*Purpose: Acute renal failure is common in pediatric patients undergoing liver transplantation (LT), with an incidence of 17-55%. Fluid, metabolic and acid-base aberrancies are often pronounced pre-operatively and further worsened by events during LT surgery, making intra-operative continuous renal replacement therapy (IO-CRRT) an attractive option for critically ill LT recipients. Often used in adult LT recipients, literature supporting IO-CRRT use in pediatric LT is lacking. We present a single center case series of pediatric patients with successful IO-CRRT use during LT.

*Methods: All pediatric LT recipients at our institution who underwent IO-CRRT between January 2017- November 2021 were included. Patient demographics and clinical data including graft outcomes, intraoperative findings, indications for and logistics of IO-CRRT were collected from the electronic health record.

*Results: 9 pediatric patients received IO-CRRT during LT (Table 1). Ages at time of LT ranged from 34 days to 17 years; with 4 infants under 10 kg. 3 patients received simultaneous or sequential liver/kidney transplants. Dialysis and hemodynamic monitoring access was secured prior to transplant, CRRT circuit blood flow (QB) was reduced by about 25-50% during cross-clamping of the inferior vena cava, and QB was readjusted after organ reperfusion. Metabolic, acid-base and fluid aberrancies, were maintained within acceptable limits intra-operatively for all. Multiple dialysate and replacement fluids compositions were readily available to best react to clinical changes, particularly following organ reperfusion. 6 patients continued CRRT post-operatively, with longest period extending through post-operative day 13. All living patients (8/9) have good kidney function (CKD Stages 1-2) and excellent liver allograft function, with follow-up of 4 months to 4.5 years.

*Conclusions: Intra-operative CRRT during pediatric LT, although challenging, is a promising tool to support medically complex patients during their intra-operative course. This intervention allows for close monitoring and control to decrease the risk for electrolyte, fluid and acid-base aberrancies that might otherwise result in poor patient and allograft outcomes. We demonstrate that IO-CRRT can be safely performed in pediatric LT recipients, including very young, small infants, children and adolescents.

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