*Purpose: The need for donor blood complicates the clinical translation of normothermic and subnormothermic perfusion for preservation and graft function evaluation. As such, hemoglobin-based oxygen carriers (like Hemopure) are of interest. In this study, we evaluate blood-free renal graft preservation and reperfusion with Hemopure. Additionally, we study the effect of adding hydrogen sulfide donor AP39 to Hemopure during preservation.

*Methods: Following 30m of warm ischemia to mimic donation after cardiac death (DCD), both kidneys were nephrectomized and preserved using static cold storage (SCS) on ice (4°C) or subnormothermic perfusion (21°C) with Hemopure or Hemopure + 200nM AP39 (n=6 in each group). Following 4h of preservation, all kidneys were reperfused (37°C) for 4h with Hemopure supplemented with nutrients. Urine output, tissue oxygenation and perfusate parameters (pH, lactate, pO₂, pCO₂, electrolytes) were measured hourly during reperfusion. Histopathological analyses were conducted after reperfusion.

*Results: Subnormothermic perfusion with Hemopure + 200nM AP39 resulted in significantly higher urine output (p<0.05) during preservation compared to perfusion with Hemopure alone. During reperfusion, kidneys preserved with Hemopure + 200nM AP39 exhibited significantly higher urine output (p<0.05) than kidneys preserved using SCS or Hemopure alone. Preservation with Hemopure and Hemopure + 200nM AP39 led to higher tissue oxygenation during reperfusion than SCS. All groups were comparable in terms of perfusate parameters and histopathology scores.

*Conclusions: We demonstrate, for the first time, that subnormothermic perfusion at 21°C with Hemopure + AP39 improves renal graft outcomes compared to SCS, the standard of care, using a blood-free model of preservation and reperfusion.

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