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Background Continuous Renal Replacement Therapy (CRRT) is often used to support the intraoperative course during liver transplantation (LT) for patients with HRS. However, the use of intraoperative CRRT (IOCRRT) is not without its problems. Living donor liver transplantation (LDLT) is a planned operation and is possible without IOCRRT as the recipient can be optimized. Aim To study the peritransplant outcomes of patients with CLD and HRS undergoing LT without IOCRRT. Methods Analysis of LT program database for perioperative outcomes in patients with HRS from Feb 2017 to Dec 2018. Results 87/363 (23.9%) adult LDLT patients had HRS, of whom 31 (35.6%) did not respond (NR) to standard medical therapy (SMT) prior to LT. Modified perioperative protocol enabled the NR patients (who were sicker and in persistent renal failure) to undergo LT without IOCRRT. Postoperative renal dysfunction was similar (2 in NR and 2 in R) at 1 year. Post‐LT survival was also not different at one month (83.87% in NR and 87.5% in R [p = .640]) and at 1 year (77% in NR vs 80.4% in non‐responders [p = .709]). Conclusion IOCRRT can be avoided in HRS patients undergoing LDLT without compromising their outcomes (post‐LT survival and RD), even in patients who have not responded to SMT, preoperatively.

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Pulmonary complications are important cause for high incidence of mortality in chronic liver disease patients admitted to the intensive care unit. Up to 50–70% of patients report shortness of breath, reflecting the high prevalence of respiratory failure, defined as an arterial pressure of oxygen (PaO2) of less than 60 mm Hg. The causes of respiratory failure are multifactorial in chronic liver disease. Although much attention is given to the pathologies of pulmonary microcirculation (i.e., portopulmonary hypertension and hepatopulmonary syndrome), these specific conditions are found in <20% of cirrhotic patients. The impact of liver disease on respiratory function extends far beyond these two specific conditions and include micro-aspirations associated with hepatic encephalopathy, fluid overload, hepatic hydrothorax, and basal atelectasis and restriction due to large ascites. The impact of altered bile-acid composition induces a shift in the gut microbiome and this may shed a new light on the molecular basis for the ‘gut–liver–lung axis’ as the driver for multiple organ failure. This chapter focuses on current evidence surrounding the prevalence, management, and complications from various etiologies of respiratory insufficiency in end-stage liver disease patients.