BACKGROUND: Static cold storage is generally used to preserve kidney allografts from deceased donors. Hypothermic machine perfusion may improve outcomes after transplantation but there have been few studies with limited power that have addressed this issue. OBJECTIVE: To review the evidence for the effectiveness of storing kidneys from deceased donors after cardiac death prior to transplantation, using cold static storage solutions or pulsatile hypothermic machine perfusion. DATA SOURCES: Electronic databases were searched in September 2011 for systematic reviews and/or meta-analyses, randomized controlled trials and other study designs that compared delayed graft function and graft survival. Sources included Cochrane Library, PUBMed and EMBASE. Studies excluded from review included those that were unable to discriminate between donation after cardiac death (DCD) and a neurologically deceased donor (NDD). REVIEW METHODS: Our primary outcomes were delayed graft function (DGF) and one year graft survival. Statistical analysis was carried out using the Review Manager software from the Cochrane database. RESULTS: A total of nine studies qualified for review. We found that pulsatile perfusion pumped kidneys from DCD donors had reduced DGF rates compared to kidneys that were placed in cold storage (p = 0.03; odds ratio 0.64, CI 0.43 - 0.95). Although, there was a trend towards improved 1 year graft survival in the pulsatile perfusion group, statistical significance was not reached (p = 0.17; odds ratio 0.74, CI 0.48 - 1.13). CONCLUSION: Pulsatile machine perfusion of DCD kidneys appears to reduce delayed graft function rates. There did not appear to be a benefit in regards to one year graft survival. Due to the great heterogeneity among the trials along with several confounding factors the overall impact upon allograft function and survival requires more study.