Aims: To establish the safety and efficacy of regional citrate anticoagulation (RCA) for pediatric liver failure (LF) patients receiving extracorporeal liver support (ELS) with albumin-assisted dialysis. Methods: Retrospective review of pediatric LF patients receiving ELS from April 2014 to December 2016 at a tertiary children’s hospital pediatric intensive care unit. Demographic and ELS data collected by chart review. Citrate accumulation (CA) was defined as total calcium (mmol/L): ionized calcium (mmol/L) > 2.5 (tCa:iCa). Efficacy was assessed by treatment duration. Safety was assessed by adverse events: bleeding, hemodynamic instability, arrhythmias, unplanned treatment discontinuation. Results: Fifteen patients (median age 3 [interquartile range (IQR) 0.7–8.0]) received 108 ELS treatments (median 5 [IQR 4–7.5]). Sixty-eight episodes of CA were identified. Of those, 6 coincided with intervention and 1 coincided with ELS discontinuation. There were no deaths attributed to ELS or RCA. Conclusion: RCA provides safe and effective anticoagulation for pediatric LF patients requiring ELS.