Graefes Arch Clin Exp Ophthalmol (2015) 253:11111119

DOI 10.1007/s00417-015-3008-0

CORNEA

Adverse effects of low-dose systemic cyclosporine therapy

in high-risk penetrating keratoplasty
Jong Joo Lee 1 & Mee Kum Kim 2,3 & Won Ryang Wee 2,3

Received: 21 August 2014 / Revised: 19 March 2015 / Accepted: 31 March 2015 / Published online: 21 April 2015
# Springer-Verlag Berlin Heidelberg 2015

Abstract
Purpose The purpose of this study was to investigate the adverse effects of low-dose oral cyclosporine (CsA) therapy following high-risk corneal transplantation.
Methods The medical records from 88 subjects who had undergone high-risk penetrating keratoplasties and had been administered oral CsA were retrospectively analyzed. High risk
was defined as a history of graft rejection, three or more quadrants of vascularization, or the presence or history of intraocular inflammation. An initial CsA dose of 35 mg/kg per day
was given for 37 days, followed by 2.53.5 mg/kg per day
for approximately 1 month. The concentration of CsA was
maintained at the target trough level of 120150 ng/ml for at
least 6 months or until serious complications developed. The
relationship between the cumulative dose and duration of CsA
administration and the adverse systemic effects, including the
frequency of herpes keratitis, was evaluated. The incidence of
herpes keratitis in the study subjects was compared with the
incidence in 185 patients who had not received CsA therapy
following penetrating keratoplasty.
Electronic supplementary material The online version of this article
(doi:10.1007/s00417-015-3008-0) contains supplementary material,
which is available to authorized users.
* Mee Kum Kim
kmk9@snu.ac.kr
1

Department of Ophthalmology, Chungnam National University

College of Medicine, Daejeon, Korea

Department of Ophthalmology, Seoul National University College of

Medicine, 103 Daehak-ro, Jongno-gu, Seoul 110-799, Republic of
Korea

Laboratory of Ocular Regenerative Medicine and Immunology,

Seoul Artificial Eye Center, Seoul National University Hospital
Biomedical Research Institute, Seoul, Korea

Results The mean survival time of the grafts was 33.6 months.
Adverse effects occurred in 81.8 % of subjects. Hypertension,
elevated liver enzyme levels, elevated serum creatinine level,
and decreased absolute neutrophil count (ANC) were observed in 14.8, 6.8, 5.7, and 5.7 % of subjects, respectively.
Simvastatin-induced rhabdomyolysis also developed in one
case. Some patients exhibited minor complications, with gastrointestinal problems and hypertrichosis recorded in 5.7 and
3.4 % of subjects, respectively. Hypertension and hepatotoxicity most frequently occurred after 4 to 8 weeks of medication, while ANC decrease and nephrotoxicity generally developed after 24 weeks of treatment, with incidence related to the
cumulative dose. Herpes keratitis occurred more frequently
(31.8 %) in the CsA-treated subjects than in subjects that did
not receive CsA therapy (p=0.005). Most of the adverse effects were reversed after discontinuation of CsA therapy.
Conclusion The results of this study suggest that low-dose
oral CsA therapy may induce various adverse effects, the most
common of which are herpes keratitis and hypertension.
Keywords Cornea . Cyclosporine . Adverse effects .
Penetrating keratoplasty . Hypertension . Herpes keratitis

Introduction
Penetrating keratoplasty (PKP) is the most common form of
solid tissue transplantation, with a rejection rate of less than
10 % within the first 5 years in an avascular low-risk disease
like keratoconus [13]. In contrast, the rejection rate can be
70 % or greater in high-risk keratoplasty without systemic
immunosuppression, and the 5-year survival rate for the allograft is less than 30 % in such cases [4, 5]. Therefore, if a graft
is placed into a pre-sensitized host or a vascularized, inflamed
recipient bed at Bhigh-risk^ [6], postoperative long-term

1112

systemic immunosuppressive therapy is regarded as the treatment of choice [2].

