The Effectiveness of Pleural Cholesterol Levels in Differentiating Transudate from Exudate and Comparison with Light’s Criteria

Background: Differentiating exudative from transudative pleural effusions is essential for accurate diagnosis and management. Although Light’s criteria remain the standard diagnostic method, they may incorrectly classify a substantial proportion of transudative effusions as exudates. This study aimed to evaluate the diagnostic performance of pleural fluid cholesterol and compare it with Light’s criteria. Methods: This retrospective study included 751 patients with pleural effusion who underwent diagnostic evaluation between 2015 and 2024 and had a definitive etiological diagnosis. All patients underwent ultrasound-guided thoracentesis with simultaneous pleural fluid and serum biochemical analyses. Based on final etiological diagnosis, effusions were classified as transudative or exudative. Results: The mean age was 68.6 ± 15.8 years. Of the pleural effusions, 516 (68.7%) were exudative and 235 (31.3%) were transudative. Malignant pleural effusion was the most common cause of exudates, whereas congestive heart failure predominated among transudates. Pleural fluid cholesterol levels were significantly higher in exudative than transudative effusions (91.1 ± 30.7 vs. 28.9 ± 13.5 mg/dL, p < 0.001). Receiver operating characteristic (ROC) analysis demonstrated excellent diagnostic performance for pleural fluid cholesterol (AUC = 0.976, 95% CI 0.965–0.987, p < 0.001). A pleural cholesterol cut-off value of ≥50 mg/dL demonstrated 92.2% sensitivity, 94.9% specificity, 97.5% positive predictive value, and 84.8% negative predictive value for identifying exudative effusions. Light’s criteria showed higher sensitivity (99.2%) but lower specificity (84.4%). Light’s criteria misclassified 15.6% of transudative effusions as exudates, whereas pleural cholesterol misclassified only 5.1%. Conclusions: Pleural fluid cholesterol measurement demonstrated high diagnostic accuracy in differentiating exudative and transudative pleural effusions and substantially reduced false exudate classification compared with Light’s criteria. Routine assessment of pleural cholesterol may improve the diagnostic evaluation of pleural effusions.