*Purpose: Studies conflict whether obesity is associated with higher risk of failure and death among kidney transplant recipients. ESRF patients show the obesity paradox where the heavier patients have lower mortality.The aim of the study was to define the importance of recipient weight in the modern transplant era and see if this risk factor was more important in certain donors.

*Methods: All 771 patients transplanted during 7 years were separated in 4 quartiles according to their BMI. A new variable (BMIext) was created where the lighter and heavier quartile were combined to one group (group A, BMI less than 23 or BMI greater than 30.6) and contrasted to the mid two quartiles (group B, BMI 23-30.6). Primary outcomes were graft and patient survival. Secondary outcomes DGF, eGFR at 12 and 36 months.

*Results: Graft and patient survival were not associated to the patient BMI linearly. Graft survival was dependent on the recipient age (p=0.002), donor type (LD vs. deceased, p=0.001) and the BMIext (p=0.04).In sub-analysis it seemed the entire effect was restricted to male donors; Graft survival among recipients of male donors at 1 and 5 years was 95% and 79% in group B compared to 89% and 68% in group A (p=0.018). BMIext was significant in Cox regression (p=0.009). Patient survival of male donors was also numerically higher at 1 and 5 years in group B (97% and 83%) vs. group A (94% and 79%), not significantly so (p=0.2). BMIext was significant for patient survival in Cox regression (p=0.016).Patient BMI (or BMIext) was not related to the eGFR at 12 or 36 months. DGF was increased among obese patients (p=0.002).

*Conclusions: The renal failure survival paradox is partly modified through transplantation so that the highest BMI group has an increased failure and death rate. This effect is mainly restricted to recipients of male donors. This could be due to agender mismatch effect.

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