Patients from the Jehovah’s Witness (JW) faith are considered high-risk surgical candidates as their religious beliefs forbid them from accepting most blood components, even if it is deemed lifesaving treatment. A blood group incompatible (ABOi) kidney transplant recipient and living donor pair, who are both of JW faith, were referred for assessment to the Royal Prince Alfred Hospital renal transplant unit that raised multiple medical, surgical and ethical considerations. The risks of blood loss and the inability to provide lifesaving blood transfusion is a common risk of surgery on JW patients. Recent studies from overseas show that peri-operative mortality in JW is 6% and predominantly due to anaemia secondary to blood loss. The aim of this case review is to explore the transplant options available to ABOi living donor pairs who are Jehovah’s Witnesses. It also aims to explore common strategies to optimise their haemoglobin prior to their surgery to mitigate this risk.