How to Decide When to Euthanize a Dog with Liver Failure
If you’re here because one of your canine buddies has liver failure, my heart goes out to you. Whether it came on gradually or suddenly, this disease can be a real challenge for dogs and their human friends.
As a general rule, I suggest euthanasia to my clients if their dog with liver failure stops eating for more than 48 hours. Other signs of poor quality of life include an inability to sleep well, repeated seizures, constant pain, soiling themselves and not wanting to interact with the family.
EUTHANIZING A DOG WITH LIVER FAILURE
How can I tell if my dog has a good quality of life?
Putting myself in your shoes, if my dog’s liver was in end-stage failure, I’d remind myself that the prognosis for recovery is less than 20% even with very good care. I believe I would make the decision to help them die a peaceful death rather than live in agony for another few days.
It’s never easy to decide when to euthanize a dog with liver failure but help is available.
I recommend you go through a good Quality of Life questionnaire before deciding to euthanize. I like the HHHHHMM Quality of Life Scale which gives you a more concrete evaluation than some others.
Quality of life questions focus on whether the animal can eat and drink, whether their pain can be treated, and how much they can participate in daily activities.
Answer the questions as objectively as possible. Get a trusted family member or friend to give their opinion, too. Take a day or two to weigh your choices carefully.
Is having liver failure painful for my dog?
Without speaking, dogs can still communicate whether they’re in pain or distress. You just need to watch them carefully and try to be objective when evaluating their behavior. Think about how your dog acts when he is happy and healthy.
Now compare some key activities to how he is now. Is he eating enthusiastically? Does he greet you when you come home? Is he able to get outdoors to potty when he needs to go?
I understand how scary it is watching your sick dog deteriorate. You feel helpless when you don’t know how to help him.
Please get your veterinarian involved. Even in cases where a dog is not expected to recover, we can often make them much more comfortable for the time they have left with you.
Maybe you’ve already given your dog prescribed medications and special food to try to help him feel better. If he’s still showing the behavior changes I mentioned above, he is probably suffering.
It’s at that point that I personally consider euthanasia as a humane option for my own pets.
Making the decision to say goodbye
When I think of the dogs I’ve treated with liver failure, it seems there is a spectrum of disease. Some dogs only have a picky appetite and an increased incidence of vomiting. Other dogs were so sick they couldn’t do anything besides lay on their side panting and trying to get comfortable.
It might seem obvious that the latter example would be a good candidate for euthanasia. But I know firsthand how hard it is to look at the situation objectively when it’s your furry family member.
After it’s all said and done, I frequently hear comments from my clients that they feel they waited too long to euthanize their sick pet. I’ve rarely if ever, heard anyone say they felt they euthanized a very sick pet too soon.
All the organs of the body are important in their own way but the liver does so many jobs it’s sort of extra important. It’s also a pretty tough organ that can regenerate even if most of it has been destroyed. Some of the jobs the liver does:
- Can create new red blood cells
- Produces proteins that aid blood clotting
- Creates bile acids for food digestion
- Metabolizes fats, carbohydrates and proteins
- Stores vitamins and minerals
- Removes toxins and drugs from the blood
- Supports with the immune system
What is liver failure in dogs?
Liver failure can be defined as a state of disease when liver function has decreased enough to cause severe illness. There are two main forms of liver failure: acute and chronic. Another common scenario is “acute on chronic” in which a dog with chronic disease suddenly gets a lot worse.
Acute Liver Failure (ALF)
In veterinary medicine, ALF has been defined as a sudden loss of greater than 75% of the functional hepatic mass (3).
Common causes of ALF include toxins, drug reactions, infectious disease, and parasites.
Dogs with ALF seem to have a slightly better chance at recovery than those with a slower onset of disease.
Chronic Liver Failure
Many dogs live with chronic liver disease that’s not bad enough to be called liver failure. Causes include copper accumulation, idiopathic (unknown cause), infections, and immune-mediated disease. When chronic disease progresses it causes cirrhosis and liver failure.
How does liver failure affect my dog’s body?
When the liver fails, many body systems are affected. Fluid builds up in the abdomen as less protein is produced by the organ and liver circulation becomes congested. Blood is slower to clot, infections are more likely and scarring of hepatic tissue ensues.
