Obesity is highly prevalent among patients with end-stage kidney disease (ESKD) and remains a major barrier to kidney transplantation, the optimal kidney replacement therapy for improving survival and quality of life. Weight loss strategies tailored to the ESKD population are urgently needed to expand access. This review examines the role of lifestyle interventions, pharmacotherapy, and bariatric surgery in supporting transplant candidacy. While lifestyle modification is foundational, its effectiveness in ESKD is limited by metabolic, physical, and psychosocial barriers.