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Introduction Terlipressin with albumin is standard care for cirrhosis and HRS-AKI. The CONFIRM trial found increased mortality (90-day) and serious complications including respiratory events and sepsis. MHRA guidance advises against using terlipressin in patients with severe renal impairment (serum creatinine ≥442 µmol/L) or severe liver disease (ACLF grade 3 or MELD ≥39) due to poorer outcomes. It was acknowledged that high doses of albumin in the CONFIRM trial may have contributed to fluid overload and respiratory events.1 We audited our use of terlipressin and albumin in HRS-AKI against this guidance.Method A retrospective review of 45 admissions and 44 patients St George’s Hospital (January 2022 – December 2023) for terlipressin IV bolus and albumin use in HRS-AKI. Data collected included terlipressin and albumin doses and duration, respiratory function, infections, 30- and 90-day mortality and MELD scores.Results The average MELD score was 24.6; two patients had MELD ≥39 and two had baseline serum creatinine ≥442 µmol/L. Thirty-day mortality was 38% (17/45), and 90-day mortality was 60% (27/45). No significant differences in daily average and cumulative terlipressin or albumin doses were found between survivors and non-survivors at 30 days. Infections occurred in 38% (17/45) and new/worsening respiratory issues in 31% (14/45). Eleven patients received multiple courses of terlipressin. The average course of terlipressin was 6.8 days, with 76% co-prescribed with albumin. No significant associations were found between average and cumulative terlipressin or albumin doses and infection or respiratory events. According to the Delhi model2, 50% responded to terlipressin. Duration of terlipressin and time from admission to terlipressin initiation was not significant between 90-day survivors and non-survivors. The Delhi model predicted subsequent infection (p=0.05). Response according to the Delhi model is associated with 90day mortality (χ2 4.301, p=0.036 [likelihood ratio])Conclusion Our 90-day mortality rate of 60% closely aligns with the CONFIRM trial’s findings of 51%. Infection (38%) and respiratory complications (31%) in our cohort were either consistent with or more prevalent than those reported in the CONFIRM study, which observed infections (10%), pneumonia (2%), sepsis (2%), acute respiratory failure (4%) and respiratory complications (16%). These findings highlight the need for further research to refine the optimal use of terlipressin and albumin in the management of HRS-AKI.