Obesity Management in End-Stage Kidney Disease: Pathways to Improve Kidney Transplant Access

Obesity is highly prevalent among patients with end-stage kidney disease (ESKD) and remains a major barrier to kidney transplantation, the optimal kidney replacement therapy for improving survival and quality of life. Weight loss strategies tailored to the ESKD population are urgently needed to expand access. This review examines the role of lifestyle interventions, pharmacotherapy, and bariatric surgery in supporting transplant candidacy. Although lifestyle modification is foundational, its effectiveness in ESKD is limited by metabolic, physical, and psychosocial barriers. Pharmacologic agents, particularly glucagon-like peptide-1 receptor agonists, offer promising weight loss and metabolic benefits although access and safety data in ESKD remain limited. Bariatric surgery, increasingly performed in this population, provides durable weight loss, especially for patients requiring ≥20% reduction in weight to meet the transplant body mass index criterion. We also highlight the systemic barriers, including payor policies, program-level variability, and disparities in access, that shape patient outcomes. An integrated approach combining clinical strategies with supportive policies is essential to reduce inequities and expand timely access to kidney transplantation for patients with ESKD and obesity.