Patients with type 2 diabetes mellitus (T2DM) receiving maintenance dialysis remain at very high cardiovascular risk, while comparative outcome data for incretin-based therapies are limited in this setting. A cohort study using a target trial emulation framework, published in Diabetes, Obesity and Metabolism, evaluated cardiovascular outcomes with glucagon-like peptide-1 receptor agonists (GLP-1RAs) versus dipeptidyl peptidase-4 inhibitors (DPP-4 inhibitors) in this population.

The analysis used a Japanese administrative claims database and included adults aged 20 years or older with T2DM receiving maintenance dialysis who initiated either a GLP-1RA or a DPP-4 inhibitor between April 2015 and March 2023. The primary outcome was 3-year major adverse cardiovascular events (MACE), defined as acute myocardial infarction, stroke, or 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 initiated a GLP-1RA and 4,236 initiated a DPP-4 inhibitor. The estimated 3-year risk of MACE was 29.7% (95% confidence interval [CI] 22.3% to 38.3%) in GLP-1RA users and 37.6% (95% CI 35.2% to 40.8%) in DPP-4 inhibitor users. This corresponded to an absolute risk difference of −8.0% (95% CI −15.5% to 0.9%) and a risk ratio of 0.79 (95% CI 0.59 to 1.03).

These findings suggest sustained GLP-1RA use may be associated with lower cardiovascular risk than DPP-4 inhibitor therapy in patients with T2DM receiving dialysis. Randomized controlled trials are needed before these results are applied to routine clinical practice.