MASLD Practice Exam: Diabetes Chapter 42

Formerly known as Non-Alcoholic Fatty Liver Disease (NAFLD), Metabolic Dysfunction-associated Steatotic Liver Disease (MASLD) affects up to 70% of people with Type 2 diabetes. The 2024 Clinical Practice Guidelines Update introduces a major paradigm shift: moving from passive observation to active screening for liver fibrosis to prevent cirrhosis and liver-related mortality.

This practice exam tests your ability to apply the new nomenclature, utilize the recommended two-step screening algorithm, and select appropriate pharmacotherapy that addresses both metabolic and hepatic health.

Key Concepts Covered in This Exam:

New Nomenclature: Recognizing the shift from NAFLD to MASLD to more accurately reflect the pathophysiology driven by metabolic dysfunction.
Screening Algorithm: Mastering the two-step screening strategy for adults with Type 2 diabetes: utilizing the FIB-4 index (based on age, AST, ALT, and platelet count) as the initial triage tool every 3 years.
Advanced Assessment: Knowing when to refer for second-line non-invasive testing, such as Vibration Controlled Transient Elastography (VCTE/FibroScan) or the Enhanced Liver Fibrosis (ELF) test, for patients with indeterminate or high FIB-4 scores.
Pharmacotherapy: Identifying GLP-1 receptor agonists (semaglutide, liraglutide) and SGLT2 inhibitors as preferred agents for patients with T2D and MASLD, and the specific role of pioglitazone in improving liver histology in confirmed steatohepatitis (MASH).
Statin Safety: Reinforcing that statins are safe and indicated for cardiovascular risk reduction in patients with MASLD and should not be withheld due to mild liver enzyme elevations.

1. What negative predictive value does a FIB-4 score <1.3 have for ruling out advanced liver fibrosis?

95%
75%
99%
85%

2. A multidisciplinary team is discussing the care of patients with T2D and MASLD. Which statement best reflects guideline recommendations for cardiovascular risk management?

Statins should be avoided in all patients with liver disease
Only lifestyle modifications are recommended for CV risk reduction
Cardiovascular protection is crucial
Cardiovascular protection is secondary to liver-specific treatments

3. According to the updated nomenclature, what is the current term for the condition previously known as nonalcoholic fatty liver disease (NAFLD)?

Metabolic-associated steatohepatitis (MASH)
Metabolic dysfunction–associated steatotic liver disease (MASLD)
Hepatic steatosis syndrome (HSS)
Metabolic dysfunction–associated fatty liver disease (MAFLD)

4. What minimum sustained weight loss percentage is recommended to potentially reverse liver fibrosis?

≥10%
≥15%
≥5%
≥3%

5. What is the relationship between hepatic steatosis and the development of type 2 diabetes?

T2D must precede hepatic steatosis
There is no relationship between the two conditions
Hepatic steatosis is protective against T2D development
Hepatic steatosis increases the risk of developing T2D

6. Case: A 48-year-old man with T2D and decompensated cirrhosis is on statin therapy. What is the appropriate action?

Increase the statin dose for enhanced CV protection
Continue statin therapy as usual
Switch to a fibrate
Discontinue statin therapy

7. Case: A 62-year-old man with T2D, BMI 31 kg/m², and FIB-4 of 2.4 has transient elastography showing LSM of 6.5 kPa and ELF of 7.2. How should these results be interpreted?

High probability of advanced fibrosis; refer to hepatology immediately
Only the FIB-4 score should be used for clinical decision-making
LSM <8 kPa and ELF <7.7 suggest no advanced fibrosis
Results are discordant; liver biopsy is required

8. Case: A patient with MASLD cirrhosis (F4) asks about surveillance. How often should hepatocellular carcinoma (HCC) screening be performed?

Every 3 months
Every 6 months
Every 2 years
Annually

9. Case: A healthcare team is reviewing noninvasive tests for MASLD in their T2D population. The team discusses that diagnostic tests may have lower performance in people with T2D. What is the clinical implication?

