Background: Donation after cardiac death (DCD) was (re)introduced in Belgium in 2000 to expand the pool of kidney grafts. We reviewed the Belgian experience of DCD kidney transplantation (KTx) and compared short and long term graft and patient survival between machine perfusion (MP) and cold storage (CS) preservation. Methods: We reviewed all DCD KTx performed in Belgium between 01/2000 and 12/2009. Donor and recipient data were collected from Eurotransplant and all 6 Belgian KTx centers. Results: During the study period, 287 DCD KTx were performed (13% of all deceased KTx). Median follow up was 34 (8-130) months. Kidneys were stored by CS (n=135) or MP (n=152). The incidence of delayed graft function (DGF) was 10% lower in MP compared to CS kidneys (p=0.07), despite longer cold ischemia time (CIT) [17.9 (4.30-30.8) h versus 13.8 (3.5-26.7) h; p<0.001)) and anastomotic time [34 (20-70) min versus 31 (11-71) min; p<0,001) and more uncontrolled DCD donors (10.5% versus 3%) in MP kidneys. In multivariate analysis, MP reduced the risk of DGF (Odds ratio 0.30 (0.14-0,66); p=0,003). CIT was also an independent risk factor of DGF (Odds ratio 1.14 (1.05-1.23);p<0.001). The 1, 3 and 5-year patient/censored graft survival were comparable between MP and CS (97%, 96%, 92%/97%, 93%, 93% MP versus 96%, 92%, 81%/93%, 89%, 78% CS; log rank 0,06/0,20). Conclusion: DCD KTx in Belgium is associated with excellent short and middle term results. In this Belgian patient cohort and in line with previous studies, MP decreases the risk of development of DGF whereas CIT increases this risk. In addition, our data strongly suggest that the impact of CIT on DGF is reduced by MP.