*Purpose: Type 2 Diabetes Mellitus (T2DM) is the most common cause of renal failure in patients undergoing kidney transplantation (KT) and highly correlated with obesity. The aim of this study was to understand the interplay between T2DM and obesity on long-term outcomes after KT.

*Methods: This was a longitudinal cohort study in KT recipients using national SRTR data from 2002-18. The primary outcomes were graft loss and death; assessed using multivariable Cox regression with obesity and T2DM interaction terms.

*Results: Of 233,703 recipients included, 53,725 (23%) had T2DM. T2DM KT patients tended to be older (mean age 58.8±9.4 vs 48.4±13.9 yrs), male (67.3% vs 57.6%) and had higher BMIs (30.2±5.1 vs 27.4±5.3 kg/m². The risk of death-censored graft loss was not significantly associated with T2DM status. However, those with T2DM had significantly higher risk of death following KT; the adjusted HR for death with BMI of 18.5-30 was 1.51 (95% CI 1.47-1.55, p<0.001), for BMI of 30-35, 1.53 ( 95% CI 1.48-1.58,p<0.001) and for BMI >35, 1.58 (95% CI 1.51-1.65, p<0.001). The increased risk persisted even after correcting for age. These risks did not significantly vary by BMI (p>0.05 for T2DM*BMI interaction term).

*Conclusions: T2DM substantially increases the risk of overall graft loss, driven by death with a functioning graft. The impact of T2DM is independent and does not vary based on BMI. These finding highlight the importance of reducing mortality risk in those with T2DM to improve overall graft survival.

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