*Purpose: Cardiac events (CE) remain an important cause of morbidity and mortality after the first post-transplant year. We sought to determine whether acute rejection in year-one was a risk factor for subsequent CE.

*Methods: We analyzed the association between biopsy confirmed acute rejection and subsequent CE in all solitary kidney transplant recipients performed at our center between 01/2006 and 12/2016. CE were defined as de novo heart failure, arrhythmia, or ischemic events.

*Results: A total of 2,205 patients underwent kidney transplantation, of which 356 (14.2%) experienced acute rejection during the first year. There incidence of CE after the first year was 8.9% (n=222), including 35 CE in patients with a history of rejection. Acute rejection was significantly associated with CE in repeated measures unadjusted (HR 2.38, 95%Cl 1.60 to 3.55, p<0.0001) and multivariable analyses adjusting for confounders including age, gender, race, donor type, DGF, dialysis time prior to transplant, BMI, and cause of ESRD (HR 2.09, 95%Cl 1.38 to 3.16, p<0.0001). Thymoglobulin, rituximab, plasmapheresis, IVIG, and pulse steroids alone were used in 30%, 3%, 9%, 18%, and 40% of patients, respectively, to treat rejection. In a multivariable regression model including all these treatment strategies, Thymoglobulin (HR 2.6, 95%CI 1.10 to 6.20, p=0.029) and rituximab (HR 5.3, 95%CI 1.02 to 28.39, p=0.047) were independently associated with higher incidence of subsequent CE compared to pulse steroids alone.

*Conclusions: Kidney allograft rejection during the first-year after transplant is associated with increased risk of cardiac events. Risk was greatest in those requiring therapy with thymoglobulin or rituximab.

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