Hepatorenal syndrome with acute kidney injury (HRS-AKI), is a unique subset of AKI representing about 11-20% of HRS-AKI episodes in patients with cirrhosis [1,2]. Before the availability of terlipressin in the US in 2022, HRS-AKI therapeutic options had been limited to off-label use of varied vasopressors primarily midodrine with octreotide combination with albumin [3]. Recent studies have shown low mortality (17.6%) and substantial HRS reversal (47.6%) in patients using terlipressin, however <21% patient receive terlipressin as first-line treatment [4,5]. There is sparse evidence in literature assessing real-world treatment patterns and their impact on HRS-related outcomes. Our study aims to fill this gap prior to 2022 and establish a baseline against which future studies of terlipressin can be evaluated in the United States.