Introduction: Orthotopic Liver Transplant (OLT) is the established treatment for fulminant liver failure (FLF)  worldwide. Due to the capacity for eventual native liver recovery particularly in children, Auxiliary Partial Orthotopic Liver Transplantation (APOLT) has emerged as a surgical alternative to standard OLT for the treatment of FLF.  In this approach, part of the native liver is preserved, giving it the opportunity for recovery while the transplanted auxiliary graft functions as the sole functioning liver. Once the native liver recovers completely, withdrawal of immunosuppression or removal of the graft is done. It's a complex procedure and despite its advantages, is not commonly performed with very limited worldwide experience.  In Australia, our unit is the only centre performing this and the objective of the present study is to review our experience with APOLT in children with FLF.   
Methods: Retrospective review of patients with FLF who underwent APOLT performed in a single centre from 2002 to 2024.
Results: We retrospectively reviewed 6 patients who underwent APOLT for FLF aged between 8 months and 12 years between 2002 and 2024.  Aetiology of FLF was Non A-G hepatitis in 5 patients and haemophagocytic lymphohistiocytosis (HLH) in one patient. In the patient with HLH, the diagnosis was only discovered following 2 failed transplants- the first being the APOLT.  Unfortunately, he died due to underlying HLH.  5 children got Left lateral Segment (LLS) deceased donor grafts and one (the first child – done in 2002) had a living donor LLS graft.   In all the patients, arterial inflow was directly from the infra-colic aorta using conduits from native saphenous vein in the child who received the living donor graft, and deceased donor arteries in the remainder. In the first child who received a living donor graft, the native liver did not recovered, and he remains well with his transplanted liver 22 years later. In the remaining 4 patients, complete recovery of their native livers occurred in 3 and their transplant livers have been explanted at 3, 10 and 14 months post-APOLT. The most recent transplant was in an 8-month-old child who is now 10 months post-transplant with evidence of ongoing native liver recovery.  
Conclusion: Based on our experience, we believe APOLT is feasible in children with FLF. APOLT is an attractive option in children, when possible, as it can potentially allow time for spontaneous native liver recovery and spare them the burden of lifelong immunosuppression.