Purpose of Review <p>An aging population combined with increasing prevalence of obesity and obesity-related comorbidities will undoubtedly impact the incidence of end-stage kidney disease (ESKD) among older adults with obesity. Unfortunately, data to guide management of this growing population is scarce. Given the limited understanding of the unique challenges of assessing and managing older kidney transplant (KT) candidates with obesity, we provide this review of landmark studies and recent publications on the topic.</p> Recent Findings <p>Older adults on dialysis experience progressive frailty and cognitive decline with only 3.6% of those age ≥ 75 years maintaining good physical activity after 2 years of dialysis and 12.4% demonstrating cognitive impairment at admission for KT. Prehabilitation may moderate some of this decline but a recent pilot study, though promising, was limited by recruitment. Early access to transplantation likely provides the greatest benefit for older adults with ESKD and obesity but referral is often limited, perhaps because of provider bias. Robotic-assisted KT has been proposed to mitigate some of the surgical risks among patients with body mass index &gt; 40&#xa0;kg/m² but has not been extensively studied in older patients. Bariatric surgery and weight-loss medications are safe before or after KT among patients with ESKD and obesity but have also not been studied in older adults.</p> Summary <p>There is an increasing number of older adults with both ESKD and obesity, yet there remains limited data to guide clinical decision making. Future studies are necessary to prepare clinicians for the challenges of managing this vulnerable population.</p>