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<Provider Id="sundheddkcms"> <Item Id="{75EB2C74-7EE0-4008-BCAE-16072A7C2C82}" Name="fib4" Type="LHContentPage" ParentProviderId="sundheddkcms" ParentItemId="{954990FB-BCA1-4322-A1A9-62D3FD4B2E07}" SortOrder="13200" PublishDate="2020-07-14T00:00:00" DeleteDate="2999-12-31T00:00:00" PotItemType=""> <Content> <HtmlField Name="PageContent"><![CDATA[<h2>Definition</h2> <ul> <li>FIB-4 (Fibrosis-4) er en beregnet score, der bruges til at estimere sværhedsgraden af leverfibrose. Den anvendes generelt ved fibroseudredning og hos patienter med nonalkoholisk fedtleversygdom</li> <li>Scoren kan bruges både hos voksne og muligvis hos børn</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 leverkræft</li> <li>Udredning af patienter mistænkt for NASH omfatter: <ul> <li>Billeddiagnostik (ultralydsskanning af leveren)</li> <li>Almindelige blodprøver, herunder ALAT, ASAT, basisk fosfatase, bilirubin, trombocytter, INR, albumin, HbA1c</li> <li>Blodprøvebaserede fibrosetests, heriblandt FIB-4, en score beregnet ud fra patientens alder og laboratoriemålinger af ASAT, ALAT samt trombocyttal</li> <li>Evt. leverbiopsi</li> </ul> </li> <li>Dansk Selskab for Gastroenterologi og Hepatologi anbefaler måling af FIB-4 hos patienter mistænkt 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 <span style="background-color: #ffffff; letter-spacing: 0.1px; color: #1b1b26;">patienter med overvægt, type-2 diabetes eller tilfældig påvisning af enten steatose (ultralydsskanning) eller forhøjede levertal. </span>Scoren er også 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> og er tilgængelig som laboratorieanalyse i alle regioner i Danmark. Ved rekvisition af FIB-4-bestemmelse bestilles automatisk ASAT, ALAT og trombocytter, og scoren beregnes efter formlen: </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 svær eller ingen fibrose. Den negative prædiktive værdi for at ekskludere svær fibrose er bedre end den positive prædiktive værdi for forekomsten af fibrose. Således kan FIB-4 udpege patienter med lav risiko for fibrose, hvorimod identificeringen af patienter med betydende fibrose er behæftet med større usikkerhed</li> <li>FIB-4 bør rekvireres på 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 mistænkt for NAFLD og henvise patienter med høj score (<span style="background-color: #ffffff; letter-spacing: 0.1px; color: #1b1b26;">FIB-4 over 2,67)</span> til nærmere 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 </h3> <p>NPU58634 Pt—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 været foreslået forskellige FIB-4 grænser for lav, mellem og høj risiko for fibrose. I en statusartikel fra Ugeskrift for Læger 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 grænser som til dels bygger på nyere europæiske 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 foreslås følgende: <ul> <li>Er FIB-4 < 1,3, er risikoen for fibrose lav, og der kræves ikke andet end almindeligt fokus på relevante livsstilsændringer</li> <li>Er FIB-4 mellem 1,3 og 2,67, er risikoen for fibrose moderat, og man kan fx gentage testen efter 6 måneders livsstilsintervention og henvise til gastroenterologisk/hepatologisk hospitalsudredning, hvis ikke scoren forbedres sv.t. en lav risiko</li> <li>Er FIB-4 over 2,67, bør patienten henvises til hospitalsudredning i gastroenterologisk/hepatologisk regi</li> </ul> </li> </ul> <h2> Prøvetagning</h2> <ul> <li>Veneblodprøve</li> <li>Kan udføres døgnet rundt med kort svartid (1-2 timer)</li> <li>Prøvematerialet er holdbart i 1 dag ved 4°C</li> </ul>]]></HtmlField> <LinkListField Name="Spot2"> <LinkField linktype="internal">{99A85AFD-2F7A-4B5D-A1C9-C2701D5E7D30}</LinkField> </LinkListField> <TextField Name="DoctorsHandbookID">40491</TextField> <TextField Name="PageTitle">FIB4</TextField> <TextField 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]]></Media> 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