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Background The efficacy and safety of pharmacoinvasive strategy following fibrinolysis for ST-elevation myocardial infarction (STEMI) in relation to renal function have not been established. Methods Using patient-level data from 4 randomized controlled trials, we examined the efficacy and safety of pharmacoinvasive versus standard treatment after fibrinolysis for STEMI. Patients were stratified based on the estimated glomerular filtration rate (eGFR) on presentation ( 2 vs ≥60 mL/min/1.73 m 2 ). The primary outcome was the composite of death or reinfarction at 30 days. Results Of 2,029 patients, 457 (23%) had an eGFR 2 . Patients with eGFR 2 were older and had higher Thrombolysis in Myocardial Infarction risk scores. Compared with patients with eGFR ≥ 60 mL/min/1.73 m 2 , patients with renal dysfunction had higher rates of the primary outcome (5.3% vs 11.8%, respectively; P P heterogeneity = .73) or the rate of death or reinfarction at 1 year ( P heterogeneity = .64) in relation to eGFR. Patients with renal dysfunction had higher rates of in-hospital major bleeding compared with patients with eGFR ≥60 mL/min/1.73 m 2 (7.7% vs 4.3%, respectively; P = .004); however, there was no difference in bleeding events between treatment arms in the overall cohort or in relation to eGFR ( P heterogeneity = .67). Conclusions Renal impairment is associated with increased rates of adverse events in STEMI patients treated with fibrinolysis. However, the safety and efficacy of pharmacoinvasive strategy are preserved in patients with renal impairment on presentation.