GLP-1 Drugs on Dialysis and the Kidney Transplant Waiting List: BMI Cutoffs, Survival Data, and the Trials Still Running

For many people on dialysis, a kidney transplant is the best treatment available, and body weight can decide whether they are allowed to wait for one. Most U.S. transplant programs set a body mass index (BMI) limit for listing, most often 40. BMI is weight in kilograms divided by height in meters squared. That puts GLP-1 drugs such as semaglutide (Ozempic, Wegovy) and tirzepatide (Mounjaro, Zepbound) in an unusual position: for some patients, weight loss is not only a health goal but the condition for getting a new kidney.

The evidence for people on dialysis is growing, but almost all of it is observational. That means researchers looked back at records of people who did or did not take the drugs, rather than randomly assigning them. Several large U.S. studies link GLP-1 drugs to lower death rates on dialysis and, in one study, to a 66% higher chance of being added to the transplant waiting list. Small clinic reports describe patients who lost enough weight to be listed and then received a kidney. No randomized trial has yet tested whether starting a GLP-1 drug on dialysis helps people live longer or get transplanted, and the first ones are still enrolling.

This guide covers what the studies found, the safety questions that matter on dialysis and around transplant surgery, and what is known about using these drugs after a transplant. For the FLOW trial and GLP-1 drugs in earlier-stage kidney disease, see Ozempic for Kidney Disease: What the FLOW Trial Changed.

Transplant teams worry that obesity raises the risk of problems after surgery, such as slow wound healing. Many programs therefore use a BMI cutoff when deciding who to evaluate and list.

A 2024 survey of U.S. kidney transplant programs, run by an American Society of Transplantation work group and published in the American Journal of Transplantation in 2025, drew responses from 113 programs that handle about 71% of U.S. transplants. It found that 72.5% of programs used a BMI cutoff for evaluation and 74.3% for listing, most commonly 40. A 2024 survey of UK kidney providers, covering 78.6% of UK kidney centres, found listing rules varied widely and the most common cutoff was a BMI of 35 or below. Only about a third of UK respondents reported using incretin drugs, the class that includes GLP-1 drugs, to help patients lose weight before transplant.

International guidance is less strict than many programs. The 2020 KDIGO guideline on evaluating transplant candidates says candidates should not be excluded from transplantation solely because of obesity. In practice, a patient with a BMI of 42 at a program with a cutoff of 40 needs to lose roughly 5% of body weight, while a patient with a BMI of 50 needs to lose about 20%. A 2026 review in the American Journal of Kidney Diseases noted that bariatric surgery gives the most durable weight loss for patients who need to lose 20% or more to meet a program's BMI criterion.

Dialysis replaces some of the work of failed kidneys. In hemodialysis, blood is filtered through a machine, often three times a week at a clinic. People on dialysis have high rates of heart disease and death, and about 60% of the roughly 808,000 Americans on dialysis have diabetes, according to the 2025 study described below.

The major GLP-1 trials did not include them. FLOW, the kidney trial that won semaglutide its kidney indication, required an estimated glomerular filtration rate (eGFR) of at least 25 and excluded anyone on dialysis or who had been on dialysis in the previous 90 days. eGFR is a blood-test estimate of how well the kidneys filter; FLOW counted an eGFR below 15 as kidney failure.

Several studies have since used national dialysis records:

• NYU, 2025 (Clinical Journal of the American Society of Nephrology). Among 151,649 adults with type 2 diabetes who started dialysis from 2013 to 2021, GLP-1 use was associated with 23% lower mortality (adjusted hazard ratio 0.77) and a 66% higher chance of being added to the transplant waiting list (adjusted hazard ratio 1.66). Users lost an average of 4.0 kg, compared with 1.5 kg among nonusers.
• DaVita, 2026 (same journal). In 2,492 patients who started in-center hemodialysis with a GLP-1 prescription, each matched with a patient without one, GLP-1 use was associated with a 9% lower hospitalization rate and a 17% lower death rate.
• Duke, 2026 (Journal of the American Society of Nephrology). Compared with matched users of DPP-4 inhibitors, an older class of diabetes pills, new GLP-1 users on dialysis had a 13% lower risk of heart attack, stroke, or death and 17% lower mortality over up to two years.
• Thomas Jefferson University, 2026 (Kidney International Reports). Here the result depended on whether patients kept taking the drug. Comparing everyone who started a GLP-1 with everyone who started a DPP-4 inhibitor, mortality was about the same (hazard ratio 0.98). Among people who stayed on treatment, GLP-1 users had 19% lower mortality. But 53% of GLP-1 users had stopped within a year, compared with 42% of DPP-4 users.
• Thomas Jefferson University, 2026 (Diabetes Care). Among 3,913 hemodialysis patients, semaglutide users had lower mortality than dulaglutide or liraglutide users (subdistribution hazard ratio 0.82; one-year death rate 11% vs. 13%) and lost more weight at one year (4.8% vs. 3.4%). The advantage held against dulaglutide but was not statistically significant against liraglutide alone.