Cyclosporine A (CsA) is a potent T-cell immunosuppressant that has shown a positive effect in solid organ transplantation. In high-risk corneal transplantation, graft survival has
improved considerably since the introduction of systemic CsA
therapy [5, 4, 7]. Recent studies have reported that systemic
CsA therapy had a short-term effect on reducing corneal graft
rejection [1, 811], but was associated with a high incidence of
adverse side effects, despite the use of a lower dose of CsA
than that used for other forms of solid organ transplantation
[12]. Severe side effects occurred in up to 40 % of cases, and
CsA had to be prematurely withdrawn in 10 % of patients [13].
Given the cost of the therapy and the need for careful monitoring of CsA concentrations, an investigation of the adverse
effects associated with oral CsA therapy in the dose range
used in keratoplasty is critical. Here, we report the incidence
of various adverse effects associated with low-dose CsA therapy and examine the time- and dose-dependent relationships
between CsA and adverse effects in high-risk keratoplasties in
Korean patients.

Patients and methods

The authors conducted a retrospective chart review of Korean
patients who had undergone PKPs performed by an experienced surgeon (M.K.K.) at Seoul National University Hospital between October 2003 and May 2012. The study was approved by the hospital institutional review board (No. 1406037-584) as a retrospective chart review. "High risk" was defined as the presence of three or four quadrants of new corneal
vessels passing over the proposed graft site, a history of previous ipsilateral corneal graft rejection, the presence of active
ocular inflammation at the time of PKP, or a history of chronic
intraocular inflammation. Systemic CsA had not been administered to patients with a history of malignant disorders or
systemic infections, to those with active peptic ulcers or who
were pregnant, or to patients younger than 16 years of age,
even if they were considered high-risk. We retrieved the records of 88 patients who had undergone high-risk PKPs and
had been treated with systemic cyclosporine (CsA group).
Patients who had undergone PKPs by the same surgeon during the same period, but who had not been regarded as high
risk and had not been treated with systemic cyclosporine, were
designated as the no-CsA group (control), and the occurrence
of herpetic keratitis in this group was compared with that in
the CsA group. Both the CsA group and control group
(n=185) maintained the use of prednisolone acetate 1 % (Pred
Forte; Allergan Pharmaceuticals Ireland, Mayo, Ireland) four
times a day for 1 year.
Corneas were obtained from Korean donors or from eye
banks in the United States. No human leukocyte antigen

Graefes Arch Clin Exp Ophthalmol (2015) 253:11111119

(HLA) matching was performed. The grafts were punched

out from the endothelial side and were 0.25 to 0.50 mm larger
than the recipient beds. To secure the graft, 10-0 nylon was
used for interrupted sutures or combined interrupted and one
continuous suture. Prednisolone acetate 1 % (Pred Forte;
Allergan Pharmaceuticals) and topical antibiotics were administered every 2 to 4 h on the first day following PKP and were
then gradually reduced to four times a day; this dose was
maintained for 1 year. Oral corticosteroids were also administered, starting at a dose of 3060 mg prednisolone (Nisolone;
Kukje Pharmaceutical Industrial Co. Ltd., Seoul, Korea),
which was then gradually decreased over the next 3 weeks.
In addition, aceclofenac (Asec; Hanmi Pharmaceutical Co.,
Ltd., Seoul, Korea) 100 mg was prescribed, and was administered orally twice a day for 3 days after surgery.
A CsA (Cipol-N microemulsion soft capsule (Chong Kun
Dang Pharmaceutical Corp., Seoul, Korea) was given twice
daily postoperatively in a loading dose of 5 mg/kg/day for 3
7 days, followed by 2.53.5 mg/kg per day. Monitoring of
serum CsA concentration was initiated within a month of
PKP, with the aim of achieving trough levels of 120 to
150 ng/mL, and dosage was adjusted to maintain therapeutic
levels. Patients were followed up on a monthly basis for the
detection of graft rejection and adverse side effects. At each
visit, an ocular examination, blood pressure (BP) measurement, and laboratory sampling were performed. Serum creatinine (Cr), aspartate aminotransferase (AST), alanine aminotransferase (ALT), and glucose levels were measured, and a
complete blood cell count (CBC), including absolute neutrophil count (ANC), was performed. Patients were instructed to
visit the ophthalmologic clinic immediately if they experienced ocular pain, reduced vision, or ocular trauma. CsA therapy was continued for at least 6 months to 1 year unless severe
side effects developed that required cessation or graft failure
was diagnosed. No other systemic immunosuppressive drugs
were used for graft maintenance.
CsA-induced hypertension was diagnosed when systolic
BP rose above 140 mmHg or diastolic BP rose above
90 mmHg on two consecutive occasions. BP elevation of
more than 2 mmHg during CsA administration was also considered CsA-induced hypertension in patients with a history of
hypertension. Patients with BP levels that were consistently
180/110 mmHg or higher were immediately evaluated for any
associated organ damage. A diagnosis of newly developed
diabetes mellitus (DM) was based on a fasting plasma glucose
(FPG) concentration 126 mg/dL on two separate occasions,
or a random casual glucose concentration 200 mg/dL with
symptoms of hyperglycemia such as polyuria or polydipsia.
For patients with previously well-controlled DM, it was considered to have become uncontrolled when preprandial plasma glucose (PrePG) concentration increased to 130 mg/dL
or postprandial plasma glucose (PPG) concentration increased
to 180 mg/dL after CsA administration. An increase of