Noninvasive tests should not be used in T2D populations
All patients with T2D require liver biopsy for diagnosis
Findings from non-T2D populations should not be directly extrapolated to T2D patients
FIB-4 is more accurate in T2D than in non-diabetic populations

10. What is the primary determinant of adverse hepatic and non-hepatic outcomes in people living with MASLD?

Degree of hepatic steatosis
ALT and AST levels
Degree of liver fibrosis
BMI classification

11. What ELF (Enhanced Liver Fibrosis) score threshold indicates high risk of advanced fibrosis requiring specialist referral?

≥10.5
≥6.0
≥9.0
≥7.7

12. A patient with T2D and MASLD asks about statin therapy. The patient has compensated cirrhosis. What is the appropriate recommendation?

Statins should be stopped immediately due to hepatotoxicity risk
Statins are contraindicated in all liver disease
Statins can be continued for cardiovascular risk reduction
Statins should only be used if ALT is normal

13. By how much does type 2 diabetes increase the risk of advanced liver fibrosis compared to the general population?

8- to 10-fold
3- to 4-fold
2- to 3-fold
5- to 6-fold

14. Case: A clinical team is evaluating a 47-year-old woman with T2D who consumes 180 g of alcohol per week. She has hepatic steatosis on imaging and metabolic syndrome criteria. How should her liver disease be classified?

Pure MASLD
Alcoholic liver disease (ALD)
MetALD
Cryptogenic steatotic liver disease

15. Case: A diabetes educator is developing a screening protocol for MASLD in a diabetes clinic. The clinic has limited access to specialists and advanced testing. Based on the guidelines, what is the most appropriate first-line screening strategy?

Ultrasound for all patients with T2D to detect hepatic steatosis
Refer all patients with T2D directly to hepatology
Calculate FIB-4 score using routine laboratory values
Order liver biopsy for all patients with elevated ALT

16. What percentage of individuals with T2D have metabolic-associated steatohepatitis (MASH)?

12%
37%
24%
54%

17. Case: A clinical pharmacist is reviewing the evidence for resmetirom in MASLD treatment. Based on the guidelines, what is the current status of this medication in Canada?

Resmetirom is approved for type 1 diabetes only
Resmetirom received FDA approval but was not approved by Health Canada
Resmetirom is Health Canada approved and widely available
Resmetirom has been rejected by all regulatory agencies

18. What is MetALD?

Metabolic syndrome without hepatic steatosis
MASLD occurring in individuals with type 1 diabetes
MASLD combined with alcohol intake above MASLD limits but below ALD thresholds
A severe form of MASLD with rapid progression

19. Up to what percentage of individuals with advanced liver fibrosis may have normal transaminase levels (ALT, AST)?

10%
5%
15%
25%

20. Which laboratory values are required to calculate the FIB-4 score?

Age, BMI, albumin, and platelet count
Age, AST, ALT, and platelet count
Age, AST, albumin, and INR
AST, ALT, GGT, and bilirubin

21. Case: A 54-year-old patient with T2D and MASH (F2 fibrosis) has been on pioglitazone for 12 months with good glycemic control but limited weight loss (3%). The patient asks if adding a GLP-1 RA would provide additional hepatic benefits. Based on the guidelines, what is the most appropriate response?

There is no evidence for combining these medications
The combination improves diabetes management and is associated with weight loss
Only one agent should be used for MASH treatment
GLP-1 RAs should never be used with pioglitazone

22. Case: A 50-year-old woman with T2D has intermediate FIB-4 (2.1) but transient elastography is unavailable locally. What is the alternative approach?

Wait until transient elastography becomes available
No further evaluation is needed
Proceed directly to liver biopsy
Direct referral to gastroenterology/hepatology may be considered

23. What is the leading cause of death in people living with MASLD?

Cardiovascular disease
Hepatocellular carcinoma
Renal failure
Liver cirrhosis

24. A diabetes educator is counselling a patient about the relationship between diabetes duration and liver complications. Based on the evidence, which statement is most accurate?

Diabetes duration >10 years increases HCC risk
Diabetes duration has no effect on liver outcomes
HCC risk decreases with longer diabetes duration
Only patients with diabetes for >10 years develop liver fibrosis

25. Case: A patient with T2D and MASLD without obesity (BMI 23 kg/m²) asks about weight loss recommendations. What should be advised?

