fib4 (LH Indholdsside)

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<ul>
    <li>FIB-4 (Fibrosis-4) er en beregnet score, der bruges til at estimere sv&aelig;rhedsgraden af leverfibrose. Den anvendes generelt ved fibroseudredning og hos patienter med nonalkoholisk fedtleversygdom</li>
    <li>Scoren kan bruges b&aring;de hos voksne og muligvis hos b&oslash;rn</li>
</ul>
<h2>Baggrund</h2>
<ul>
    <li>Omkring 25 % i Danmark har nonalkoholisk fedtleversygdom (NAFLD). NAFLD omfatter et sygdomsspektrum fra simpel steatose, en asymptomatisk og reversibel tilstand, til nonalkoholisk steatohepatitis (NASH), en inflammatorisk tilstand i leveren. Patienter med NASH kan udvikle fibrose, cirrose, leversvigt, og leverkr&aelig;ft</li>
    <li>Udredning af patienter mist&aelig;nkt for NASH omfatter:
    <ul>
        <li>Billeddiagnostik (ultralydsskanning af leveren)</li>
        <li>Almindelige blodpr&oslash;ver, herunder ALAT, ASAT, basisk fosfatase, bilirubin, trombocytter, INR, albumin, HbA1c</li>
        <li>Blodpr&oslash;vebaserede fibrosetests, heriblandt FIB-4, en score beregnet ud fra patientens alder og laboratoriem&aring;linger af ASAT, ALAT samt trombocyttal</li>
        <li>Evt. leverbiopsi</li>
    </ul>
    </li>
    <li>Dansk Selskab for Gastroenterologi og Hepatologi anbefaler m&aring;ling af FIB-4 hos patienter mist&aelig;nkt for NAFLD med fibrose<a href="https://dsgh.dk/wp-content/uploads/2022/06/nafld_nash_2020.pdf" data-type="other-reference" data-value="Non-alkoholisk fedtleversygdom (NAFLD): Diagnostik og behandling, Dansk Selskab for Gastroenterologi og Hepatologi, 2018" data-url="https://dsgh.dk/wp-content/uploads/2022/06/nafld_nash_2020.pdf" title="Non-alkoholisk fedtleversygdom (NAFLD): Diagnostik og behandling, Dansk Selskab for Gastroenterologi og Hepatologi, 2018">1</a>, fx kan det overvejes ved&nbsp;<span style="background-color: #ffffff; letter-spacing: 0.1px; color: #1b1b26;">patienter med overv&aelig;gt, type-2 diabetes eller tilf&aelig;ldig p&aring;visning af enten steatose (ultralydsskanning) eller forh&oslash;jede levertal.&nbsp;</span>Scoren er ogs&aring; anbefalet i den Nationale Kliniske Retningslinje omhandlende NAFLD<a href="https://www.sundhedsstyrelsen.dk/da/viden/sundhedsvaesen/nkr-og-nka/puljefinansierede-nkr/non-alkoholisk-fedtleversygdom" data-type="other-reference" data-value="National Klinisk Retningslinje, Tidlig opsporing og behandling af non-alkoholisk fedtleversygdom og non-alkoholisk steatohepatitis, Sundhedsstyrelsen, 2019" data-url="https://www.sundhedsstyrelsen.dk/da/viden/sundhedsvaesen/nkr-og-nka/puljefinansierede-nkr/non-alkoholisk-fedtleversygdom" title="National Klinisk Retningslinje, Tidlig opsporing og behandling af non-alkoholisk fedtleversygdom og non-alkoholisk steatohepatitis, Sundhedsstyrelsen, 2019">2</a>&nbsp;og er tilg&aelig;ngelig som laboratorieanalyse i alle regioner i Danmark.&nbsp;Ved rekvisition af FIB-4-bestemmelse bestilles automatisk ASAT, ALAT og trombocytter, og scoren beregnes efter formlen:&nbsp;</li>
</ul>
<p><img alt="" src="E53C12AE1478484F864F6F1A362296DD-479-141" style="height: 141px; width: 479px;" height="141" width="479"></p>
<ul>
    <li>FIB-4 er bedst til at skelne mellem forekomsten af sv&aelig;r eller ingen fibrose. Den negative pr&aelig;diktive v&aelig;rdi for at ekskludere sv&aelig;r fibrose er bedre end den positive pr&aelig;diktive v&aelig;rdi for forekomsten af fibrose. S&aring;ledes kan FIB-4 udpege patienter med lav risiko for fibrose, hvorimod identificeringen af patienter med betydende fibrose er beh&aelig;ftet med st&oslash;rre usikkerhed</li>
