Semaglutide, a glucagon-like peptide-1 receptor agonist, has demonstrated efficacy for weight loss and glycemic control in patients with obesity and type 2 diabetes mellitus, but data are limited for patients with end-stage kidney disease on dialysis. We examined the weight loss efficacy and safety of semaglutide when prescribed to patients on dialysis to improve transplant candidacy and activation status. We conducted a retrospective chart review of 36 patients on dialysis who were prescribed semaglutide through a metabolic clinic between September 2021 and December 2023. Outcomes included weight loss efficacy, safety, and change in waitlist status at 1 year. Patients achieved a mean total body weight loss of 7.8% (SD 6.1). Of patients who were ineligible for transplant due to elevated body mass index, 48.2% achieved waitlist activation after successful weight loss. Treatment-limiting gastrointestinal side effects occurred in 16.7% of patients. Patients on peritoneal dialysis (PD, 30.8%) versus hemodialysis (8.7%) discontinued therapy more frequently. In a single-center cohort, patients who received semaglutide experienced significantly greater weight loss and increased rates of waitlist activation compared with a lifestyle-only intervention. Semaglutide was generally well-tolerated. Prospective studies should examine whether patients on PD experience severe GI side effects more frequently on semaglutide.