Graefes Arch Clin Exp Ophthalmol (2015) 253:11111119

0.3 mg/dL or 30 % in Cr concentration was used to define

worsening renal function. An elevation of ALT > 40 IU/L and
AST > 40 IU/L was used as a cutoff to monitor for hepatocellular injury. An ANC below 1800/l was defined as decreased
ANC and an ANC lower than 500/l was considered to represent severe neutropenia.
Herpes keratitis was diagnosed when classic dendritic keratitis, an irregular-shaped epithelial defect responding only to
antiviral therapy, stromal keratitis or endotheliitis with edema
and endothelial precipitates were observed. Diagnosis was
confirmed by observation of reduced corneal sensitivity and
a positive polymerase chain reaction (PCR) result for herpes
simplex virus (HSV). Patients with a previous history of herpetic keratitis (n=13) received oral acyclovir 400 mg twice
daily for at least 6 months after PKPs for a prophylaxis. In the
event of recurrence, patients were treated by topical antiviral
agents such as acyclovir 3 % ointment (Herpecid; Samil
Pharmaceutical Co., Ltd., Seoul, Korea) or ganciclovir
0.15 % gel (Virgan; Thea Pharmaceuticals Ltd., Keele, Staffordshire, UK) five times a day and increasing dose of systemic acyclovir (400 mg, five times a day). Antiviral therapy
was tapered based on clinical improvement.
The initial onset and incidence of adverse effects were evaluated. Cumulative dose (mg/kg) was calculated as the sum of
administered doses (mg) divided by body weight (kg). The
number of new adverse systemic events was analyzed in relation to the duration of administration and cumulative dose.
Pearson correlation analysis of the relationship between duration of administration (days) and cumulative dose was also
performed. Differences in mean age and gender ratio between
patients with adverse events (CAE group) and those without
(NCAE group) were determined using t tests and chi-square
tests. To predict the occurrence of adverse events, logistic regression analysis was performed using one or more of the following variables: age, gender, body weight, history of diabetes
or hypertension, co-medication with intraocular pressure (IOP)lowering drugs or anti-herpetic drugs, and cumulative dose or
duration of administration of CsA. KaplanMeier survival analysis was used to estimate graft survival, and mean survival time
was compared between the CAE and NCAE groups using the
log-rank test. The chi-square test was used to compare the incidence of herpes keratitis between the CsA group and the noCsA group. Statistical analysis was conducted using SPSS Statistics version 18.0 (SPSS Inc., Chicago, IL, USA). A significance level of 5 % was used.

