Liver Disease in Dogs
Disclaimer: I am not a veterinarian, nor do I have any formal training in any medical field. The information presented here is not meant to replace your vet's advice or prescribed medications, but only to suggest additional options to explore, based on your dog's condition.
Diet for dogs with liver disease is controversial. I have often seen low protein diets recommended, but recent studies indicate that too little protein can actually make liver problems worse. Low fat is also often recommended, but is only needed for dogs having problems with fat malabsorption. Dogs need fat for energy, and again, too little can cause problems. A low-purine (not low-protein) diet is recommended for dogs with liver shunts (see below for more info).
Please remember that mildly elevated liver enzymes do not necessarily indicate liver disease. Check out the following excerpts from Diagnosing Liver Disease: A Roundtable Discussion:
"So the question becomes, “What percentage of animals with abnormal liver enzyme activities truly have liver disease?” I suspect it’s less than 10%."See the chart on page 10, "The steps for Investigating Liver Disease," for some easy to follow input on liver tests.
"Something as simple as dental disease may be causing the increased liver enzyme activities."
"Out of 100 dogs with a twofold or threefold ALT elevation, only a few develop liver disease requiring treatment."
"In animals with twofold to threefold ALT increases, I’d recheck them in three to four weeks. If the enzyme activities are persistently high—that red flag has gone up two or three times—practitioners need to pursue additional diagnostics, even in clinically normal animals."
"I perform additional diagnostics immediately in patients with a fivefold to sevenfold increase in ALT activity, even if they don’t have clinical signs. But in cases with up to fivefold ALT elevations, I monitor them and add other tests as needed."
"Of my canine patients with greater than fourfold ALKP elevations, about 80% have Cushing’s disease, long-term corticosteroid administration, or some other condition—not cholestatic disease. So I would say 20% of dogs with fourfold ALKP elevations have cholestatic disease, but that’s purely an estimate."
"The bottom line is that if practitioners obtain abnormal serum bile acid concentrations in patients that probably don’t have liver disease (based on the entire clinical picture), they should consider malabsorption diseases, such as small intestinal disease and pancreatic insufficiency, which are often associated with changes in the intestinal microflora."
In general, no diet changes are needed unless your dog has problems with hepatic encephalopathy, fat malabsorption, or has a liver shunt (more info below). Dogs with severe liver disease will benefit from dietary changes, supplements and medications, but dogs with mildly elevated liver enzymes do not require a change in diet. Liver-supportive supplements can be given at any stage if desired.
Hepatic encephalopathy (HE) is the name given to neurological problems caused by the build-up of ammonia in the dog's system due to liver failure. Symptoms may include tremors, seizures, head pressing, staggering, circling, pacing, blindness, and behavioral changes. See this video for an example of a dog suffering from hepatic encephalopathy: Liver Shunt Behavior in a Yorkie named Ginger
If your dog is showing signs of hepatic encephalopathy, it is important to reduce the amount of ammonia in the system. This is when protein restriction may become necessary. Red meat produces more ammonia and should only be used in very limited amounts or not at all. Cottage cheese (and other dairy products) and eggs are good sources of low ammonia-producing protein. Even in dogs with HE, you must be careful not to reduce protein too much, as protein malnutrition can result, leading to ascites and other problems.
Lactulose is a prescription soluble fiber supplement usually recommended to help reduce ammonia if signs of hepatic encephalopathy are present. Antibiotics such as Amoxicillin, metronidazole, and neomycin, which kill ammonia-producing bacteria and thus lessen the amount of ammonia exposure, are also given to dogs with HE.
Feeding several small meals daily, rather than one or two larger meals, can also reduce signs of HE.
See Feeding Dogs with Hepatic Encephalopathy for more information.
Dogs with portosystemic shunts (PSS) have specific dietary requirements that are different from dogs with other types of liver disease. While surgery is the treatment of choice, dogs with liver shunts can benefit from a low-purine diet, to prevent the formation of urate bladder stones (uroliths). Lowering purines does not require that you feed a low-protein diet, which would be contraindicated. It is important to feed proteins that are high-quality and low in purines. High-protein foods that are low in purines include dairy, such as cottage cheese (better to use low-sodium varieties), ricotta cheese and yogurt, as well as eggs. White fish, chicken, and turkey are medium-purine foods that are still good to feed. Organ meats, seafood and soy have a high purine content.
