Rajeev SHARMA, Alok Kumar DWIVEDI
Experimental and Clinical Transplantation - 2026;24(9):676-682
Objectives: Obesity remains a common barrier to kidney transplant access, but the clinical relevance of severe obesity depends on donor and ischemic risk. Materials and Methods: We analyzed Scientific Registry of Transplant Recipients aggregate summary tables for deceased donor kidney transplants performed in the United States from January 1, 2014, to December 31, 2024, stratified by recipient body mass index (calculated as weight in kilograms divided by height in meters squared) of <35, 35 to 40, and >40. Primary outcomes measured were graft survival and delayed graft function. We compared delayed graft function across body mass index groups using X2 test and evaluated graft and patient survival by using Kaplan-Meier estimates from the Scientific Registry of Transplant Recipients. Results: Among 180,849 transplants (131,379 donation after brain death recipients and 49,470 donation after circulatory death recipients), delayed graft function increased stepwise across the body mass index groups (29.3%, 37.8%, and 42.4%; P < .001). Compared with body mass index <35, the 35 to 40 (odds ratio 1.46; 95% CI, 1.42-1.51) and >40 (odds ratio 1.77; 95% CI, 1.65-1.90) body mass index groups were associated with higher odds of delayed graft function. In donation after brain death recipients, 5-year graft survival declined from 77.51% to 74.33% and to 70.03% across ascending body mass index strata. Lower graft survival with higher body mass index persisted across Kidney Donor Profile Index, donor age, and cold ischemia time. Conclusions: Higher recipient body mass index was associated with substantially increased risk of delayed graft function and decreased graft survival after deceased donor kidney transplant. The adverse association appeared strongest when obesity coexisted with less favorable donor or ischemic characteristics, supporting individualized donor-recipient risk stratification rather than stand-alone body mass index exclusion thresholds.