Results
Patient demographics
Patient demographics are shown in Table 1. Of the 88 patients
included in the study, 55 were male (62.5 %) and 33 were

1113
Table 1

Patient demographics and outcomes of high-risk keratoplasties

Characteristics
Gender
Male
Female
Age

Medical history
Diabetes mellitus
Hypertension
Body weight
High-risk category
History of graft rejection
3 Qs of vascularization
Intraocular inflammation
Preoperative diagnosis
Chronic rejection
Impending perforation or uncontrolled infection
Bullous keratopathy with opacity after infection
Bullous keratopathy and neovascularization
(long-standing high IOP after intraocular surgeries)
Old corneal opacity and thinning with new vessels
Severe phlyctenular keratoconjunctivitis

No. patients (%)

55 (62.5)
33 (37.5)
53.6 years (mean)
(range
1679 years)
13 (14.8)
12 (13.6)
61.7 kg (mean)
(range 3392 kg)
55 (62.5)
22 (25.0)
11 (12.5)
55 (62.5)
10 (11.4)
3 (3.4)
9 (10.3)
8 (9.1)
1 (1.1)

Alkali burn
1 (1.1)
Eccentric cyst after trauma
1 (1.1)
Graft survival (post-op mean follow-up period 666 days)
Clear graft
30 (34.0)
Chronic rejection
51 (58.0)
Non-immunological graft failure
7 (8.0)

female (37.5 %), with mean age at the time of treatment of

53.615.6 years (meanSD; range, 1679 years). Preoperatively, 62.5 % of patients (n=55) were diagnosed as showing
chronic rejection, and 11.4 % (n=10) had to undergo PKP
because of impending perforation or uncontrolled infection.
A total of 55 patients (62.5 %) had a history of corneal graft
rejection, 22 patients (25.0 %) exhibited new corneal vessel
growth, and 11 patients (12.5 %) had evidence of or a history
of intraocular inflammation.
Outcome of PKP
During the follow-up periods (mean, 766 days), corneal grafts
remained clear in 30 patients (34.0 %). Irreversible chronic
rejection occurred in 51 cases (58.0 %) after a mean 563 days
of follow-up, and non-rejection graft decompensation was detected in 7 cases (8.0 %) after a mean 987 days of follow-up.
Based on a KaplanMeier plot, the mean graft survival time
was estimated at 33.6 months (Fig. 1a).

1114

Graefes Arch Clin Exp Ophthalmol (2015) 253:11111119

Fig. 1 a Graft survival in highrisk penetrating keratoplasty

(PKP) in which oral cyclosporine
A (CsA) was administered. The
mean survival was 33.6 months. b
The survival curves of PKP grafts
with no occurrence of CsA
adverse events (NCAE group,
black line) and those with CsA
adverse events (CAE group, gray
dotted line). There was no
significant difference between the
two groups in mean graft survival
time, as estimated by Kaplan
Meier analysis, after 30 months in
the NCAE group and 37 months
in the CAE group (log-rank test).

CsA was administered for an average of 214 days. The

mean graft survival following CsA discontinuation was
418 days. Of the 51 chronic rejection cases, rejection developed and became irreversible while CsA was being administered in 18 cases (35.3 %). After the occurrence of adverse
events, the administration of CsA was either discontinued
(56.8 %) or the dose was reduced (43.2 %). In the NCAE
group, the mean duration of CsA therapy was 236 days and
the mean cumulative dose was 802.0 mg/kg, while the mean
duration in the CAE group was 190 days and the mean cumulative dose was 617.9 mg/kg. However, the differences in

duration and cumulative dose between the two groups were

not significant. There was also no significant difference in
mean graft survival time as estimated by KaplanMeier analysis (log-rank test, Fig. 1b) between the two groups: 30 months
for the NCAE group and 37 months for the CAE group.
Incidence and peak time of adverse effects
Of the 88 patients included in the study, 72 (81.8 %) experienced adverse effects. Table 2 lists all the types of adverse
effects encountered in the patients.

