All data from Necker Hospital regarding the donors and recipients were extracted from the

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1 SUPPLEMENTAL MATERIAL Data collection procedures All data from Necker Hospital regarding the donors and recipients were extracted from the DIVAT clinical prospective cohort (official website: Data from Saint-Louis Hospital were extracted from the French national registry agency (Agence de la Biomédecine) database CRISTAL (official website: The DIVAT and CRISTAL database networks have been approved by the National French Commission for Bioinformatics Data and Patient Liberty: DIVAT: CNIL, registration number: , validated June 8, 2004, and CRISTAL: CNIL, registration number: , validated April 3, Codes were used to ensure strict donor and recipient anonymity and blinded assays. Informed consent was obtained from the participants at the time of transplantation. The data were computerized in real time as well as at each transplant anniversary and were submitted for an annual audit. Post-transplantation induction protocols and maintenance of immunosuppressive therapy All patients received induction therapy consisting of rabbit antithymocyte globulin (1.5 mg per kg per day, for 10 days) or basiliximab (20 mg at day 0 and day 4) immediately after transplantation. All sensitized patients were induced with rabbit antithymocyte globulin. In addition, patients considered to be at the highest immunological risk (i.e., those with preexisting DSA according to a Luminex assay and cytotoxic reactivity with a historical positive CXM or PRA>20%) received supplementary immunosuppression at the time of transplantation, which consisted of prophylactic high-dose intravenous immunoglobulin (IVIg) courses, 5 plasma exchange sessions and Rituximab (375 mg per square meter of body surface area). Intravenous immunoglobulin was administered at a dose of 2 g/kg BW over 72 1

2 hours. The first IVIg course was started before reperfusion, with subsequent courses given on days 21, 42 and 63 after kidney transplantation. Subsequent maintenance immunosuppressive protocols consisted of prednisone, mycophenolate mofetil (1000 mg twice daily), tacrolimus (administered to maintain a target blood level of 8 to 10 ng per ml for the first 3 months and 6 to 8 ng per ml thereafter), or cyclosporine (administered to maintain a target C2 blood level of 800 to 1200 ng per ml for the first 3 months and 600 to 800 ng per ml thereafter). Treatment of allograft rejection episodes Patients with rejection episodes that were diagnosed as T-cell-mediated were treated with methylprednisolone pulses (500 mg/d for 3 days). Patients with rejection uncontrolled by this regimen received additional rabbit antithymocyte globulin (1.5 mg per kg per day for 5 days) or muromonab-cd3 (5 mg/d for 5 days). Patients who had episodes of antibody-mediated rejection were initially given methylprednisolone pulses (500 mg per day for 3 days), intravenous immunoglobulin (2 g per kg, repeated every three weeks for 4 rounds), four plasmaphereses and two weekly doses of rituximab (375 mg per square meter of body surface area), following the January 2004 recommendations of the French Society for Organ Transplant. 2

3 SUPPLEMENTAL RESULTS Research in context We searched the PubMed database for reports in any language published before April 16, 2015, with the search terms cardiovascular risk factors, arteriosclerosis and antibodies. We identified 382 reports overall, of which 101 were reviews, 3 were letters, 2 were responses to letters, 1 was an editorial, 1 was a survey, 11 were studies in small animals, 8 were in vitro studies, 9 were case reports, 6 were randomized controlled trials and 240 were observational studies performed in humans; 57 studies addressed the association between antibodies and arteriosclerosis in autoimmune settings and 77 studies in infectious settings, 27 studies addressed the association between lipid-related antibodies and arteriosclerosis, 10 studies addressed the association between anti-heat shock protein antibodies and arteriosclerosis, 3 studies addressed the association between donor-specific anti-hla antibodies and chronic allograft vasculopathy in heart allografts, and 66 studies addressed an association between various biomarkers/surrogate markers and arteriosclerosis. Among the 174 studies addressing an association between antibodies and arteriosclerosis, we found 3 population-based prospective studies (anti-phosphorylcholine, anti-oxidized LDL and anti-phospholipid antibodies). None of these studies integrated the simultaneous assessment of circulating antibodies, arteries, traditional cardiovascular risk factors and clinical events. 3