    <li>FIB-4 b&oslash;r rekvireres p&aring; patienter, der henvises til hepatologisk udredning for nonalkoholisk fedtleversygdom</li>
    <li>I almen praksis kan man anvende FIB-4 til vurdering af fibroserisikoen hos patienter mist&aelig;nkt for NAFLD og henvise patienter med h&oslash;j score (<span style="background-color: #ffffff; letter-spacing: 0.1px; color: #1b1b26;">FIB-4 over 2,67)</span> til n&aelig;rmere udredning</li>
</ul>
<h2>NPU-kode</h2>
<p>Pt-Lever fibrose (FIB-4) NPU nr. NPU58634</p>
<h2>Navn</h2>
<p>Lever fibrose (FIB-4);Pt</p>
<h3>Langt navn&nbsp;</h3>
<p>NPU58634 Pt&mdash;Lever fibrose; egenskabsart(FIB-4; WHO 2016; proc.) = ?</p>
<h3>Kort navn</h3>
<p>Fib-4;Pt</p>
<h2>Referenceinterval og fortolkning</h2>
<ul>
    <li>Der har gennem tiden v&aelig;ret foresl&aring;et forskellige FIB-4 gr&aelig;nser for lav, mellem og h&oslash;j risiko for fibrose. I en statusartikel fra Ugeskrift for L&aelig;ger i 2022<a href=" " data-type="journal-reference" data-value="Hansen CD, Lindvig KP, Grønbæk H, Gluud LL, Thiele M, Krag A, Management of non-alcoholic fatty liver disease. Ugeskr Laeger 2022;184: " data-value-piped="Hansen CD, Lindvig KP, Grønbæk H, Gluud LL, Thiele M, Krag A|Management of non-alcoholic fatty liver disease.|Ugeskr Laeger|2022|184||36305262" data-url="reference-link" data-pubmedid="36305262" title="Hansen CD, Lindvig KP, Grønbæk H, Gluud LL, Thiele M, Krag A, Management of non-alcoholic fatty liver disease. Ugeskr Laeger 2022;184: ">3</a> anbefales gr&aelig;nser som til dels bygger p&aring; nyere europ&aelig;iske guidelines<a href=" " data-type="journal-reference" data-value="European Association for the Study of the Liver. Electronic address: easloffice@easloffice.eu, Clinical Practice Guideline Panel, Chair:, EASL Governing Board representative:, Panel members:, EASL Clinical Practice Guidelines on non-invasive tests for evaluation of liver disease severity and prognosis - 2021 update. J Hepatol 2021;75: 659-689" data-value-piped="European Association for the Study of the Liver. Electronic address: easloffice@easloffice.eu, Clinical Practice Guideline Panel, Chair:, EASL Governing Board representative:, Panel members:|EASL Clinical Practice Guidelines on non-invasive tests for evaluation of liver disease severity and prognosis - 2021 update.|J Hepatol|2021|75|659-689|34166721" data-url="reference-link" data-pubmedid="34166721" title="European Association for the Study of the Liver. Electronic address: easloffice@easloffice.eu, Clinical Practice Guideline Panel, Chair:, EASL Governing Board representative:, Panel members:, EASL Clinical Practice Guidelines on non-invasive tests for evaluation of liver disease severity and prognosis - 2021 update. J Hepatol 2021;75: 659-689">4</a>. Der foresl&aring;s f&oslash;lgende:
    <ul>
        <li>Er FIB-4 &lt; 1,3, er risikoen for fibrose lav, og der kr&aelig;ves ikke andet end almindeligt fokus p&aring; relevante livsstils&aelig;ndringer</li>
        <li>Er FIB-4 mellem 1,3 og 2,67, er risikoen for fibrose moderat, og man kan fx gentage testen efter 6 m&aring;neders livsstilsintervention og henvise til gastroenterologisk/hepatologisk hospitalsudredning, hvis ikke scoren forbedres sv.t. en lav risiko</li>
        <li>Er FIB-4 over 2,67, b&oslash;r patienten henvises til hospitalsudredning i gastroenterologisk/hepatologisk regi</li>
    </ul>
    </li>
</ul>
<h2>
Pr&oslash;vetagning</h2>
<ul>
    <li>Veneblodpr&oslash;ve</li>
    <li>Kan udf&oslash;res d&oslash;gnet rundt med kort svartid (1-2 timer)</li>
    <li>Pr&oslash;vematerialet er holdbart i 1 dag ved 4&deg;C</li>
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]]></Media>
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