*Purpose: At our high-volume center, we often perform liver transplantation (LT) on surgically complex patients that includes re-transplantation, prior open liver resection, bariatric surgeries, extensive upper abdominal surgeries and/or extensive portal vein thrombosis.

*Methods: We retrospectively reviewed 159 out of 1,471 LT between 1/1/2010 and 6/30/2020 that received intraoperative hemodialysis (IOP-HD) and were classified as a surgically complex cases. Patients were selected to receive IOP-HD based surgeon-anesthesiologist criteria for expected difficult LT with extensive dissection, excessive blood loss, and/or expected prolonged operative time, irrespective of pre-op renal status or dysfunction.

*Results: 159/1,471 (10.8%) LT were classified as surgically complex cases. Of those 159 complex LT, 127 (80%) received IOP-HD. Compared with surgically complex patients that did not receive IOP-HD, surgically complex LT patients who received IOP-HD had a higher MELD (IQR 27, 21-31 vs. 16, 8.25-18.75. p <0.0001) and greater intra-operative blood loss (IQR 4.5 L, 2.5-17 L vs. 2.25 L 0.85-6 L. p<0.0001).

They also received more blood products: RBC (IQR 8.5 U, 5-18.25 vs. 4 U, 2-6.5 U. p<0.0001) and FFP (IQR 9 U, 4-31 vs. 4 U, 3-15.6 U. p=0.0001).

There was no difference in patient or graft survival at 30-day, 90-day, or 1-year. In addition, there was no difference in early allograft dysfunction, intraoperative cryoprecipitate or platelet administration.

*Conclusions: The use of IOP-HD in surgically complex patients did not increase mortality, graft failure, or early allograft dysfunction. Although there was selection bias, we hypothesize that use of IOP-HD in surgically complex LT patients may help to minimize the effect of drastic volume changes and massive transfusions, temperature variation, and electrolyte and acid-base disturbances .

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