High ammonia levels build up because of decreased liver metabolism of protein. This leads to a condition that adversely affects the brain (hepatic encephalopathy). The body sometimes even tries to bypass a diseased liver with alternate blood circulation routes.
SYMPTOMS OF END-STAGE LIVER DISEASE
In a 17-year-long retrospective study of 49 dogs with acute liver insufficiency, the most common presenting symptoms were anorexia, vomiting, neurologic abnormalities, increased thirst and increased urination (5).
Some other common symptoms include:
|Poor Appetite||Nausea from blood toxins, gastritis secondary to liver failure|
|Vomiting||Nausea from blood toxins, gastritis secondary to liver dysfunction|
|Increased thirst||Physiological attempt to balance increased fluid loss and dilute blood toxins|
|Increased or decreased urination||Due to changes in thirst, electrolyte abnormalities, blood sugar abnormalities|
|Strange behavior (wandering, circling, vocalizing)||High blood ammonia levels, hepatic encephalopathy|
|Seizures||From the buildup of toxins in the blood, low blood sugar|
|Bruising or spontaneous bleeding||Abnormal blood clotting|
|Jaundice (often seen on skin, tongue/gums and white part of eyes)||Excess bilirubin in the blood|
|Edema (noticeable fluid collection in legs, underbelly, etc)||Abnormal lymph circulation or infection|
|Shaking||Reaction to toxin buildup or pain|
|Drooling||Secondary to nausea|
|Fever||Response to liver inflammation or infection|
|Diarrhea, may be bloody, orange or yellow colored||Abnormal blood clotting, poor digestion, increased bilirubin|
|Weight loss||Due to poor appetite, abnormal food metabolism|
|Distended abdomen/ascites (fluid in the abdomen)||Decreased albumin (a blood protein) production, increased pressure on liver blood vessels|
|Increased panting||Physiological attempt to balance blood gases, response to pain and nausea|
|Strong foul breath odor||Buildup of toxins in the blood|
|Dark yellow or orange urine||High bilirubin levels in blood|
|Bloody or blackish stool||Abnormal blood clotting|
|Increased infections||Poor liver function not supporting immune system|
|Crusting of lips, nose, feet, elbows and around the eyes||Rare-hepatocutaneous syndrome possibly due to cellular starvation and nutritional imbalances|
Which dog breeds are more prone to liver disease?
Any breed of dog can be affected by toxins, parasites and trauma. But there are some breeds that seem to have more liver problems than others. Some have more congenital problems like portosystemic shunts and others are suspected to lack normal de-toxifying processes.
- American Cocker Spaniel
- Anatolian Shepherd
- Australian Cattle Dog
- Australian Shepherd
- Bedlington Terrier
- Bichon Frise
- Cairn Terrier
- Clumber Spaniel
- Dandie Dinmont terrier
- Doberman Pinscher
- German Shepherd Dog
- Golden Retriever
- Irish Setter
- Irish Wolfhound
- Labrador Retriever
- Maltese Terrier
- Miniature and Toy poodles
- Miniature Schnauzer
- Old English Sheepdog
- Pembroke and Cardigan Welsh Corgis
- Scottish Terrier
- Shih Tzu
- Silky Terrier
- Skye Terrier
- Tibetan Spaniel
- West Highland White Terrier
- Yorkshire terrier
What causes liver failure in dogs?
In one 2016 study, the most common causes of canine liver failure were cancer (27%), presumed Leptospirosis (8%), and ischemia/disruption of blood supply (2%) (5). Over 900 different drugs, toxins and herbs have been identified as the cause for ALF (3).
Drugs are the one of the most common causes of fulminant liver failure in dogs (2). Some drugs cause direct injury to hepatic cells, but some drugs cause an idiosyncratic (unexpected) adverse reaction. Idiosyncratic reactions usually happen when the liver processes the drug into a toxic substance.
Drugs that are more likely to cause idiosyncratic toxic reactions are non-steroidal anti-inflammatory drugs, trimethoprim-sulfa, Lysodren, ketoconazole and azathioprine. There is no way to predict which dogs will have a problem and which ones won’t. The drug might be fine in most dogs but can cause a major problem in a few.