Dalmatians often have a metabolic condition that requires a low-purine diet. See my article on Urate, Cystine and Other Less Common Urinary Stones for more information, including info on the level of purines in various foods.
Sojo's Complete uses turkey and eggs for protein, and does not appear to have any high-purine ingredients, so it might work as a low-purine diet. You may still want to add some eggs and dairy for increased nutrition.
Note that vegetarian diets are sometimes recommended. I'm not a fan of vegetarian diets for dogs, and think they can be dangerous (see this article for more information). However, you might be able to use a commercial vegetarian diet as a base, and then add low-purine, animal-protein foods such as eggs and dairy. Avoid foods that contain soy, cauliflower, spinach, asparagus, peas, mushrooms and legumes (beans). Compare the ingredients to those listed on the sites above to check for other high-purine foods.
See the following for more information on dogs with liver shunts:
- Apparent dietary protein requirement of dogs with portosystemic shunt (this study shows that dogs with liver shunts need normal amounts of protein, not low-protein diets)
- Congenital Portosystemic Shunt
- Recognition and Management of Portosystemic Shunts in Dogs
- Portosystemic Shunts
- Can clinical signs and laboratory data be used to differentiate between acquired and congenital portosystemic shunts?
You may want to join the Liver Shunt and MVD Support group for more information.
A recent study showed that the use of levetiracetam at 20 mg/kg given orally every eight hours for a minimum of 24 hours prior to surgical extrahepatic PSS correction with an ameroid constrictor significantly decreased the risk of postoperative seizures and death.
Current research indicates SAM-e (S-Adenosyl-L-Methionine) may be beneficial for liver problems -- give 200 mg twice a day to a large dog (recommended dosage is 10 mg per pound of body weight daily). SAMe is best given on an empty stomach, at least one hour before or two hours after eating (longer is better). Puritan's Pride and Vitacost have the best prices I've found; Costco also has good prices, as do iHerb and Sam-e Source. If you have a small dog, you may need to use the veterinary drug Denosyl, which is just SAMe but comes in a 90 mg size, see VetAmerica for better prices (they also now offer a generic 100 mg version which would be fine for small dogs), though these are not in blister packs and may be affected by moisture. Now Foods also offers 100 mg size. You can also give Denamarin, which is a combination of SAM-e and milk thistle extract (silybin). When giving SAM-e, you should also give a B-vitamin supplement, which is good for the liver as well.
There are several herbal products that are recommended for dogs with liver disease:
Hepato Support by Rx Vitamins is a high-quality supplement that contains milk thistle, B vitamins, choline, dl-methionine and alpha lipoic acid. DiscountNutritionShop has the best price I found for 90 capsules and 180 capsules, although I don't know if they are reputable or not (there are a number of complaints filed against them with the BBB). Also available at PureFormulas.
Country Life BioChem Liver Support Factors, which contains milk thistle and a variety of other herbs, seems to work better than milk thistle alone. See Liver Support Factors for a couple of reliable first-person accounts of how this supplement helped their dogs.
Skin and Liv-A-Plex is an herbal tincture (liquid) that contains milk thistle. Recommended dosages of milk thistle alone range from 50 to 200 mg two or three times a day.
Hepagen-C by Thorne Research contains milk thistle, alpha-lipoic acid, and other liver-supportive ingredients.
Picrorhiza, an Ayurvedic (Indian) herb, has been shown to be even more effective than milk thistle for treating liver problems, but I haven't heard any direct reports from anyone who has used it.
A 2003 study from Korea demonstrated that Korean red ginseng significantly improved liver function and accelerated regeneration of the liver in experimental dogs following partial hepatectomy (this is not the same as other forms of ginseng)..
Note that many liver supplements contain similar ingredients, so if you give more than one at a time, you may be overdosing some things. For example, Liver Support Factors contains 100 mg of l-methionine per tablet, which is part of the s-adenosyl-methionine (SAM-e) found in Denosyl and SAM-e supplements. Liver Support Factors also contains milk thistle (silybum marianum, which is included in Denamarin (a combination of SAM-e and the milk thistle extract silybin) and other liver support supplements. It would be better to rotate between different supplements rather than doubling up on some of these ingredients.