Focus only on glycemic control
No weight loss is needed since they are not overweight
Bariatric surgery is recommended
Weight loss of 3–5% is still encouraged

26. Which fibrosis stages are classified as “advanced fibrosis” in MASLD?

F2–F3
F3–F4
F2–F4
F1–F2

27. Which dietary pattern has shown the most consistent benefits for improving insulin resistance and reducing MASLD severity?

Ketogenic diet
Low-fat vegan diet
Mediterranean diet
Carnivore diet

28. What FIB-4 score threshold indicates a LOW probability of advanced liver fibrosis?

<0.5
<2.67
<2.0
<1.3

29. Case: A patient with T2D and MASLD is considering bariatric surgery. They have BMI 38 kg/m² and have been unsuccessful with lifestyle modifications. They have compensated cirrhosis. What is the most appropriate recommendation based on the guidelines?

Bariatric surgery may be considered
Bariatric surgery is contraindicated in all patients with MASLD
Bariatric surgery should be delayed until cirrhosis completely resolves
Bariatric surgery is only indicated if BMI exceeds 40 kg/m²

30. Case: A patient with T2D has the following: BMI 28 kg/m², triglycerides 1.9 mmol/L, HDL-C 0.9 mmol/L (male), BP 138/86 mmHg. Which cardiometabolic criteria for MASLD evaluation does this patient meet?

Only overweight/obesity
Overweight/obesity, dyslipidemia, and hypertension
None of the criteria
Overweight/obesity and hypertension only

31. Case: A 52-year-old man with type 2 diabetes has a FIB-4 score of 1.8. What is the most appropriate next step?

Immediate referral to hepatology
No further workup needed
Further evaluation with liver stiffness measurement
Schedule liver biopsy

32. A policy committee is considering recommendations for MASLD screening in the T2D population. Which statement best supports the rationale for universal screening with FIB-4?

All patients with T2D will eventually develop cirrhosis
Hepatic steatosis is the primary driver of adverse outcomes
FIB-4 is cost-effective, uses routine lab values
Transient elastography is required for all patients

33. Which tests are used for HCC surveillance in patients with MASLD cirrhosis?

Ultrasonography and serum alpha-fetoprotein
CT scan and CA-125
MRI and CEA
PET scan and liver biopsy

34. Case: A 58-year-old patient with T2D, MASLD, and F2 fibrosis is currently on metformin monotherapy with suboptimal glycemic control. The physician is considering adding pioglitazone. What potential benefit for MASLD may this provide?

Resolution of steatosis only
May reduce steatohepatitis and progression of fibrosis
No hepatic benefit expected
Guaranteed reversal of cirrhosis

35. Case: A 45-year-old woman with prediabetes has a FIB-4 score of 0.9. How should she be managed?

Refer to gastroenterology for further evaluation
Manage metabolic syndrome in primary care
Start pharmacotherapy for MASLD
Order transient elastography immediately

36. What percentage of people with type 2 diabetes are estimated to have MASLD globally?

Approximately 69%
Approximately 88%
Approximately 48%
Approximately 21%

37. What liver stiffness measurement (LSM) threshold on transient elastography indicates high risk of advanced fibrosis?

≥5 kPa
≥8 kPa
≥12 kPa
≥6 kPa

38. Case: A patient with T2D and MASH asks about vitamin E supplementation. What should be explained?

Vitamin E is recommended for all patients with MASH
Vitamin E is not recommended for people with T2D
Vitamin E significantly reduces liver fibrosis in T2D patients
Vitamin E should be the first-line treatment as an adjunct

39. Case: A 55-year-old man with T2D and MASLD with F3 fibrosis needs antihyperglycemic therapy optimization. Which of the following agents may be preferentially considered?

Canagliflozin
Glyburide
Pioglitazone
Metformin

40. Case: A 55-year-old woman with T2D has a FIB-4 score of 3.2. What is the recommended management?

Referral to hepatology
Manage in primary care with lifestyle interventions
Repeat the FIB-4 calculation in 3 months
Order transient elastography and reassess in 6 months

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