Introduction: For Jehovah's Witnesses (JW) religious principles organ transplant is permitted but blood transfusions are proscribed. JW represents a challenge for the surgeon: even if often unnecessary, there is no proof that transfusions can be avoided systematically and safely. Especially for non-lifesaving organs, doubts remain about the wisdom to engage in such a complicated procedure. Moreover, denial of transfusions may be considered an additional risk factor for premature graft loss and might discourage transplant physicians from enrolling JW in their waiting lists. This study aims to describe a single-center experience and analyze the issues still present in surgical decision-making.
Methods: This was a retrospective observational single-center study. From 2013 to 2022, 19 JW received a KTx at our institution. Grafts procured from deceased donors were allocated to JW based on regional allocation rules. 3 living donations were performed. To secure JW's needs, various techniques have been developed for reducing the extent of bleeding and recovering the blood loss intraoperatively. A systematic literature review was carried out, analyzing publications from 1990 to 2023 concerning the application of bloodless surgery to organ transplantation. 
Results: An operative protocol, focused on the patient's cardiovascular system, has been established, allowing our center to achieve two major results: 1. no differences in DGF incidence between JW’s and the general population; 2. no statistical differences in the trend of kidney function. The intensity of the relationship between preoperative (preOp) and postoperative (postOp) hemoglobin (Hb) values in the JW population turned up to be statistically significant with a p-value of 0.007 and a confidence interval of 95%. We found a threshold of preOpHb value of 11.7 g/dl above which Hb values are highly likely to exceed 10g/dl in postOp, with an AUC = 0,55.
In the literature review, a total of 536 articles were found, but only 18 items were included after the text analysis: no established operative protocols have been previously described.
Conclusions: The ethical debate is still open on the risk of reduced chance of graft survival, which may be seen as a violation of the rights of non–JW recipients who might accept any therapy to save the organ. In the era of inclusions and unlimited medical resources, with worldwide connection between specialized centers, we think that might be unfair to deny transplant listing to a JW right up front and that the patient must be referred where clinicians are properly trained to take care of them. More effort is needed to establish international protocols that allow careful selection of candidates and optimize perioperative management. In the case of live-donation programs, donor safety is undoubtedly the ultimate concern. A comprehensive approach to bloodless surgery is a necessity for a successful outcome.