If your dog is showing symptoms of liver disease, it may make sense to make some dietary adjustments. It is better to feed several small meals a day rather than one or even two, if possible. I would recommend feeding moderate amounts of both high quality protein and fat. Dairy products, including cottage cheese, ricotta cheese and yogurt, may be easier to digest and produce less ammonia than meat products -- you may want to look for low salt varieties if you feed a lot of cottage cheese, or if your dog develops ascites (fluid retention). Eggs are an excellent protein source for dogs with liver disease. White fish can also be used.
Liver disease is one condition where it makes sense to add grains, as soluble fiber helps remove ammonia from the system so the liver does not have to process it. Oatmeal is particularly high in soluble fiber and would be good to use, as long as your dog doesn't have any problems with it (use whole rolled or quick oats (cooked), which have more soluble fiber than instant). Boiled white rice and, to a lesser degree, pasta are useful due to their high digestibility. I prefer feeding at least half meat and other animal products, and no more than half grains and other carbohydrates, unless less protein is needed to control symptoms of hepatic encephalopathy. For those who use a spreadsheet, you should feed a minimum of 1 gram of protein per pound of body weight daily (as determined by a nutritional analysis, not grams of meat), and carbohydrates should not provide more than 45% of calories.
Avoid supplements with copper and foods that are high in copper, including most organ meats, especially beef liver (but not chicken or turkey liver, which have little copper) -- see Vitamin & Mineral Content of Various Organ Meats for more information; also see the Copper Nutrient List but be aware that you can't compare these foods directly as they use different measurement sizes for different foods. Copper can accumulate in the liver when bile excretion is reduced and cause further damage. Lamb, pork, duck and salmon are high in copper; turkey, chicken, and other fish have moderate amounts of copper; and beef, cheese and eggs are low in copper. In advanced stages of liver disease, both copper and sodium (salt) must be severely restricted; salt is restricted to help prevent ascites (fluid build-up in the abdomen) related to low albumin levels, which are caused by poor liver function. You can use the USDA Nutrient Database to check for amounts of these nutrients in specific foods. You can also give a zinc supplement to help bind copper, especially if you suspect copper accumulation. See this article on Copper Toxicity/Chronic Active Hepatitis for more information.
The amino acid l-carnitine can help with fat metabolism and thereby be beneficial for liver disease, and l-arginine may be helpful in reducing ammonia that can accumulate with liver disease. Dogs with problems absorbing fat may benefit from a low fat diet using medium-chain triglycerides (MCTs), a form of fat found in dairy products and coconut oil. Use virgin (unrefined) coconut oil sold in glass jars and give up to 1 tsp per 10 lbs of body weight (start with less and increase gradually).
Good supplements to give would also include Vitamin B complex and vitamin E. Zinc should be increased above normal levels to help bind copper, and because its antioxidant properties help to protect the liver. Vitamin A should be limited with liver disease -- normal amounts are fine, but don't give higher amounts. Cod liver oil, which is high in vitamin A, should be used sparingly, if at all, and liver should also be limited (liver is also high in copper). Vitamin C should not be given to dogs with copper retention, but otherwise is beneficial. Fish oil (body oil, not liver oil) can be given in moderate amounts, maybe 1000 mg per 20-30 lbs of body weight, it's not known whether it's helpful for liver disease or not but can help with inflammation.
Dr. Jean Dodds recommends her Liver Cleansing Diet for dogs with liver disease, but it is very important to understand that this type of diet is only needed for dogs with very severe liver disease that is causing hepatic encephalopathy (neurological problems caused by too much ammonia in the system). It is definitely not indicated simply because your dog has elevated liver enzymes, which may not even indicate liver disease (see above). Although I feel it is unnecessary, I see no problem using this diet short-term (two or three months) for dogs that may have liver disease, if it makes you feel better and your dog does not object, but I do not recommend feeding such a restricted diet with so little variety long-term unless absolutely necessary. If your dog is suffering from hepatic encephalopathy and needs a severely restricted diet for this reason, this diet would be appropriate, though more variety would still be preferable. See Revised GARD Diet for a more complicated, but more complete, version of the same diet. It's fine to use the simple version in the short term, but if you need to feed a restricted diet for more than two or three months, you should use the more complete version. Again, you should also use variety rather than always feeding the same exact foods (for example, Dr. Dodds mentions substituting chicken for fish, and adding eggs to the diet).
