也无法预测纤溶或胸外科治疗的需求，医生还是依赖胸腔积液 pH 值来决定是否需要进行胸腔引流管置管。本研究旨在探讨可溶性尿激酶型纤溶酶原激活物受体（suPAR）——胸腔积液分隔的潜在生物标志物，与传统胸腔积液生物标志物（pH 值、葡萄糖和乳酸脱氢酶）相比，预测脓胸性胸腔积液需要侵入性治疗的能力。前瞻性招募了胸腔积液患者进行观察性研究，在研究开始时采集生物样本进行存储。使用 suPARnostic 双单克隆抗体夹心 ELISA 法检测 93 例脓胸性胸腔积液患者和 47 例对照患者（良性和恶性胸腔积液）的胸腔积液和血清 suPAR 水平。分隔性脓胸性胸腔积液的胸腔积液 suPAR 水平明显高于非分隔性脓胸性胸腔积液（中位数分别为 132ng/ml 和 22ng/ml；<0.001）。与胸腔积液 pH 值（曲线下面积 [AUC] 0.82；95%置信区间 [CI]，0.73-0.90）相比，胸腔积液 suPAR 能更准确地预测随后插入胸腔引流管的情况，AUC 为 0.93（95%CI，0.89-0.98）。与传统胸腔积液生物标志物（pH 值、葡萄糖和乳酸脱氢酶）组合相比，suPAR 预测胸腔内纤溶或胸外科手术的转诊率具有更高的优势（AUC 0.92 与 0.76）。升高的胸腔积液 suPAR 预测患者需要接受更侵入性的脓胸性胸腔积液治疗，并为传统生物标志物提供了附加价值。这些结果需要在前瞻性多中心试验中进行验证。
