*Purpose: Body Mass Index (BMI) limits for liver transplant (LT) candidacy are controversial. We evaluated waitlist and post-LT outcomes, prognostic factors, and regional patterns of LT waitlist registration in patients with BMI ≥40 compared to those with BMI 18-39.9.

*Methods: UNOS data was analyzed for adult primary LT candidates from 3/1/2002-12/1/2017. Waitlist dropout and post-LT survival were compared at various BMI ranges. Prognostic factors were analyzed using multivariable and competing risk analyses. The distribution of waitlisted morbidly obese (BMI ≥40) patients by UNOS region was compared to the Centers for Disease Control Behavioral Risk Factors Surveillance System (BRFSS) data.

*Results: Analysis of post-LT outcomes demonstrated a small but significantly lower 1- and 3-year graft and patient survival rate for patients with BMI ≥40 vs lower BMI groups (Table 1). Risk factors for patients with BMI ≥40 included age >60 (p=0.011), prior surgery (p<0.001), and diabetes (p=0.008) on multivariable analysis. MELD >30 was significant only on univariable analysis. Median MELD at LT was consistently higher in all regions for BMI ≥40 with 4 regions showing a higher rate of waitlist dropout. Using BRFSS data, the proportion of listed patients with BMI ≥40 versus the rate of morbid obesity in the adult population was lower in three regions (Table 2). The range of listing median calculated MELD for the three regions with a lower proportion vs higher proportion of listed patients with BMI ≥40 was 27.5-37 and 25-37 respectively.

*Conclusions: Careful patient selection can ameliorate the modestly lower post-LT patient survival for BMI ≥40. It is necessary to further explore the causes of regional variations in listing of high BMI patients as well as the causes behind the higher waitlist dropout rates.

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