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In this review, we discuss evidence of the increasing prevalence of obesity among people with chronic and end-stage kidney disease (ESKD) and implications for kidney transplant (KT) candidate selection and management. Although people with obesity and ESKD receive survival and quality-of-life benefits from KT, studies show that most KT programs maintain strict body mass index (BMI) cut-offs to determine transplant eligibility. However, BMI does not distinguish between visceral adiposity, which confers higher cardiovascular risks and risks of perioperative and adverse post-transplant outcomes, and muscle mass, which is protective in ESKD. Furthermore, requirements for ESKD patients with obesity to lose weight before KT should be balanced with the findings of numerous studies that show weight loss is a risk factor for death among ESKD patients, independent of starting BMI. Data suggest that KT is associated with survival benefits relative to remaining on dialysis for candidates with obesity, although recipients without obesity have higher delayed graft function rates and longer transplant hospitalizations. Research is needed to determine the optimal body composition metrics for KT candidacy assessments and risk stratification. In addition, ESKD-specific obesity management guidelines are needed that will address the neurologic, behavioral, socioeconomic, and physical underpinnings of this increasingly common disease.