Background: Obesity remains a major barrier to kidney transplantation despite the survival benefit of transplantation over dialysis. This study evaluated the cost-effectiveness of four strategies for adults with end-stage kidney disease and obesity undergoing kidney transplant evaluation in the United States. Methods: A state-transition Markov cohort model was developed from the health-sector perspective. Four strategies were compared: liberal waitlisting, bariatric surgery, glucagon-like peptide-1 receptor agonist therapy, and intensive lifestyle management. Inputs were drawn from publicly available evidence published between 2015 and 2023. The primary outcome was the incremental cost-effectiveness ratio per quality-adjusted life-year gained. Results: Over a 10-year horizon, liberal waitlisting had the lowest discounted cost ($246,100), whereas bariatric surgery had the highest discounted effectiveness (4.891 quality-adjusted life-years). Compared with liberal waitlisting, bariatric surgery increased cost by $35,400 and effectiveness by 0.079 quality-adjusted life-years, yielding an incremental cost-effectiveness ratio of $448,101 per quality-adjusted life-year gained, above conventional U.S. willingness-to-pay thresholds. Glucagon-like peptide-1 receptor agonist therapy improved outcomes versus lifestyle management but remained less efficient than bariatric surgery. Conclusions: Liberal waitlisting was the economically preferred strategy in the 10-year base-case analysis. Bariatric surgery produced the greatest health gain but was not cost-effective relative to liberal waitlisting, while glucagon-like peptide-1 receptor agonist therapy improved on lifestyle management without surpassing the other strategies in overall economic performance.