*Purpose: Patients with extreme obesity (EO, BMI ≥40 kg/m²) are frequently excluded as renal transplant candidates. The study purpose was to analyze outcomes of deceased donor kidney transplant (DDKT) recipients with EO, emphasizing pre-operative CT scan evaluation to discern pelvic anatomy.

*Methods: Single center retrospective review of DDKT recipients with EO. Recipient selection was based on clinical evaluation and abdominal CT scan review focused on skin-to-external iliac vessel depth and pelvic angle.

*Results: From 2006-2018, we performed 51 DDKTs (donor characteristics: mean age 32±15 years, KDPI 37%, cold ischemia time 25±19 hours) into patients with EO (mean BMI 43±3 kg/m²; range 40-47 kg/m²). Mean recipient age was 46±13 years; 65% were African American, with 38 women (W, BMI: 43±3 kg/m²) and 13 men (M, BMI: 42±2 kg/m²). CT scan revealed differences in skin-to-external iliac depth (W: 15±2cm; M: 17±2cm) and pelvic angle (W: 37±3; M: 31±3) between women and men (p<0.01). Mean follow-up was 5.1 years. 1-year graft survival (GS), patient survival (PS) and death censored graft survival (DCGS) were 95%, 98% and 98%, while overall GS, PS and DCGS were 78%, 84% and 90%, respectively. 1-year mean serum creatinine was 1.5±0.7 mg/dl, with no significant variance between genders. EO patients compared to lower BMI patients transplanted at our center (<40 kg/m²) displayed comparable rates of major infection (28 vs 25%, NS), 30 day readmission (21 vs 20%, NS) and rejection (12 vs 15%, NS) with increased rates of delayed graft function (DGF; 43 vs 28%, p<0.01) and reoperation (12 vs 6%, p<0.01).

*Conclusions: BMI alone is a poor predictor of technical transplantability as body habitus varies between people. Women tend to have shallower iliac vessels and wider pelvic angles, facilitating transplantation at higher BMIs than men. Well selected patients with EO can be safely transplanted with favorable medium term results. Exclusion of potential transplant candidates based on BMI alone is not indicated, although pre-transplant weight loss and referral to Weight Management is recommended because of higher rates of DGF and surgical complications following transplantation.

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