There are so many reports of different drugs, herbs and supplements causing liver problems in dogs, it would be impractical to list them all here. This list includes some of the more common culprits but ANY drug can cause an unexpected toxic reaction in any dog (9).
|Drug Type/Class||Drug Name(s)|
|Acetaminophen toxicity||Tylenol, Paracetamol|
|Amiodarone (heart medication)||Pacerone, Cordarone|
|Anabolic steroids||Stanozolol, Winstrol|
|Arsenicals (heartworm infection treatment)||Melarsomine (Diroban, Immiticide)|
|Antiadrenal drug (used for Cushing’s Disease)||Mitotane (Lysodren)|
|Anticonvulsant drugs||Phenobarbital (Luminal), zonisamide (Zonegran)|
|Antifungals||Griseofulvin (Gris-PEG), itraconazole (Sporanox),ketoconazole (Nizoral)|
|Antineoplastic drugs||CCNU (Lomustine), Crizotinib, pembrolizumab|
|Benzodiazepines||Diazepam (Valium, Diastat)|
|Halothane (gas anesthetic)||Fluothane|
|Non-steroidal antiinflammatories (NSAIDs)||Carprofen (Rimadyl), meloxicam (metacam), deracoxib (Deramaxx), firocoxib (Prevacox), ibuprofen, naproxen, aspirin|
|Sulfonamides||Trimethoprim sulfa (Tribrissen, Bactrim), sulfasalazine (Azulfidine)|
|Tetracycline antibiotics||Doxycycline (Vibramycin, Monodox, Sumycin), tetracycline (Tetracap)|
Infectious diseases can set up house in the liver, destroying cellular function and tissue structure. All dogs are susceptible, but younger dogs, those that spend a lot of time outdoors have a higher risk of contracting the following infections:
- Viral – Canine Adenovirus I (puppies)
- Bacterial – Leptospira, Salmonella, Rickettsial/tick-borne
- Fungal – Histoplasmosis, Blastomyces, Coccidioides
- Parasitic – Heartworms, protozoa
Congenital disease describes a problem present at birth. It may not become apparent until much later in life.
In normal dogs, nutrients are absorbed in the intestinal blood vessels and carried to the liver by the portal vein. A portosystemic shunt (PSS) is caused by abnormal blood vessels that bypass the liver. The result is that nutrients go directly to the body instead of being processed in the liver. The effect is similar to a dog that has a non-functional diseased liver. Some breeds with a risk of PSS are Yorkshire Terriers and Maltese Terriers.
Portal vein hypoplasia is another anatomic anomaly that prevents blood from circulating through the liver properly. Breeds that may inherit this problem include Yorkshire Terriers, Maltese, Cairn Terriers and German Shepherds.
Copper storage hepatopathy (CSH) has a complex genetic basis. It happens when too much copper is stored in the liver. It can be caused by an inability to excrete copper or excess copper in the diet of susceptible dogs. Breeds with a higher rate of CSH include Bedlington Terriers, Dalmatians, Labrador Retrievers, Doberman Pinschers and West Highland White Terriers.
The world is full of potential liver toxins and dogs like to eat lots of things they shouldn’t. Sometimes it’s a chewed ornamental plant from your yard or a fungal contaminant in dog food. Sometimes we never figure out where the toxin came from.
Some common toxins that can cause liver failure in dogs:
|Aflatoxin||Toxins produced by certain molds. Dog food can cause liver failure if it contains high levels of aflatoxin.|
|Amanita phalloides (Death Cap), Amanita virosa (Destroying Angel) & various other mushrooms||Wild-growing fungi contain strong toxins that affect the liver|
|Blue Green Algae (cyanobacteria)||Type of bacteria that grows in water that is highly toxic to humans and animals|
|Chemicals, industrial solvents and heavy metals||Lead (ammunition, batteries), zinc (pre-1982 pennies)|
|Pennyroyal oil||Plant-derived oil used medicinally in humans and as a flea repellant in animals|
|Sago palm||Ornamental plant|
|Xylitol (1)||Sugar substitute used to sweeten many human foods|
The pancreas is a digestive and endocrine organ situated very close to the liver. Inflammation of the pancreas, a.k.a. pancreatitis is very common in dogs. In severe cases, the liver can be damaged by leakage of pancreatic enzymes into the tissues of the abdomen.
