The Model for End-stage Liver Disease with sodium correction (MELD-Na) is designed to prioritize liver transplantation (LT). MELD-Na predicts 90-day mortality in cirrhosis but it is unclear whether MELD-Na captures the clinical severity of patients with acute-on-chronic liver failure (ACLF). We compared observed 90-day mortality in patients with ACLF with expected mortality based on the calculated MELD-Na. We also examined the consequences of underestimating clinical severity by MELD-Na.We identified patients with ACLF during hospitalization for cirrhosis at any of the 127 VA hospitals between 01/01/2004 and 12/31/2014 from the VA Corporate Data Warehouse. We examined the MELD-Na by ACLF presence and grade (1, 2 or 3+ organ failures). We used the actual and observed 90-day mortality to estimate standardized mortality ratio (SMR) by ACLF presence and grade. We used transplant center-specific median MELD-Na at Transplantation (MMaT) determined by United Network for Organ Sharing (UNOS) to estimate the proportion likely to receive priority for LT based on MELD-Na alone. Last, we examined the proportion of patients in whom LT was discussed as a treatment option by searching the electronic medical records as well as the proportion who were listed for transplantation based on data from the UNOS.Of 71,894 patients hospitalized for decompensated cirrhosis, 18,979 (26.4%) patients met the criteria for ACLF on admission. The median (P25, P75) MELD-Na on admission was 26 (22, 30) for ACLF compared to 15 (12, 20) for patients without ACLF; it was 24 (21, 27), 27 (23, 31), and 32 (26, 37) for ACLF-1, 2 and 3 patients, respectively. At 90 days, 40.0% with ACLF died (30.8%, 41.6% and 68.8% in ACLF-1, 2 and 3, respectively) compared to 21.3% of patients without ACLF. Compared with the expected death rate based on calculated MELD-Na, presence and grade of ACLF had greater mortality risk as determined by the SMR (95%CI): 1.52 (1.48, 1.52), 1.46 (188.8.131.52), 1.50 (1.44, 1.55), 1.66 (1.58, 1.74) for overall ACLF, ACLF-1, -2 and -3 respectively. Only 9.1% of ACLF patients reached the national median MELD-Na of 35 and between 17.3% to 35.1% exceeded the MMaT at any of the VA Transplant Centers. During index admission, 589 (0.8%) of ACLF patients were considered for LT evaluation and 16 (0.1%) patients were listed for LT.In a U.S. cohort of hospitalized patients with decompensated cirrhosis. MELD-Na did not capture 90-day mortality risk in ACLF. Only a small proportion of ACLF patients exceeded the median MELD thresholds for transplantation in designated LT centers. Few patients were considered and listed for LT despite high short-term mortality. Patients with ACLF are at a mortality disadvantage in the current MELD-Na based system.