*Purpose: The growing end stage kidney disease burden paired with substantial rates of obesity in the United States (US) has prompted increased approval of obese living kidney donors. Compared to non-obese living donors, obese living donors have demonstrated higher rates of diabetes, but risk of diabetes attributable to the donation event itself remains unknown. The purpose of this study was to evaluate diabetes-free life expectancy among obese living kidney donors compared to obese non-donors.

*Methods: In this longitudinal cohort study utilizing multicenter data from 58 US transplant centers, Scientific Registry of Transplant Recipients, and 2 US longitudinal cohort studies (Coronary Artery Risk Development in Young Adults (CARDIA) and the Atherosclerosis Risk in Communities (ARIC)), adult obese living kidney donors (1976-2020) were matched to non-donors on base characteristics (age, sex, race, body mass index, systolic and diastolic blood pressure) and diabetes-specific risk factors (family history of diabetes and impaired fasting glucose). Non-parametric survival methods and Accelerated Failure Time models were utilized to evaluate diabetes-free life expectancy.

*Results: Among the total 4447 participants, 2102 (47%) were living donors and 2345 (53%) non-donors. Within the cohort matched on base characteristics and diabetes-specific risk factors, 9% (22/247) of donors and 26% (63/247) of non-donors developed diabetes over a median follow-up time of 8.6 (interquartile range (IQR):5.4-12.9) and 14.4 (IQR: 6.1-21.1) years, respectively (log rank p=0.01; Figure 1A). Living donors were estimated to live diabetes-free 1.8 times longer than non-donors (estimate 1.80; 95% CI: 1.13-2.86, p=0.01; Figure 1B).

*Conclusions: Obese living kidney donors were estimated to live significantly longer diabetes-free compared to obese non-donors, suggesting there was no increased risk of diabetes attributable to donation in this population.

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