Abstract: Background and aims: A two-step assessment with fibrosis index-4 (FIB-4) and transient elastography has been established as an appropriate screening strategy for liver fibrosis in >50 years old with metabolic risk factors. However, a screening program needs to guarantee the greatest accessibility for the population at risk. Our aim was to determine the prevalence of high risk of advance fibrosis (AdF) by FIB-4 in the general population and, therefore, subjects susceptible to undergo a second fibrosis assessment. Method: Cross-sectional study in Spain based on general population that included subjects aged 50-70 from: A) Cantabria Cohort (volunteers and random sampling of the entire population of Cantabria -585,222 inhabitants-) enrolled from October 2021 to April 2022; B) Santander health area (315, 000 inhabitants) who had an analysis from Primary Care between August-October 2021. The risk of AdF was determined using FIB-4: low risk (FIB-4 65 years), intermediate risk (1.3-2.67/2.0-2.67 in >65 years) and high risk (>2.67). Results: From Cantabria cohort, 6,687 subjects were included (mean age 58.7 ± 5.8; 41.0% men; 23.6% obese). 2,545 subjects (38.1%) had an intermediate risk, and 155 subjects (2.3%) had a high risk. No differences were found in the prevalence of high risk of AdF between obese and non-obese subjects (2.0% vs. 2.3%; p = 0.4). FIB-4 could be calculated in 16,263 of the subjects in the Santander health area (mean age 60.4 ± 6.0; 41.7% men). Intermediate risk was observed in 5,185 cases (31.9%) and high risk in 498 (3.1%), similar to the general population cohort (Fig). Conclusion: In a health area of 315,000 inhabitants, a two-step fibrosis screening strategy in subjects aged 50-70 years, without considering metabolic factors, would entail the application of a second test in approximately 1500 subjects/month and, therefore, this implies that approximately 150 subjects/month need to be referred to a specialized consultation; which is a number of patients that can be assumed by the Hepatology unit service of a tertiary referral hospital.

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