Until recently liver transplantation has been considered a contraindication in patients with multi-organ failure. However, developements in surgery and anesthetic technique involving intraoperative extrarenal purification provide adequate conditions for performing synchronous liver-kidney transplantation (SLKT), and it is clear that double transplantation is the best therapeutic option in end stage liver and kidney disease. Liver transplantation involves a large blood loss and fluid replacement, as well as administration of large amounts of blood products. Patients with end stage liver and kidney disease have a reduced capacity to excrete free water, predisposing them to an accumulation of extravascular water. Precise monitoring and the intraoperative use of an extrarenal purification technique to maintain these patients within acceptable hydroelctrolyte and hemodynamic parameters is needed. We experienced two cases of SLKT and report on anesthetic management and problems.