These studies adjust for many differences between patients, but they cannot rule out that healthier patients were more likely to be prescribed a GLP-1 drug. An October 2026 editorial in the Clinical Journal of the American Society of Nephrology summed up the situation in its title: "The Evidence Grows, but Trials Must Follow."

The NYU study's 66% higher waitlisting rate is the strongest population-level signal, and smaller clinic reports describe how it can play out for individual patients.

At HUB-Erasme hospital in Brussels, 23 dialysis patients who had been turned down for transplant because of obesity received semaglutide up to 1 mg weekly from 2021 to 2023. After a median of about 12 months, they had lost an average of 11.4 kg and 3.9 BMI points. Thirteen (56.5%) were added to the waiting list within a median of 5.4 months, and 8 of those 13 received a transplant. Of the 10 who were not listed, 9 had not lost enough weight. Nearly half reported mild stomach symptoms, and one stopped the drug because of them. The study, published in Frontiers in Transplantation in 2025, had no comparison group.

At the Medical University of Vienna, a 12-week open-label study gave semaglutide to 13 dialysis patients with a BMI of 30 or higher who had not been listed because of their weight. They lost an average of 4.6 kg, one stopped because of nausea and vomiting, and two died of causes the authors judged unrelated. About nine months after starting, three were able to seriously reconsider being listed.

Not every analysis agrees. A 2026 study of U.S. Renal Data System records, published in Surgery for Obesity and Related Diseases, compared patients with type 2 diabetes and at least class II obesity (BMI 35 or higher). GLP-1 users were no more likely to be waitlisted than DPP-4 inhibitor users, while bariatric surgery patients were more likely to be waitlisted than either group. Surgery also carried higher mortality in the first one to three years. At a Vancouver transplant program, GLP-1 users lost an average of 2.5 kg at 12 months, which the authors called modest.

A 2026 review in Transplantation Reviews raised another caution: reaching a BMI cutoff is not the same as being ready for surgery. The authors argue that programs should also track muscle strength, nutrition, and frailty, because weight lost as muscle could leave a patient less able to recover. Few transplant studies measure those things.

The closest thing to randomized data comes from a 2026 Diabetes Care analysis of four large semaglutide trials (SUSTAIN-6, SELECT, FLOW, and SOUL). Of 34,064 participants, 307 started dialysis during the trials, and 165 stayed on their assigned treatment afterward: 71 on semaglutide and 94 on placebo. Serious adverse events occurred in 45% of the semaglutide group and 57% of the placebo group. The rate of major heart events was 9.7 vs. 16.1 per 100 person-years, and the death rate was 13.8 vs. 18.1. Because this was a small analysis done after the trials ended, the authors concluded only that continuing semaglutide after dialysis starts appears safe and that efficacy should be tested.

Trials built for dialysis and transplant patients are under way, according to ClinicalTrials.gov:

• DIALYSIS-TIR (NCT06042153), UT Southwestern. 43 people with type 2 diabetes on dialysis randomized to semaglutide or placebo, measuring time with blood sugar in range. Enrollment is closed, with primary completion expected in 2027.
• NCT07017270, Unity Health Toronto. About 100 dialysis patients randomized to weekly semaglutide or usual care for 26 weeks, to test whether a larger heart-outcomes trial is feasible.
• OK-TRANSPLANT 2 (NCT06396416), Western University in Ontario. About 60 people with obesity and advanced kidney disease or dialysis who hope to be transplanted, randomized to semaglutide with virtual weight-management coaching or to usual care. It is testing whether the larger trial can recruit enough patients.
• NCT07858331. A larger trial using the same semaglutide-and-coaching approach, with an estimated 880 participants and change in body weight as its main outcome, is not yet recruiting.

None of these is large enough to show whether GLP-1 drugs help dialysis patients live longer.

Dosing and kidney function. The FDA labels for Ozempic and for Zepbound say no dose adjustment is recommended for kidney impairment, and studies found no meaningful change in drug levels in people with kidney failure. Both labels warn about acute kidney injury caused by dehydration, which has sometimes required dialysis. Most reported cases followed nausea, vomiting, or diarrhea. For people on dialysis who still make some urine, ask how the team will protect the kidney function that remains.

Low blood sugar. The labels warn that the risk of low blood sugar rises when a GLP-1 drug is combined with insulin or a sulfonylurea, and the tirzepatide label advises considering a lower insulin or sulfonylurea dose when starting.

