Cardiovascular function, serum ionized calcium (Ca+2), and serum citrate were measured intraoperatively in patients (n = 9) undergoing orthotopic hepatic homotransplantation. Serum citrate increased 20-fold (P< 0.0006) following transfusion of citrated blood products in the absence of a functional liver. Serum ionized calcium decreased (P< 0.003) with concomitant decreases in cardiac index (P< 0.005), stroke index (P< 0.004), and left ventricular stroke work index (P< 0.001). Hemodynamic depression and ionic hypocalcemia were reversed following the administration of CaCl2. In contrast to patients with normal hepatic function, who may tolerate large amounts of citrated blood, patients with end-stage liver disease demonstrate acute ionic hypocalcemia with concomitant hemodynamic depression when receiving citrated blood products during the course of hepatic transplantation.