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1 Supplementary Online Content Zarbock A, Schmidt C, Van Aken H, et al; for the RenalRIPC Investigators. Effect of remote ischemic preconditioning on kidney injury among high-risk patients undergoing cardiac surgery: a randomized clinical trial. JAMA. doi: /jama/ The RenalRIPC Investigators etable 1. etable 2. Cleveland Clinic Foundation Score KDIGO criteria efigure S. Percentage of patients with postoperative AKI stratified by urinary [TIMP-2] [IGFBP7] concentration efigure S. Forest plot randomized controlled trials efigure S. Proposed conceptual model for how RIPC results in fewer AKI events ereferences This supplementary material has been provided by the authors to give readers additional information about their work.

2 The RenalRIPC Investigators The members of the RenalRIPC Trial are as follows: Coordinating Center: Alexander Zarbock, Christoph Schmidt, Hugo Van Aken, Carola Wempe, Sven Martens, Dennis Görlich, Melanie Meersch. Recruiting Centers (Site Principal Investigators are listed in Italics) - University Hospital Bochum, Bochum, Germany Peter K. Zahn, Britta Wolf. University Hospital Freiburg, Freiburg, Germany Ulrich Goebel, Christian I. Schwer. University Hospital Tübingen, Tübingen, Germany Peter Rosenberger, Helene Haeberle. University of Pittsburgh, PA, USA John A. Kellum.

3 Supplementary Tables etable S1: Cleveland Clinic Foundation Score according to Thakar et al. 1 Risk Factor Points Female gender 1 Congestive heart failure 1 Left ventricular ejection fraction < 35% 1 Preoperative use of Intra-aortic ballon pump (IABP) 2 Chronic obstructive Pulmonary Disease (COPD) 1 Insulin-requiring diabetes 1 Previous cardiac surgery 1 Emergency surgery 2 Valve surgery only 1 Coronary Artery Bypass Grafting + valve surgery 2 Other cardiac surgeries 2 Preoperative creatinine 1.2 to <2.1 mg/dl (reference to 1.2) 2 Preoperative creatinine 2.1 /reference to 1.2) 5

4 etable S2: KDIGO criteria according the KDIGO guidelines 2 Stage Serum creatinine Urine output times baseline < 0.5 ml/kg/h for 6-12 hours OR 0.3 mg/dl increase times baseline < 0.5 ml/kg/h for 12 hours times baseline OR Increase in serum creatinine to 4.0 mg/dl OR < 0.3 ml/kg/h for 24 hours OR Anuria for 12 hours Initiation of renal replacement therapy

5 Supplementary Figures efigure S1. - Percentage of patients with postoperative AKI stratified by urinary [TIMP-2] [IGFBP7] concentration before (A) and 4h after (B) CPB. PB, cardiopulmonary bypass. Patients with missing data (due to missing samples) were excluded for the respective analysis.

6 efigure S2. Meta-analysis of number of patients developing acute kidney injury after cardiac surgery. The heterogeneity was not significant (p=0.11). RIPC, remote ischemic preconditioning; AKI, acute kidney; RR, relative risk; CI, confidence interval. _ENREF_2 3-7

7 efigure S3. - Proposed conceptual model for how RIPC results in fewer AKI events. Remote ischemic preconditioning (RIPC) results in reduced risk for AKI by (1) inducing release of damage-associated molecular patterns (DAMPs) which bind to pattern recognition receptors (PRRs) on surface of renal epithelial cells. Next, (2) alarm markers, tissue inhibitor of metalloproteinases-2 (TIMP-2) and insulin-like growth factor-binding protein 7 (IGFBP7) are released from the epithelial cells signaling in autocrine and paracrine fashion to down-regulate cell function and energy utilization. While subsequent surgical stress results in injury to renal epithelium with release of both alarm biomarkers as well as damage markers such as neutrophil gelatinase-associated lipocalin (NGAL), this injury is attenuated in the RIPC condition compared to control (3).

8 Supplementary References 1. Thakar CV, Arrigain S, Worley S, Yared JP, Paganini EP. A clinical score to predict acute renal failure after cardiac surgery. Journal of the American Society of Nephrology : JASN. Jan 2005;16(1): KDIGO AKI Work Group: KDIGO clinical practice guideline for acute kidney injury. Kidney international. Supplement. 2012;2: Choi YS, Shim JK, Kim JC, et al. Effect of remote ischemic preconditioning on renal dysfunction after complex valvular heart surgery: a randomized controlled trial. The Journal of thoracic and cardiovascular surgery. Jul 2011;142(1): Zimmerman RF, Ezeanuna PU, Kane JC, et al. Ischemic preconditioning at a remote site prevents acute kidney injury in patients following cardiac surgery. Kidney international. Oct 2011;80(8): Gallagher SM, Jones DA, Kapur A, et al. Remote ischemic preconditioning has a neutral effect on the incidence of kidney injury after coronary artery bypass graft surgery. Kidney international. Feb 2015;87(2): Ali ZA, Callaghan CJ, Lim E, et al. Remote ischemic preconditioning reduces myocardial and renal injury after elective abdominal aortic aneurysm repair: a randomized controlled trial. Circulation. Sep ;116(11 Suppl):I Venugopal V, Laing CM, Ludman A, Yellon DM, Hausenloy D. Effect of remote ischemic preconditioning on acute kidney injury in nondiabetic patients undergoing coronary artery bypass graft surgery: a secondary analysis of 2 small

9 randomized trials. American journal of kidney diseases : the official journal of the National Kidney Foundation. Dec 2010;56(6):

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