Stomach side effects and stopping. Nausea and vomiting are the most common reasons people stop. In the Kidney International Reports study, more than half of GLP-1 users on hemodialysis had stopped within a year, and gastrointestinal symptoms were 11% more common than with DPP-4 inhibitors. See GLP-1 Nausea Peaks During the Dose Climb for what helps.

Eyes. Two of the largest studies found more diabetic retinopathy among GLP-1 users: 32% more in the NYU dialysis study and 49% more in a related study of transplant recipients. People who already have diabetic eye disease should ask whether they need closer eye exams. See GLP-1 Drugs and Your Eyes.

Muscle and nutrition. Weight lost on a GLP-1 drug includes some lean mass. The Transplantation Reviews authors found that transplant studies rarely report muscle mass, handgrip strength, walking speed, or nutrition, and they want programs to track these along with BMI. See GLP-1 Weight Loss and Lean Mass.

A kidney from a deceased donor can become available with only hours of notice, and GLP-1 drugs slow how fast the stomach empties. That creates a specific risk: stomach contents could be inhaled into the lungs under general anesthesia, even after a normal fast.

In a 2025 commentary in Clinical Kidney Journal, transplant and anesthesia specialists at Manchester University NHS Foundation Trust wrote that waitlisted patients on GLP-1 drugs are especially vulnerable because an aspiration could go unnoticed after they have already received immunosuppressive drugs. They noted that the size of the risk is unclear and should not be exaggerated. Their unit does not stop GLP-1 drugs before surgery, because the drugs last too long for a short pause to help reliably. Instead they suggested steps such as checking the stomach with bedside ultrasound before anesthesia and making sure the whole team knows the patient is on a GLP-1 drug.

Patients on a waiting list should make sure the transplant center, not only their dialysis unit, knows they take one. For general guidance on GLP-1 drugs before surgery, see GLP-1s and Surgery.

Diabetes, weight, and other metabolic problems after a kidney transplant affect how long both the patient and the new kidney survive. GLP-1 drugs are increasingly used in this group, though again mostly outside trials.

The largest study, published in The Lancet Diabetes & Endocrinology in 2025 by the NYU group, followed 18,016 Medicare-covered kidney recipients who had type 2 diabetes at transplant; 1,969 filled a GLP-1 prescription afterward. GLP-1 use was associated with 49% lower risk of losing the new kidney (adjusted subhazard ratio 0.51) and 31% lower mortality (adjusted hazard ratio 0.69). Diabetic retinopathy was the one safety outcome that was more common, with an adjusted hazard ratio of 1.49. The authors called for clinical trials to confirm the findings.

A 2026 meta-analysis in Clinical Kidney Journal pooled 17 studies of 54,680 kidney transplant recipients. GLP-1 use was linked to lower blood sugar, lower BMI, stable or slightly better kidney function, and lower mortality in the four studies that measured it. Tacrolimus levels were unchanged at six months and modestly lower at one year without harming the kidney. Side effects were mainly mild stomach symptoms in 10% to 20% of patients. A 2025 study from San Antonio of 76 organ recipients found tacrolimus blood levels were similar before and after starting a GLP-1 drug.

GLP-1 drugs slow stomach emptying, and their labels note this can affect how oral medicines are absorbed. Tacrolimus, the main anti-rejection drug, is taken by mouth, so ask how often your levels will be checked. A randomized trial in Copenhagen (NCT05702931) is testing oral semaglutide against placebo for high blood sugar in the first weeks after kidney transplant, with primary completion expected in December 2027.

• What BMI does this transplant program require for evaluation and for listing, and how much weight would I need to lose?
• Does the program count weight loss from a GLP-1 drug, and does it also check muscle strength, nutrition, or frailty?
• Would a GLP-1 drug, bariatric surgery, or both make more sense for the amount of weight I need to lose?
• If I take insulin or a sulfonylurea, how will those doses change, and how will low blood sugar be watched?
• Do I still make urine, and how will you protect my remaining kidney function if I get nausea or diarrhea?
• Should I have an eye exam before starting, given the retinopathy findings?
• If I am called for a transplant, what should I tell the transplant team about my GLP-1 drug and when I last injected it?
• After a transplant, how often will my tacrolimus levels be checked if I start or change a GLP-1 drug?
• Will Medicare or my plan cover the drug for diabetes or for weight loss in my situation? See The Medicare GLP-1 Bridge for current Medicare rules.

GLP-1 drugs are now used on dialysis and after kidney transplant, even though the trials that proved their benefits left these patients out. Large record studies link the drugs to lower death rates in both groups. Clinic reports show some patients losing enough weight to be listed and then transplanted.

The limits are real. The studies are observational, and one large analysis found no listing advantage over another diabetes drug. More than half of dialysis patients stop within a year, and diabetic eye disease and anesthesia during a transplant call need specific attention. The first randomized trials are running now, and until they report, the decision belongs to a nephrologist and transplant team who know the individual patient.