See Sunny's Miracle Diet for information on a cooked diet and treatment protocol that one person used successfully to treat their Cairn Terrier with terminal cirrhosis of the liver. Others have also reported success using this diet, and it is not as low in protein as the Dodds diet above, so it would be a better choice for most dogs. Note this recipe doesn't include calcium. Add calcium at the rate of around 800 mg per pound of food. You can use eggshells that have been ground to powder in a clean coffee grinder, where 1/2 teaspoon ground eggshell provides about 1,000 mg calcium.You may also want to substitute eggs and dairy for some of the turkey.
Liver Disease and Diet has additional information on this subject, and I have also seen Donald Strombeck's book, Home Prepared Dog and Cat Diets recommended for liver disease recipes (these are cooked diets without bone). All of these are low in protein and so would not be appropriate except for dogs with advanced liver disease. You can see his recipes on his website: Diets for Dogs with Hepatic Disease.
There is a possibility that certain fruits are liver protective, including watermelon, grapefruit, lychee, fig, kiwi, cherry, Japanese plum, and papaya.
There are several email lists at Yahoo Groups related to liver disease in dogs:
The book Hope for Healing Liver Disease in Your Dog has been highly recommended by people I trust (though I have not seen it myself) as a great, practical, non-technical source of information to help you immediately start caring for your dog. You can check out a Free Preview and see the case study.
Following are websites with general information on liver disease in dogs:
- The Liver and Diet for Liver Needs
- New Approaches to Liver Disease
- Liver Disease: Signs, Symptoms, and Diagnosis
- Canine and Feline Liver Disease: An Overview
- Prevention is Key in Avoiding Canine Liver Disease
- Liver Disease in Dogs
- Liver Disease Summary
- Management of Chronic Liver Disease in Dogs
- Liver Disease and the Ideal Diet
- Nutritional Management of Liver Failure and Hepatic Encephalopathy
- Nutritional Support for Dogs and Cats with Hepatobiliary Disease
From the Journal of Nutrition Vol. 128 No. 12 December 1998, pp. 2733S-2746S (highly technical but lots of good info). For a simple flow chart on "Nutritional Management in Hepatobiliary Disorders", go to page 5. The very first entry says "If NOT encephalopathic: normal maintenance" -- no dietary changes needed. The second section starts out "Avoid protein restricted diets unless HE [hepatic encephalopathy]."
- Liver Diseases
Highly technical but has some good information on a variety of different causes of liver problems
- Canine Liver Disease Diet
- Excerpt from "Nutrition of Dogs with Liver Disease" (Rutgers, Biourge) in Encyclopedia of Canine Clinical Nutrition: "Provision of adequate high-quality proteins as well as calories is essential to ensure a positive protein balance and enable hepatic regeneration. Protein levels are often inappropriately restricted in dogs with liver disease in order to manage possible hyperammonemia. In fact, protein requirements are at least normal or even increased, and many dogs with liver disease do not have hyperammonemia. . . .
In general, diets for dogs with liver disease should be highly digestible with a high energy density provided by fat and carbohydrates. Moderate protein restriction may be necessary in dogs with clinically evident HE, but protein quality should be very high. In addition, the diet should contain high normal to increased levels of water-soluble vitamins, enhanced zinc (>43 mg/1000 kcal), restricted copper, restricted sodium (<0.5 g Na/1000 kcal) in case of ascites, and a moderate amount of mostly soluble fiber. Protein restriction should be avoided as much as possible, especially in dogs with acute inflammatory hepatic disease or necrosis."
Links to tests used to diagnose liver disease:
- Diagnosing Liver Disease in Dogs: What do the Tests Really Mean?
- When Your Dog Has Abnormal Liver Enzymes (scroll down)
- The ALP is elevated. What now? (scroll down)
- The diagnostic approach to asymptomatic dogs with elevated liver enzyme activities
- Tests for Liver Disease in Dogs and Bloodwork differentials for dogs and Bloodwork- AlkalinePhosphatase
- Urine Bile Acids Testing
- Urine Bile Acids Testing
- How is a Bile Acid test performed, and what does it mean?
- Preparing a Dog for a Bile Acid Test
- Bile acid response testing for possible PSS
- Bile Acids (highly technical)
- Serum bile acids and the assessment of hepatic function in dogs and cats
- Leptospirosis in Dogs (lepto can cause liver disease as well as kidney disease)
- Liver Enzyme Elevations in Dogs: Diagnostic Approach (very technical)