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

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

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

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

3. 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
Proceed directly to liver biopsy
No further evaluation is needed
Direct referral to gastroenterology/hepatology may be considered

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

Every 3 months
Annually
Every 2 years
Every 6 months

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

6. 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
Weight loss of 3–5% is still encouraged
Bariatric surgery is recommended
No weight loss is needed since they are not overweight

7. 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?

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

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

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

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

≥9.0
≥10.5
≥6.0
≥7.7

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

≥6 kPa
≥12 kPa
≥8 kPa
≥5 kPa

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

Low-fat vegan diet
Mediterranean diet
Carnivore diet
Ketogenic diet

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

≥3%
≥10%
≥15%
≥5%

13. 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
Cardiovascular protection is secondary to liver-specific treatments
Only lifestyle modifications are recommended for CV risk reduction
Cardiovascular protection is crucial

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

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

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

F1–F2
F3–F4
F2–F3
F2–F4

16. 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?

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

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

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

<1.3
<0.5
<2.0
<2.67

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

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

20. 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?

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

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

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

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

5%
10%
25%
15%

23. 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
Calculate FIB-4 score using routine laboratory values
Refer all patients with T2D directly to hepatology
Order liver biopsy for all patients with elevated ALT

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

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

25. 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?

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

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

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

27. 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

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

Cardiovascular disease
Hepatocellular carcinoma
Liver cirrhosis
Renal failure

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

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

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

85%
75%
99%
95%

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

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

32. 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?

Results are discordant; liver biopsy is required
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

33. 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?

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

34. 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?

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
There is no evidence for combining these medications

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

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

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

12%
37%
24%
54%

37. 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?

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

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

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

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
Pioglitazone
Metformin
Glyburide

40. 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

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