Children with chronic liver disease are frequently undernourished due to anorexia, malabsorption and extra losses of enteropathy. Controversy exists on the role of protein provision in patients with liver failure due to fear of encephalopathy.
However, increased protein breakdown and low protein synthesis warrant provision of protein. Studies have shown that a high protein diet versus a low protein diet has no significant clinical impact on encephalopathy. Further, exogenous protein is considered superior over endogenous protein in addressing the lack of protein stores. Provision of protein at 2g/kg/d and 3-4g/kg/d in chronic liver disease and acute liver failure, respectively, is associated with better PICU outcomes.
Acute renal failure or acute kidney injury in the PICU can be primary or consequence of multi-organ failure. As renal failure manifests with catabolic state with high protein breakdown, it is recommended to provide twice the RDA for protein.