Patients with type 2 diabetes (T2D) receiving dialysis have a very high risk of cardiovascular events. Evidence for the cardiovascular effectiveness of glucagon-like peptide-1 receptor agonists (GLP-1RAs) in this population remains limited. Here, we assessed this issue using a target trial emulation framework.

We conducted a cohort study using a Japanese administrative claims database. We included adults aged 20 years or older with T2D receiving maintenance dialysis who initiated a GLP-1RA or a DPP-4i between April 2015 and March 2023. The primary outcome was the 3-year risk of major adverse cardiovascular events (MACE), defined as a composite of acute myocardial infarction, stroke, and cardiovascular death. The observational analogue of the per-protocol effect was estimated using pooled logistic regression with inverse probability weighting to adjust for baseline and time-varying confounders.

Among 4,793 patients (557 GLP-1RA initiators and 4,236 DPP-4i initiators), the estimated 3-year risk of MACE was 29.7% (95% CI, 22.3% to 38.3%) for GLP-1RA users and 37.6% (95% CI, 35.2% to 40.8%) for DPP-4i users, giving a risk difference of −8.0% (95% CI, −15.5% to 0.9%) and risk ratio of 0.79 (95% CI, 0.59 to 1.03).

Compared with DPP-4is, sustained use of GLP-1RAs may reduce the risk of MACE among patients with T2D receiving maintenance dialysis. These findings suggest a potential cardiovascular benefit but require confirmation in randomized controlled trials before introduction into clinical practice.