*Purpose: Kidney transplant [KTx] in recipients with BMI > 35 remains controversial and has not often been studied in recipients with BMI >40. There is limited data as to whether health related quality of life [HRQOL] is adversely affected by being obese after KTx. This ambi-directional study examined the relationship between degree of obesity, KTx outcomes and HRQOL, across BMI and racial groups.

*Methods: Medical records of 227 low risk, adult, KTx recipients with BMI > 30, transplanted between 1/2009 & 10/2017 were retrospectively reviewed. A prospective approach allowed a 1 time HRQOL assessment for those who had not yet completed a Kidney Disease Quality of Life-36 [KDQOL-36] survey post KTx. The cohort was stratified into four obese groups: BMI 30-34.9, BMI 35-39.9, BMI 40-49.9 and BMI > 50. Demographics included age, race, gender, education years and zip code. Also included were number of years post KTx, dialysis years, donor source, surgical approach, history of diabetes [DM], hypertension [HTN] or vascular disease, serum albumin at KTx, and longterm use of steroids or mTOR inhibitor. Outcome measures included patient and graft survival, serum creatinine and glomerular filtration rate at 1, 3 and 5 yrs, acute rejection, delayed graft function, and wound complications. KDQOL-36 component scores were used to measure HRQOL and were compared to U.S. normative KDQOL-36 values. BMI was recorded at KTx, at KDQOL-36 survey and at study end. P values < 0.05 were considered significant.

*Results: Mean follow up was 4.5 yrs [± 2.76]. Overall, 61% of study participants were Black and 57% received living donor organs. Demographics were similar across BMI groups. Patient & graft survival reached 100% at 1 yr in all BMI groups, was above the current national average at 1 & 3 yrs, and was not significantly different at 3 or 5 yrs. Females had a .1512 [p=0.013] increase in patient survival and race did not negatively affect outcomes. A history of DM was associated with increased BMI [p=0.027] and correlated [r=0.2] with a 3.4% [p=0.0288] increase in death risk. Although age > 51yrs [p=0.000], female gender [p=0.057] and DM [p=0.020] significantly decreased KDQOL-36 physical component scores, all KDQOL-36 component scores were at or above the normative scores for the US dialysis population. Importantly, BMI class had no significant effect on HRQOL.

*Conclusions: KTx for those with BMI > 35 offered graft and patient survival and HRQOL above the US normative average for transplant recipients and patients on dialysis. Obesity should not be an absolute contraindication to KTx regardless of race or degree of BMI. However, a history of DM can predict poorer recipient survival and lower HRQOL physical component scores in obese recipients, suggesting a need for rigorous DM management pre and post KTx.

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