Primary liver cancer in dogs is pretty uncommon. It accounts for less than 1.5% of all cancers in dogs (7).
Metastatic cancer of the liver is much more common. That means it has seeded to the organ from another site in the body. Metastases from cancers like hypodermal hemangiosarcoma affecting other organs are more likely to occur in senior dogs.
Dogs with liver cancer may show typical signs of liver failure or instead they may have acute internal bleeding with no signs of liver failure. Hence, the final stage of dog liver cancer before death may be sudden weakness, pale gums, fast/weak pulse, abdominal pain and swelling.
How is dog liver failure diagnosed?
- Physical exam- a shrunken or enlarged liver, yellowed skin, abdominal pain, abdominal fluid wave/ascites
- Blood tests: elevated liver enzymes, especially ALT (alanine aminotransferase). Concern when it is 4 times or more above the high end of the normal range–a dog liver enzyme ALT above 500 U/L is a sign of severe liver disease. But sometimes these numbers go back down in end-stage liver failure. Bilirubin is also elevated above 2.9 mg/dL (10). Bile acids testing checks liver function in less severe cases where the diagnosis is not clear. Blood clotting tests are usually prolonged, too.
- Ultrasound imaging
- Biopsy-can often be done without doing invasive surgery
Dog Liver Enzymes Normal Range Chart
|Liver Test||Normal Range|
|Bilirubin, total||0-0.5 (mg/dL)|
How is liver failure treated?
The first goal is to identify the cause of liver disease and treat it appropriately. It’s not always possible to find the cause and not all underlying diseases have a specific treatment.
Supportive care is an important part of dog liver disease treatment. Anti-nausea medication, antibiotics and general liver support such as usodeoxycholic acid and SAM-e are often used. Therapeutic diets can be helpful if your dog is still eating.
Dogs who are unable to eat or have extreme symptoms of liver failure require hospitalization. Treatments for severe cases include IV fluid therapy, therapeutic enemas and plasma transfusions.
Can dogs get a liver transplant?
Technically, it is possible to give a dog a liver transplant from a donor dog. The reason it’s not done routinely is partly that it’s cost-prohibitive. The other reason is that graft rejection is a very big problem that is hard to control in dogs.
A related treatment that shows promise is stem cell therapy. A Chinese study published in 2019 showed that canine adipose-derived mesenchymal stem cells injected intravenously helped restore some level of liver function in dogs with experimentally-induced liver damage (10).
This research is encouraging but stem cell therapy in dogs has a long way to go to prove it’s safe and effective.
What is the life expectancy for dogs with liver failure?
The life expectancy of dogs with liver failure is usually a few days to weeks. Even dogs with chronic disease have a poor prognosis once they develop a bilirubin level over 2.9 mg/dL, blood clotting abnormalities or hepatic encephalopathy.
The good news is that the liver is an amazing organ that can regenerate even if 80% of its mass has been destroyed (4).
Even so, most dogs with signs that their liver has lost function have a poor prognosis. Liver injuries that happen very suddenly may have a better outcome than those that happen over a more prolonged period of time.
A retrospective study of 49 dogs treated for acute liver insufficiency found that only 7 dogs, about 14% of all cases studied, survived and were discharged. Dogs with normal albumin and blood clotting and without ascites were more likely to survive (5).
One parameter used by your veterinarian to gauge the severity of the situation is whether the prothrombin time (a measure of blood clotting) is greater than 100 seconds. If it is, it indicates a grave prognosis (7). Death would be expected to occur within a few days.
Even if a dog is able to get past the acute stage of liver failure, there is a chance they may progress on to widespread liver cirrhosis (scarring) rather than healing. If this happens, they could survive longer but would be expected to have significant clinical signs of canine liver disease.
Dogs with chronic hepatitis can survive a long time with good supportive care from you and your veterinarian, depending on the details of the situation. I’ve worked with plenty of dogs who have had waxing and waning symptoms of liver insufficiency for years.
Can my dog recover from liver failure?
