<![CDATA[Introduction: Pediatric kidney transplantation poses major hemodynamic challenges; donor–recipient size mismatch means the graft demands roughly 25% of the recipient's cardiac output, so accurate assessment is essential to protect graft perfusion and prevent delayed graft function. We demonstrate the value of integrating noninvasive (Masimo Root) and invasive (MostCare PRAM) monitoring to optimize goal-directed anesthesia. Case Description: A 10-year-old boy (24 kg) with end-stage kidney disease underwent living-related kidney transplantation using combined monitoring. Masimo Root provided continuous hemoglobin (SpHb), volume status (Pleth Variability Index), and sedation depth (Patient State Index, PSI); MostCare PRAM provided beat-to-beat stroke volume variation (SVV), cardiac output, and arterial elastance (Ea). Real-time integration guides precise fluid titration. Adequate sedation (PSI 25–50) and stable hemodynamics (SVV <10%, Ea 1.19 mmHg/mL) were maintained, and the crystalloid was restricted to 700 mL. The patient remained stable throughout the 8-hour procedure and was extubated in the operating room with prompt urine output and immediate graft function. Conclusion: Integrated Masimo Root and MostCare PRAM monitoring enables individualized goal-directed anesthesia, balancing hypovolemia and fluid overload risks, enhancing intraoperative stability, optimizing graft perfusion, minimizing fluid-related complications, and facilitating rapid recovery with early graft function in high-risk pediatric kidney transplant recipients.]]>
