Background The cardiac implications of obesity in kidney transplant recipients are not well-described. Methods We examined associations of body mass index (BMI) at transplant with post-transplant cardiac risk among 1,102 renal allograft recipients at a single center in 1991-2004. Cumulative post-transplant incidences of congestive heart failure (CHF), atrial fibrillation (AF), myocardial infarction (MI), and a composite of these cardiac diagnoses were estimated by the Kaplan-Meier method. Bivariate (hazards ratio, HR) and covariate-adjusted (aHR) relationships of BMI increments with cardiac risk were modeled by Cox's regression. We also systematically reviewed the literature on BMI and cardiac events after transplant. Results In the local data, 5-year cumulative incidence of any cardiac diagnosis rose from 8.67% to 29.35% across the lowest to highest BMI quartiles (P=0.02), driven primarily by increases in CHF and AF. In contrast, the rate of MI did not differ by BMI quartile (P=0.56). Each 5 U BMI increase predicted 26 % higher risk of the cardiac composite (HR 1.26, 95% CI 1.06 −1.48 2.14, P=0.008), a relationship that persisted with significance after covariate adjustment (aHR 1.19, 95% CI 1.00 −1.43, P=0.049). BMI independently predicted cardiac risk in sub-cohorts with pre-transplant heart disease and with non-diabetic renal failure. Data from 26 original articles support BMI as a risk factor for post-transplant CHF and AF, whereas findings for coronary/ischemic outcomes are inconsistent and predominantly negative. Conclusions High BMI at transplant predicts increased cardiac risk, especially of CHF and AF. Further research should examine whether obesity treatment modifies cardiac risk after kidney transplantation.

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