The prognosis for dogs with acute liver injury/insufficiency is not good. Greater than 80% of these dogs die in spite of all treatment. Those with chronic liver disease have a better chance of long-term survival depending on the cause and whether a specific treatment is available.
In general, once a dog has reached end stage liver disease the prognosis for recovery is poor.
What should I feed my dog with end-stage liver disease?
It’s EXTREMELY important to consult with your veterinarian about the best food to choose in this situation.
In general, owners of dogs with end-stage liver disease are advised to avoid foods high in protein. A diseased liver cannot process protein normally and nutritional protein contributes to high blood ammonia levels.
Prescription diets like Hill’s l/d are formulated with a limited amount of highly digestible protein to minimize ammonia formation while providing enough amino acids to support normal metabolism.
You could opt to use a homemade diet, but please, please get help from a veterinary nutritionist. Your dog will probably love eating fresh food but if you don’t use the right recipe you could make things worse.
I recommend you and your vet work with the experts at BalanceIT.com to develop a custom recipe for your dog’s specific needs. It’s not expensive and you may even be able to get a FREE recipe, depending on your dog’s nutritional needs. The recipes are simple and use common ingredients like potatoes and eggs.
Feeding your dog 3 to 4 times a day may help since it puts less of a load on the liver to metabolize nutrients at one time.
If your dog is nauseous, ask your vet about anti-nausea treatments. Many drugs can cause problems for dogs with severe hepatic disease, so don’t assume you can use something left over from a past prescription or prescribed for a different pet.
Deciding when to euthanize a dog with liver failure should be based on basic quality of life questions. The underlying cause of illness and the prognosis given by a veterinarian will help guide your decision.
Dog euthanasia is a viable option if your dog won’t eat, has nausea, vomiting, diarrhea, can’t walk and seems uncomfortable most of the time. If most days are bad days, deciding to euthanize your dog will spare him the suffering he might have to endure for days before dying naturally.
- Dunayer, E. K., & Gwaltney-Brant, S. M. (2006). Acute hepatic failure and coagulopathy associated with xylitol ingestion in eight dogs. Journal of the American Veterinary Medical Association, 229(7), 1113-1117.
- Guilford WG, et al. In: Center SA, ed. Strombeck’s Small Animal Gastroenterology, 1996; 654.
- Hackett, T., DVM, MS, DACVECC. (2011). Critical Care Management of Acute Liver Failure in Dogs & Cats. In American College of Veterinary Internal Medicine (ACVIM) forum 2011: Denver, Colorado, USA, 15-18 June 2011. Lakewood, CO, CO: American College of Veterinary Internal Medicine. Retrieved March 26, 2021.
- Johnson, Tony, DVM, DACVECC. Acute Hepatic Failure: Yellow Is Not So Mellow. In International Veterinary Emergency and Critical Care Symposium 2014: Veterinary Information Network, Davis, CA, USA. Retrieved March 26, 2021.
- Lester, C., Cooper, J., Peters, R. M., & Webster, C. R. (2016). Retrospective evaluation of acute liver failure in dogs (1995-2012): 49 cases. Journal of Veterinary Emergency and Critical Care, 26(4), 559-567.
- Plumb, D. C. (2018). Plumb’s Veterinary Drug Handbook: Desk. John Wiley & Sons.
- Scherk MA, Center SA: Toxic, Metabolic, Infectious, and Neoplastic Liver Diseases. . St. Louis, Saunders Elsevier 2010 pp. 1687-1689.
- Twedt, David C., DVM, DACVIM. Acute Liver Disease. In American Board of Veterinary Practitioners (ABVP) forum 2014: Department of Clinical Sciences, College of Veterinary Medicine & Biomedical Sciences, Colorado State University, Fort Collins, CO, USA. Retrieved March 26, 2021.
- Weingarten, M. A., & Sande, A. A. (2015). Acute liver failure in dogs and cats. Journal of Veterinary Emergency and Critical Care, 25(4), 455-473.
- Yan, Y., Fang, J., Wen, X., Teng, X., Li, B., Zhou, Z., … & Hua, J. (2019). Therapeutic applications of adipose-derived mesenchymal stem cells on acute liver injury in canines. Research in veterinary science, 126, 233-239.