© 2015 Elsevier Inc. All rights reserved. Acute myocardial infarction in patients with end-stage renal disease (ESRD) is associated with increased risk of morbidity and mortality. Limited data are available on the contemporary trends in management and outcomes of ST-elevation myocardial infarction (STEMI) in patients with ESRD. We analyzed the 2003 to 2011 Nationwide Inpatient Sample databases to examine the temporal trends in STEMI, use of mechanical revascularization for STEMI, and in-hospital outcomes in patients with ESRD aged ≥18 years in the United States. From 2003 to 2011, whereas the number of patients with ESRD admitted with the primary diagnosis of acute myocardial infarction increased from 13,322 to 20,552, there was a decrease in the number of STEMI hospitalizations from 3,169 to 2,558 (ptrend < 0.001). The overall incidence rate of cardiogenic shock in patients with ESRD and STEMI increased from 6.6% to 18.3% (ptrend < 0.001). The use of percutaneous coronary intervention for STEMI increased from 18.6% to 37.8% (ptrend < 0.001), whereas there was no significant change in the use of coronary artery bypass grafting (ptrend [ 0.32). During the study period, in-hospital mortality increased from 22.3% to 25.3% (adjusted odds ratio [per year] 1.09; 95% confidence interval 1.08 to 1.11; ptrend < 0.001). The average hospital charges increased from $60,410 to $97,794 (ptrend < 0.001), whereas the average length of stay decreased from 8.2 to 6.5 days (ptrend < 0.001). In conclusion, although there have been favorable trends in the utilization of percutaneous coronary intervention and length of stay in patients with ESRD and STEMI, the incidence of cardiogenic shock has increased threefold, with an increase in risk-adjusted inhospital mortality, likely because of the presence of greater co-morbidities.