Surgery for Obesity and Related Diseases · Sep 21, 2026

Metabolic bariatric surgery versus GLP-1 receptor agonists in dialysis patients with diabetes and obesity: a target trial emulation study

By Gao C, Menon G, Chen Y et al.

BACKGROUND: Metabolic and bariatric surgery (MBS) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) are effective treatments for obesity and type 2 diabetes, but their comparative survival and waitlisting benefits in end-stage kidney disease (ESKD) remain unclear. OBJECTIVES: To compare survival and kidney transplant (KT) waitlisting after MBS and GLP-1RA use among patients with ESKD, using dipeptidyl peptidase-4 inhibitors (DPP-4is) as an active comparator. SETTING: US Renal Data System, 2010-2022. METHODS: We included adults with ESKD, type 2 diabetes, and ≥class II obesity treated with MBS, GLP-1RA, or DPP-4i. Three target trials were emulated: MBS versus GLP-1RA (N = 1818), MBS versus DPP-4i (N = 2111), and GLP-1RA versus DPP-4i (N = 4338). Cox models estimated adjusted hazard ratios (aHRs) for all-cause mortality and KT waitlisting over 1-5 years. RESULTS: MBS recipients were younger at dialysis initiation than matched GLP-1RA and DPP-4i users. MBS was associated with higher short-term mortality than matched GLP-1RA (1-year aHR = 2.68, 95% confidence interval [CI]:1.98-3.63; 3-year aHR = 1.34, 95% CI: 1.09-1.64) and DPP-4i users (1-year aHR = 1.74, 95% CI: 1.35-2.25), but comparable longer-term mortality. GLP-1RA users had consistently lower mortality than matched DPP-4i users. MBS was associated with higher KT waitlisting than GLP-1RA and DPP-4i use, with no differences between GLP-1RA and DPP-4i users. CONCLUSIONS: Among patients with ESKD, type 2 diabetes, and obesity, MBS was associated with higher short-term but comparable long-term mortality, whereas GLP-1RA use was associated with lower mortality than DPP-4i use. MBS was also associated with higher KT waitlisting than GLP-1RA and DPP-4i use, suggesting distinct risk-benefit profiles of metabolic treatment in this high-risk population.

doi.org/10.1016/j.soard.2026.09.014PubMed 42907282Interventions