Pleural Fluid suPAR Levels Predict the Need for Invasive Management in Parapneumonic Effusions

David T Arnold, Fergus W Hamilton, Karen T Elvers, Stuart W Frankland, Natalie Zahan-Evans, Sonia Patole, Andrew Medford, Rahul Bhatnagar, Nicholas A Maskell

Research output: Contribution to journalArticle (Academic Journal)peer-review

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RATIONALE: 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.

OBJECTIVES: To study the ability of soluble urokinase Plasminogen Activator Receptor (suPAR), a potential biomarker of pleural fluid loculation, to predict the need for invasive management compared to conventional fluid biomarkers (pH, glucose, LDH) in parapneumonic effusions.

METHODS: 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 suPARnosticTM double-monoclonal antibody sandwich ELISA on 93 patients with parapneumonic effusions and 47 controls (benign and malignant effusions).

MEASUREMENTS AND MAIN RESULTS: Pleural suPAR levels were significantly higher in effusions that loculated versus non-loculated parapneumonic effusions (median 132ng/ml vs 22ng/ml, p<0.001). Pleural suPAR could more accurately predict the subsequent insertion of a chest tube with an AUC of 0.93 (95%CI. 0.89-0.98) compared to pleural pH (AUC 0.82, 95%CI. 0.73-0.90). suPAR was superior to the combination of conventional pleural biomarkers (pH, glucose and LDH) when predicting the referral for intrapleural fibrinolysis or thoracic surgery (AUC 0.92 vs 0.76).

CONCLUSIONS: 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.

Original languageEnglish
Number of pages42
JournalAmerican Journal of Respiratory and Critical Care Medicine
Early online date18 Feb 2020
Publication statusE-pub ahead of print - 18 Feb 2020


  • Empyema
  • Pneumonia
  • Pleural Effusion
  • suPAR

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