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INTRODUCTION Many kidney transplant (KT) centers decline patients with a body mass index (BMI) ≥40 kg/m2 . This study's aim was to evaluate KT outcomes according to recipient BMI. METHODS We performed a single-center, retrospective review of adult KTs comparing BMI ≥40 patients (n = 84, BMI = 42±2 kg/m2 ) to a matched BMI <40 cohort (n = 84, BMI = 28±5 kg/m2 ). Patients were matched for age, gender, race, diabetes, and donor type. RESULTS BMI ≥40 patients were on dialysis longer (5.2±3.2 years vs. 4.1±3.5 years, p = 0.03) and received lower kidney donor profile index (KDPI) kidneys (40±25% vs. 53±26%, p = 0.003). There were no significant differences in prevalence of delayed graft function, reoperations, readmissions, wound complications, patient survival, or renal function at 1 year. Long-term graft survival was higher for BMI ≥40 patients, including after adjusting for KDPI (BMI ≥40: aHR = 1.79, 95% CI = 1.09-2.9). BMI ≥40 patients had similar BMI change in the first year post-transplant (delta BMI: BMI ≥40 +0.9±3.3 vs. BMI <40 +1.1±3.2, p = 0.59). CONCLUSIONS Overall outcomes after KT were comparable in BMI ≥40 patients compared to a matched cohort with lower BMI with improved long-term graft survival in obese patients. BMI-based exclusion criteria for KT should be reexamined in favor of a more individualized approach. This article is protected by copyright. All rights reserved.