Acceptance of obese individuals as living kidney donors is controversial related to possible increased risk for surgical complications and concern that obesity may contribute to long-term renal disease. We retrospectively examined 553 consecutive hand-assisted laparoscopic living kidney donations between October 1, 1999 and April 1, 2003. We stratified donors into quartiles by baseline body mass index (BMI) assessing perioperative complications and 6-12 months post-donation metabolic and renal function. Compared to BMI <25 kg/m(2), high BMI donors (> or =35 kg/m(2)) had slightly longer operative times (mean increase 19 min), more overall perioperative complications (mostly minor wound complications), yet the same low rate of major surgical complications (conversion to open and re-operation) and similar length-of-stay (2.3 vs. 2.4 days). At 6-12 months after donation (mean 11 months), renal function and microalbuminuria did not differ with BMI. These results suggest that laparoscopic donor nephrectomy is generally safe in selected obese donors and does not result in a high rate of major perioperative complications. Obese donors have higher baseline cardiovascular risk and warrant risk reduction for long-term health. While early results are encouraging, we advocate careful study of obese donors and do not support their widespread use until longer follow-up is available.