Graefes Arch Clin Exp Ophthalmol (2015) 253:11111119

Table 2 Adverse effects of oral
cyclosporine A after high-risk
penetrating keratoplasty

1115

Adverse effect

% (n)

Timing (days)
mean (range)

Cumulative dose (mg/kg)

mean (range)

Early onset
Skin eruption
Rhabdomyolysis with simvastatin use
Increase in blood glucose concentration
General weakness
Elevated liver enzymes
Hypertrichosis
Hypertension
Heartburn or indigestion
Late onset

1.1 (1)
1.1 (1)
2.3 (2)
3.4 (3)
6.8 (6)
3.4 (3)
14.8 (13)
5.7 (5)

22
30
35
60 (3690)
66 (29152)
66 (31105)
86 (33209)
111 (20367)

108.2
171.5
143.0 (142.1, 143.8)
199.0 (136.0268.9)
171.6 (96.5234.5)
282.3 (135.5471.1)
318.5 (90954.2)
477.8 (41.71702.4)

Decreased absolute neutrophil count (ANC)

Increased serum creatinine
Herpes keratitis
Total

5.7 (5)
5.7 (5)
31.8 (28)
81.8 (72)

187 (40263)
218 (83400)
225 (48425)
145 (20425)

787.4 (169.81371.7)
653.7 (286.71331.5)
668.2 (123.51371.7)
464.5 (41.71702.4)

Systemic adverse events most frequently occurred 4 to

8 weeks after CsA therapy had been initiated (36.4 %,
Fig. 2a). The incidence of adverse events peaked at a cumulative dose between 100 and 200 mg/kg (36.4 %, Fig. 2b).
Duration of therapy and cumulative dose were strongly correlated (Fig. 2c, r2 =0.890, p<0.0001). The trend line was drawn
according to the equation: cumulative dose (mg/kg)=3.647
therapy duration (days).
At the peak incidence, hypertension and hepatotoxicity
were the most common adverse events. Later in the therapy
(24 weeks or more after PKP), decreased ANC accounted for
40 % and nephrotoxicity for 30 % of adverse events. The most
common very early adverse event (before 4 weeks of therapy)
was GI discomfort (75 %). Five patients experienced two different adverse effects; all had either hepatotoxicity or hypertension as one of the adverse events.
Relationship between demographic factors and incidence
of adverse events
For mean age and gender ratio, there was no difference between the CAE and NCAE groups. Logistic regression analysis revealed that age, gender, body weight, history of diabetes
or hypertension, co-medication with IOP-lowering or antiherpetic drugs, and cumulative dose or duration of CsA treatment were not predictive of adverse events.
Adverse effect characteristics
Herpes keratitis was the most common adverse effect (31.8 %)
associated with CsA administration. In the CsA group (n=88),
herpes keratitis occurred more frequently than in the no-CsA
group (n=185) (31.8 % vs. 16.8 %, p=0.023, Table 3). The
postoperative recurrence rate for the CsA group was 61.5 % in

Fig. 2 a The number of newly developed systemic adverse events

associated with oral cyclosporine A (CsA) therapy were plotted versus
therapy duration, and showed a peak at 4 to 8 weeks after administration.
b Adverse events occurred most commonly (36.4 %) when patients had
been receiving a cumulative dose of CsA of 100 to 200 mg/kg. c The
correlation between cumulative dose and therapy duration of CsA (r2 =
0.890, p<0.0001). Trend line: Cumulative dose (mg/kg)=3.647therapy
duration (day)

1116
Table 3 Comparison of herpes
keratitis occurrence between oral
cyclosporine A administration
group (CsA group) after high-risk
penetrating keratoplasty (PKP)
and no-CsA group after normalrisk PKP

Graefes Arch Clin Exp Ophthalmol (2015) 253:11111119

A. No history of herpes
Post-op herpetic occurrence
Epithelium
Stroma
Endothelium
Total
B. Previous history of herpes
Recurrence (post-op/pre-op)
Epithelium
Stroma
Endothelium
Total

CsA group (n=75)

24.0 %** (18)
0 % (0)
2.7 % (2)
26.7 %* (20)

