Incretin therapy and transplant readiness: Distinguishing BMI-based access from physiologic reserve in solid organ transplantation

Obesity and metabolic disease frequently shape transplant candidacy, and body mass index (BMI) remains embedded in evaluation and listing criteria. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and dual GLP-1/glucose-dependent insulinotropic polypeptide (GIP) agonists now offer non-surgical pathways to clinically meaningful weight loss, including among candidates previously limited by BMI thresholds. However, in transplantation, crossing a BMI cutoff does not necessarily establish readiness for major surgery, immunosuppression, rehabilitation, and graft-protective follow-up. This focused narrative review examines evidence on incretin-based therapy in solid organ transplant candidates and recipients and proposes a distinction between an access response (achievement of BMI-related eligibility or listing goals) and a reserve response (weight loss accompanied by preserved or improved body composition, muscle strength, function, nutrition, cardiopulmonary tolerance, treatment tolerability, and immunosuppressive stability). Available transplant data are promising but largely observational and centered on weight, glycated hemoglobin, graft function, tacrolimus troughs, listing, and transplantation. Measures of lean mass, frailty trajectory, handgrip strength, gait speed, nutritional adequacy, patient-reported outcomes, perioperative events, and tacrolimus exposure variability remain underreported. We outline reserve-sensitive monitoring domains, an operational reserve-response matrix that classifies concordant favorable, access-only, metabolic-only, depletion, intolerance, pharmacokinetic-instability, and perioperative-risk trajectories, and reporting priorities for future studies. Incretin therapy may become an important bridge to transplantation, but its success should not be defined by BMI reduction alone. Prospective studies should determine whether BMI-based access gains are accompanied by preserved or improved physiologic reserve and safer progression to transplantation.