Serum samples from recipients were obtained within 48 hours before transplantation. Pre-transplant

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1 SDC, Patients and Methods Complement-dependent lymphocytotoxic crossmatch test () Serum samples from recipients were obtained within 48 hours before transplantation. Pre-transplant donor-specific CXM was performed by the standard CDC technique. In brief, the donor s B and T lymphocytes were isolated from peripheral blood, the recipient s serum was added, and the mixture was incubated at room temperature or 37 C for 60 minutes. This was followed by a 120-minute incubation with rabbit complement in order to detect any cytotoxic antibody activity against donor cells. Target cell lysis was determined by trypan blue exclusion. The CXM test was interpreted as positive when more than 20% of donor lymphocytes were lysed in excess of the baseline rate. If the test was positive, the recipient s serum was treated with dithiothreitol (DTT) for 30 minutes to act as a reducing agent to inactivate immunoglobulin M (IgM) antibodies, and the test was subsequently repeated (8). A negative CXM after DTT reduction was indicative of the presence of IgM antibodies only, whereas a positive CXM in spite of DTT treatment indicated the presence of immunoglobulin G (IgG) antibodies. Immunosuppressive regimen Before 2001, the immunosuppression protocol consisted of standard triple-drug therapy with cyclosporine, mycophenolate, and methylprednisolone. However, since 2001, a four-drug routine immunosuppressive protocol was established which included basiliximab (Simulect, Novartis), a calcineurin inhibitor (tacrolimus or cyclosporine), mycophenolate, and methylprednisolone. Basiliximab, an IL-2R antibody, was given for immune induction during the intraoperative period and then on postoperative day four. Tacrolimus (Prograft, Astellas) was started at a dose of 0.5 mg twice daily on postoperative day three. Trough concentrations of tacrolimus were adjusted to ng/ml for the first month, and then tapered over 6 months to a maintenance level of 5-8 ng/ml. Cyclosporine (Sandimmune, Novartis) was given at a dose of 2 mg/kg/day orally, and subsequently adjusted to maintain blood levels of ng/ml for the first month. After the first month, target levels were set at ng/ml. A total of 1.5 g (two doses of 750 mg) of mycophenolate (CellCept, Roche) was provided the day following liver transplantation. The mycophenolate dose was adjusted according to the occurrence of hematologic or gastrointestinal side effects.

2 A total of 500 mg of methylprednisolone was injected in all patients during the anhepatic period, followed by 500 mg on the first postoperative day. Thereafter, the drug was gradually tapered to 32 mg/day over a period of 10 days, and discontinued by 12 months after LT. None of the patients received immunosuppression therapy with anti-lymphocyte antibodies.

3 SDC, Table S1. Comparison of liver function test values for aspartate aminotransferase and alanine aminotransferase between positive and negative lymphocytotoxic crossmatch recipients Posttransplant day Aspartate aminotransferase (U/L) Alanine aminotransferase (U/L) Negative True positive P-value Negative True positive P-value 0 (immediate) (6 hr later) month months months months months months months months * All values are expressed as means

4 SDC, Table S2. Effect of true positive lymphocytotoxic crossmatch and false positive lymphocytotoxic crossmatch (IgM autoantibodies) on liver transplant outcome Values are expressed as number (%); CXM, crossmatch; *aab, IgM autoantibod A+B, absence of IgM autoantibody in recipient sera, A+C, finally reported negative result; CMV, Cytomegalovir Negative CXM Positive CXM aab* ( ) aab* (+) P-value True negative True positive False positive B vs. C vs. Final CXM result (A) (B) (C) A+B A+C Total B vs. A C vs. A B vs. C A vs. B v A+C A+B C Number of case Allograft rejection (18.6) (22.5) (31.0) (18.9) (19.1) (19.3) Biliary complication (27.1) (33.8) (31.0) (27.6) (27.3) (27.7) Vascular complication Hepatic artery (4.7) (5.0) (4.8) (4.8) (4.7) (4.8) Hepatic vein (2.8) (3.8) (4.8) (2.8) (2.8) (2.9) Portal vein (5.4) (6.3) (2.4) (5.5) (5.3) (5.4) Viral disease recurrence Hepatitis B virus (7.8) (7.5) (4.8) (7.8) (7.7) (7.0) Hepatitis C virus (3.5) (8.8) (0.0) (3.8) (3.3) (3.7) CMV infection (32.1) (37.5) (21.4) (32.5) (31.7) (32.1) de novo malignancy (4.3) (10.0) (16.7) (4.7) (4.7) (5.1) Re-transplantation (3.7) (5.0) (2.4) (3.8) (3.6) (3.7) Graft loss (GL) (23.4) (30.0) (26.2) (23.9) (23.6) (24.0) Liver-specific GL (10.9) (21.3) (11.9) (11.6) (10.9) (11.7) Patient death (22.1) (27.5) (26.2) (22.5) (22.2) (22.6) SDC, Table S3. Multivariate analysis to identify risk factors for liver-specific graft survival Variables in the equation B SE Wald df 95.0% CI for Exp(B) p-value Exp(B) Lower Upper Type of donor (living vs. deceased) Type of recipient (adult vs. pediatric) Relationship with the donor Donor gender

5 Recipient gender Allograft rejection Biliary complication Hepatic artery complication Hepatic vein complication Portal vein complication Hepatitis B viral disease recurrence Hepatitis C viral disease recurrence Cytomegalovirus infection de novo malignancy True positive crossmatch IgM autoantibody in recipient sera