Background: Donation after cardiac death (DCD) expands the pool of donor kidneys, but is associated with warm ischaemic injury. Two methods are used to preserve kidneys from controlled DCD donors and reduce warm ischaemic injury: in situ preservation using a double-balloon triple-lumen catheter (DBTL) inserted via the femoral artery and direct cannulation of the aorta after rapid laparotomy. The aim of this study was to compare these two techniques. Methods: This was a retrospective cohort study of 165 controlled DCD procedures in two regions in the Netherlands between 2000 and 2006. Results: There were 102 donors in the DBTL group and 63 in the aortic group. In the aortic group the kidney discard rate was lower (4.8 versus 28.2 per cent; P <0.001), and the warm (22 versus 27 min; P <0.001) and the cold (19 versus 24 h; P <0.001) ischaemia times were shorter than in the DBTL group. Risk factors for discard included preservation with the DBTL catheter (odds ratio (OR) 5.19, 95 per cent confidence interval 1.88 to 14.36; P = 0.001) and increasing donor age (1.05, 1.02 to 1.07; P <0.001). Warm ischaemia time had a significant effect on graft failure (hazard ratio 1.04, 1.01 to 1.07; P = 0.009), and consequently graft survival was higher in the aortic cannulation group (86.2 per cent versus 76.8 per cent in the DBTL group at 1 year; P = 0.027). Conclusion: In this retrospective study, direct aortic cannulation appeared to be a better method to preserve controlled DCD kidneys.