No-CsA group (n=149)

6.7 %** (10)
0.7 % (1)
0.7 % (1)
8.1 %* (12)

CsA group (n=13)

88.9 % (8 / 9)
0 % (0 / 2)
0 % (0 / 2)
61.5 % (8 / 13)

No-CsA group (n=36)

50.0 % (11 / 22)
57.1 % (4 / 7)
57.1 % (4 / 7)
52.8 % (19 / 36)

Herpes keratitis occurred more frequently in the CsA group (31.8 %) than in the no-CsA group (16.8 %) (p=
0.005). A. In cases with no history of herpes-associated eye disease, the frequency was higher in the CsA group
(*p<0.0001). In particular, epithelial lesions showed a significant difference (**p<0.0001). B. Among cases with
a history of herpes, there was no significant difference in the recurrence rate between the CsA (61.5 %) and noCsA groups (52.8 %). However, when only epithelial keratitis was taken into account, the recurrence rate was
higher in the CsA group than the no-CsA group ( p=0.044)

patients with a history of herpes (n=13). Herpes keratitis occurred in 26.7 % of patients in the CsA group without previous herpes infection (n=75). When herpes keratitis was categorized according to the location of the original lesion, herpes
epithelitis accounted for 92.8 % of the postoperative herpes
cases in the CsA group. Postoperative herpes epithelitis developed more often in the CsA group than in the no-CsA group
regardless of whether there was a history of ocular herpes
(Table 3a and b).
Hypertension was the second most common adverse effect,
occurring in 13 of the 88 cases (14.8 %). Two patients had
hypertension prior to CsA therapy. Temporary BP elevations
higher than systolic 180 mmHg or diastolic 110 mmHg were
recorded in three cases (3.4 %). After discontinuation of CsA,
blood pressure returned to preoperative levels.
There were five cases (5.7 %) in which serum Cr increased.
These patients were not taking any other systemic drugs at the
time, and their Cr concentration normalized after discontinuation of CsA therapy.
Rhabdomyolysis was diagnosed in a 65-year-old woman
who had received simvastatin for hypercholesterolemia. Simvastatin shares the same metabolic pathway as CsA via the
hepatic cytochrome P-450 3A enzyme system (CYP 3A4).
Simvastatin-induced rhabdomyolysis developed 1 month after
the start of CsA, an inhibitor of CYP3A4, with a cumulative
dose of 171.5 mg/kg. As a result of rhabdomyolysis, serum
levels of AST and ALT increased markedly, to 309 and
170 IU/L, respectively.
AST and ALT levels were elevated in six cases (6.8 %),
although the CsA concentration was always within the target
range when the abnormalities were detected. The elevation
was reversed after cessation of CsA therapy. ANC decreased
in five cases (5.7 %). None of these patients had any infectious

disease. One patient showed an ANC less than 1500/mm3 on

day 40, which increased after cessation of CsA therapy.
The most common minor adverse effect reported was gastrointestinal (GI) discomfort (heartburn or indigestion), which
occurred transiently in five cases (5.7 %). Three of these patients developed symptoms within 4 weeks of commencing
oral CsA therapy, while another reported symptoms after
1 year of CsA therapy. Hypertrichosis was reported in three
cases (3.4 %), most prominently on the face, especially around
the brows and ears. A general feeling of being unwell was
reported by three patients (3.4 %). One case of skin eruption
on the legs was also detected. Among 13 patients with wellcontrolled DM, 2 experienced temporary loss of control of
blood glucose levels (2.3 %). Cessation of CsA resulted in
complete resolution of these symptoms.

