Introduction: Kidney transplantation is the treatment of choice for patients with kidney disease who require replacement therapy. Dialysis is a step, but not mandatory prior to transplantation and pre-emptive transplant from deceased donors is possible. Materials and methods: This is a retrospective, observational, matched cohort study. We compared 100 pre-emptive renal transplant recipients with 100 renal transplant recipients on dialysis both groups received a first renal graft, matched by age and gender of donors and recipients, time of transplant, immunological risk, immunosuppression and cold ischemia time. Results: The percentage of recipients who presented early graft loss, delayed graft function and acute rejection was similar in both groups. No differences were observed in their renal function at 12 and 36 months after transplantation, as well as in the actuarial survival of patients (p = 0.730) and grafts (p = 0.693) in the studied period. The total calculated cost of the period on dialysis for the dialysis group was 12,172.565 Euros. Conclusions: Pre-emptive transplantation can achieve comparable outcomes to those for post- dialysis kidney transplantation, and better quality of life with a reduced cost.