Transfusion-free kidney transplantation in Jehovah’s witnesses: a propensity-score matched cohort study

Background Jehovah’s Witnesses (JWs) refuse blood transfusions on religious grounds, creating a major challenge in kidney transplantation (KT), where perioperative bleeding may necessitate transfusion support. Evidence regarding transfusion-free KT in JWs remains limited. We evaluated the feasibility and early clinical outcomes of a transfusion-free KT protocol in JW patients. Methods We performed a single-centre propensity score–matched cohort study including all JW recipients who underwent KT under a transfusion-free protocol between 2016 and 2025. The protocol included pre-transplant haemoglobin optimisation to ≥13 g/dL. JW recipients were matched 1:3 to non-JW controls based on recipient age and sex, donor type, and transplant date. Outcomes included peri-transplant transfusion, anaemia management, bleeding-related complications, and early post-transplant results. Results 27 JW recipients and 74 controls were included. Peri-transplant transfusion was completely avoided in JW recipients (0/27), whereas 24/74 controls (32.4%) required transfusion support. Bleeding-related complications occurred in 14.8% of JW recipients and 11.3% of controls (RR 1.65, 95% CI 0.44–6.21). Admission haemoglobin was higher in JW recipients (14.2 vs 11.5 g/dL; MD 2.69, 95% CI 2.15–3.22), as was nadir haemoglobin (10.0 vs 8.5 g/dL; MD 1.50, 95% CI 0.55–2.45). However, the absolute decrease from admission to nadir was greater in JW recipients (4.14 vs 3.01 g/dL; MD 1.13, 95% CI 0.21–2.06). Hospital stay was longer in JW recipients (MD 5.2 days, 95% CI −0.10 to 10.31). Conclusions A transfusion-free KT protocol was feasible in JW recipients managed at an experienced centre and enabled complete avoidance of peri-transplant transfusion. Early outcomes are reported descriptively and should be interpreted with caution because of the small sample size and residual imbalance between groups.