Obesity is among the great health problems facing Americans today. More than 32% of the US population is considered obese on the basis of a body mass index (BMI) exceeding 30 kg/m2. Obesity increases the risk for numerous perioperative complications, but how obesity affects the outcome of liver transplantation remains unclear. We compared graft/patient survival after orthotopic liver transplantation performed at the Cleveland Clinic between April 2005 and June 2011 in 2 groups: obese patients with a BMI ≥ 38 kg/m2 and lean patients with a BMI between 20 and 26 kg/m2. We included 47 obese patients and 183 lean patients, whose demographics and baseline characteristics were well balanced after weighting with the inverse propensity score. After we controlled for observed confounding, no significant differences were observed in graft/patient survival between obese and lean patients (P = 0.30). The estimated hazard ratio for obese patients to experience graft failure or death was 1.19 [95% confidence interval (CI) = 0.85-1.67]. There were 134 patients who had follow-up for more than 3 years, and they included 27 obese patients and 107 lean patients. Within this subset, the odds of having metabolic syndrome were significantly greater for obese patients (46%) versus lean patients (21%; odds ratio = 4.76, 99.5% CI = 1.66-13.7, P < 0.001). However, no significant association between obesity and any other long-term adverse outcomes was found. In conclusion, this study shows that transplant outcomes were comparable for lean and obese recipients. We thus recommend that even morbid obesity per se should not exclude patients from consideration for transplantation. Liver Transpl 19:907-915, 2013. © 2013 AASLD.