*Purpose: We compared post-transplant outcomes in patients with morbid obesity undergoing pre-transplant bariatric surgery to non-obese and obese patients without bariatric surgery.

*Methods: Adult recipients of a primary deceased donor renal transplant at a single center between 2010 and 2021 (n=1077), were grouped as follows: 1) BMI <30 (non-obese, n= 753), 2) BMI ≥ 30 (obese, n=213), 3) BMI ≥ 35 (morbidly obese, n=69), and 4) BMI ≥ 30 with bariatric surgery performed prior to listing (n=42). High Kidney Donor Risk Index (KDRI) was designated as >1.2 (n=465). Graft success and survival was compared using one way ANOVA and the Logrank Test.

*Results: At 5 years, cumulative graft survival was 89%, 80%, 73% and 86% for non-obese, obese, morbidly obese, and bariatric surgery groups, respectively (pooled comparison, p<0.001). At 5 years, high KDRI graft survival in groups 1-4 were 82%, 80%, 88%, and 100% respectively (pooled comparison, 0.502). Seven of 25 patients with diabetes prior to bariatric surgery experienced resolution afterward. For diabetic transplant patients, cumulative graft survival in groups 1-4 was 86%, 90%, 92% and 100% respectively (pooled comparison, p=0.510).

*Conclusions: Bariatric surgery improves 5-year graft survival for morbidly obese renal transplant candidates with or without diabetes and should be considered as an important pre-transplant risk reduction measure.

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