4 SUPPLEMENTAL TABLE AND FIGURE LEGENDS Online Table I: Determinants of MACE after 1 year: univariate Cox analysis. Online Table II: Characteristics of circulating anti-hla DSA based on MACE occurrence. Online Table III: Determinants of arteriosclerosis comparing cv scores of 1, 2 and 3 vs. 0 in a single multinomial logistic regression analysis. Online Table IV: Determinants of arteriosclerosis using grade of arteriosclerosis as a continuous variable in a generalized linear model. Online Table V: Determinants of severe arteriosclerosis at 1 year: multivariate analysis integrating the preimplantation evaluation of arteriosclerosis via biopsy. Online Table VI: Multivariate Cox model of the determinants of MACE, excluding PAD. Online Table VII: Baseline patient characteristics at the time of transplantation (principal and validation cohort). Online Table VIII: Determinants of severe arteriosclerosis: multivariate analysis (validation set, n=321). Online Table IX: Allograft injury phenotype according to arteriosclerotic lesions at 1 year in the validation cohort (N=321). Online Figure IA: Kidney allograft survival in the validation cohort. Online Figure IB: Patient survival in the validation cohort. 4

5 Online Table I: Determinants of MACE after 1 year: univariate Cox analysis. of patients of MACE OR 95% CI p Recipient cardiovascular profile at time of transplantation Age (per 1-yr increment) [ ] < Sex Female Male [ ] Hypertension No Yes [ ] Diabetes mellitus No Donor cardiovascular profile Yes [ ] Hypercholesterolemia No Yes [ ] Tobacco No Yes [ ] Body mass index (per 1-kg/m² increment) History of MACE No [ ] Yes [ ] Age (per 1-yr increment) [ ] Sex Female Male [ ] Hypertension No Yes [ ] Diabetes mellitus No Yes [ ] Hypercholesterolemia No Yes [ ] Tobacco No Yes [ ] Donor type Living Cardiovascular cause of death [ ] Other cause of death [ ]

6 Online Table I (continued) Transplant characteristics Recipient cardiovascular profile post-transplant of patients of MACE OR 95% CI p Graft Rank > [ ] Cold ischemia time [ ] < (per 1-hour increment) HLA A/B/DR mismatch [ ] Systolic blood pressure (per mmhg increment) [ ] Diastolic blood pressure (mmhg) [ ] Diabetes mellitus No Yes [ ] Blood LDL [ ] Immunological and functional profile post-transplant Antihypertensive No treatment Yes [ ] Antiaggregant treatment No Yes [ ] Statin treatment No Yes [ ] Calcineurin inhibitor No treatment Yes [ ] Corticosteroid dose (per mg increment) Delay graft function No [ ] Yes [ ] Allograft GFR at 6 months Acute rejection episode No Circulating donorspecific antibodies [ ] [ ] Yes [ ] No Yes [ ]

7 Online Table II: Characteristics of circulating anti-hla DSA based on MACE occurrence. Patients with MACE Patients without MACE p DSA characteristics N N DSA (no., %) (40%) (22%) HLA class of DSA (no., %) I II 29 9 (31%) 20 (69%) (35%) 96 (65%) DSA MFI (mean±sem) ± ± Complement-binding DSA (no., %) (62%) (20%) <0.0001

8 Online Table III: Determinants of arteriosclerosis comparing cv scores of 1, 2 and 3 vs. 0 in a single multinomial logistic regression analysis. cv scores of patients OR 95% CI p Donor age (per 1-yr increment) vs [ ] 2 vs [ ] 3 vs [ ] < Donor diabetes mellitus No 1 vs Yes 1 vs [ ] No 2 vs Yes 2 vs [ ] No 3 vs Yes 3 vs [ ] Cold ischemia time (per 1-hour increment) [ ] Post-transplant recipient hypertension requiring antihypertensive therapy [ ] [ ] No Yes [ ] No Yes [ ] Circulating donor-specific antibodies* No Yes [ ] No Yes [ ] No Yes [ ] No Yes [ ] <0.0001

