Blood type ABO-incompatible (ABOi) kidney transplantation has become established therapy for people with kidney failure. It can be a viable option for some individuals with an ABOi living donor to overcome the continued disparity between supply and demand for deceased donor kidneys. However, recent meta-analyses from published cohort studies demonstrate inferior survival outcomes when comparing ABOi and ABO-compatible kidney transplant recipients.1,2 The caveat to these studies is the comparison between apples and pears: patients undergoing ABOi kidney transplantation from a living donor do not have an alternative compatible kidney offer to consider.