9 Online Table IV: Determinants of arteriosclerosis using grade of arteriosclerosis as a continuous variable in a generalized linear model. of patients ß (s.e.) Arteriosclerosis means p Donor age (per 1-yr increment) ( ) < Donor diabetes mellitus No Yes 29 ( ) Cold ischemia time (per 1-hour increment) 664 Post-transplant recipient hypertension requiring antihypertensive therapy ( ) No Yes 592 ( ) Circulating donor-specific antibodies No Yes 168 ( ) <0.0001

10 Online Table V: Determinants of severe arteriosclerosis at 1 year: multivariate analysis integrating the preimplantation evaluation of arteriosclerosis via biopsy. of patients of patients with severe arteriosclerosis at 1 year OR 95% CI p Donor age (per 1-yr increment) [ ] < Donor diabetes mellitus No Yes [ ] Circulating donor-specific antibodies No Severe arteriosclerosis on preimplantation biopsy Yes [ ] No Yes [ ] The final multivariate logistic regression model was obtained by entering risk factors from the univariate model that reached p and including the preimplantation biopsy-based evaluation of arteriosclerosis as the threshold in the single multivariate proportional hazards model. The final multivariate model was adjusted for the following parameters: recipient age, donor hypertension, donor hypercholesterolemia, donor type, recipient systolic blood pressure, allograft GFR post-transplant, cold ischemia time, and recipient blood profile posttransplant.

11 Online Table VI: Multivariate Cox model of the determinants of MACE, excluding PAD. of patients of MACE HR 95% CI p Recipient age (per 1-yr increment) [ ] Recipient history of MACE No Yes [ ] Recipient diabetes mellitus posttransplant No Yes [ ] Cold ischemia time (per 1-hour increment) Circulating donor-specific antibodies [ ] No Yes [ ]

12 Online Table VII: Baseline patient characteristics at the time of transplantation (principal and validation cohorts). N Principal cohort (N=744) N Validation cohort (N=321) p Recipient characteristics Age (years) ± ± Male sex - no. (%) (58%) (58%) Retransplantation - no. (%) (19%) (17%) Time since dialysis (years) ± ± Donor characteristics Age (years) ± ± Male sex - no. (%) (55%) (56%) Deceased - no. (%) (81%) (88%) Cold ischemia time (hours) ± ±7.8 < Immunologic characteristics HLA A/B/DR mismatch - no. (%) ± ±1.4 < Recipient blood group type A/B/O/AB /57/326/ /39/128/ Anti-HLA DSA at day 0 - no (%) (20%) (20%) 0.861

13 Online Table VIII: Determinants of severe arteriosclerosis: multivariate analysis (validation set, N=321). OR 95% CI p Donor age (per 1-yr increment) [ ] < Donor diabetes mellitus (Yes/No) [ ] Cold ischemia time (per 1-hour increment) [ ] Recipient hypertension post-transplant requiring antihypertensive therapy (Yes/No) [ ] Circulating donor-specific antibodies (Yes/No) [ ] 0.041

14 Online Table IX: Allograft injury phenotype based on arteriosclerotic lesions at 1 year in the validation cohort (n=321). Minimal arteriosclerosis (N=198) Severe arteriosclerosis without antibodies (N=72) N N N Severe arteriosclerosis with antibodies (N=51) p C4d deposition no. (%) (5%) 72 0 (0%) 51 5 (10%) Microcirculatory inflammation no. (%) (20%) (18%) (59%) < Arteritis no. (%) (5%) 72 1 (1%) 51 9 (18%) Arterial hyalinosis no. (%) (50%) (83%) (84%) < Fibrosis-atrophy no. (%) (47%) (86%) (90%) <0.0001

15 Online Figure IA: Kidney allograft survival in the validation cohort.

16 Online Figure IB: Patient survival in the validation cohort.