Discussion
In the present study, we examined the various temporary adverse effects (81.8 %) associated with low-dose CsA administration that can develop even when CsA concentration is
maintained within the target range (120150 ng/ml). Herpes
keratitis was the most common side effect (31.8 %), and hypertension was the second most common (14.8 %). Elevation
of blood pressure or liver enzyme levels most frequently occurred 4 to 8 weeks after the start of medication, while ANC
reduction and nephrotoxicity were most noticeable after
24 weeks of therapy.
Corneal herpetic recurrence rates between 29 and 52 %
have been reported after PKP in patients with a history of
herpetic keratitis [14]. The 1-year recurrence rate has ranged
from 21 to 39 % [1517], and a 2-year rate of 44 % was

Graefes Arch Clin Exp Ophthalmol (2015) 253:11111119

reported [17]. Herpetic recurrence is thought to be triggered

by systemic immunosuppression [14]. CsA-treated patients
can acquire viral infections such as herpes or cytomegalovirus
[18]. Cytotoxic CD8 T cells are known to play an important
role in the clearance of infectious herpes simplex virus (HSV).
CD4 T helper cells are also involved in the clearance of infectious HSV-1 [19, 20]. A previous study reported herpetic recurrence in 32.1 % of grafts among 84 high-risk keratoplasties
treated with a postoperative combined systemic therapy of
acyclovir and immunosuppression with mycophenolate mofetil (n=79) or CsA (n=5) [14].
In the present study, herpes keratitis occurred in 31.8 % of
cases and the herpetic recurrence rate was 61.5 % among
patients with a history of herpes keratitis (Table 3b). In this
study, newly developed herpes keratitis accounted for 71.4 %
(n=20) of patients with postoperative herpes, while herpetic
recurrence was observed in only eight patients with a previous
history of herpes infection. The mean time to development of
herpes keratitis after CsA administration was 145 days.
An interesting finding from this study was that, regardless
of patient history, herpetic epithelitis occurred more often in
the low-dose CsA group than in the no-CsA group. This suggests that prophylactic treatment of herpes may be necessary
not only in patients with a previous history of herpes, but also
in patients with no history of infection when CsA therapy is
initiated.
In high-risk keratoplasty, the incidence of systemic complications associated with CsA has been reported in a range of 13
to 45 % [5, 811, 14, 21]. Some reports found that kidney
dysfunction was the most common complication (1626 %)
[8, 9], while others found hypertension to be the most frequent
side effect (10 %) [13].
New onset or worsening of hypertension is a common side
effect of CsA. The main target tissues considered to mediate
CsA-induced hypertension are the kidneys, vascular smooth
muscle, endothelium, and central nervous system [18, 2224].
In the present study, lowering the dose of CsA reduced blood
pressure levels, and the use of vasodilators was not necessary.
Since the CsA dose used in our study was low, elevations in
blood pressure appear to have been caused by CsA sensitization of the vascular smooth muscles, endothelium, or central
nervous system rather than by kidney toxicity.
Nephrotoxicity and hypertension are well-known adverse
effects of CsA following renal transplantation [24]. In stable
renal transplant recipients, CsA is usually maintained at a dose
of 3 to 6 mg/kg/day for more than 12 months, and the recommended blood trough concentration range is 250400 ng/mL
[24], which is higher than that for keratoplasty. The lower
incidence of renal toxicity in keratoplasty found in our study
appears to be related to the lower dose and shorter exposure to
CsA in our patients.
Even when a low dose is used, sustained administration of
CsA can cause a significant increase in plasma creatinine

1117

levels. In a prospective study of 41 patients with posterior

idiopathic uveitis, long-term low-dose CsA treatment resulted
in significantly impaired renal function [25]. The incidence of
hypertension in patients also increased from 15 % at baseline
to 81 % at 5 years. A higher cumulative dose was associated
with poorer renal function, and the same was true for the
trough level, with higher trough levels associated with decreased renal function. The study suggested that lowering
the daily dose to 3.16 mg/kg might prevent CsA-induced
nephrotoxicity [25]. In this study, the maintenance dose generally fell below the range of 2.5 to 3.5 mg/kg/day, and nephrotoxicity began to appear after 83 days (mean 218 days) of
CsA administration.
Renal dysfunction can be either acute or chronic. Acute
toxicity usually occurs within weeks and is reversible in most
cases by dose reduction. The hemodynamic dysfunction was
originally identified as acute toxicity, although tubular
vacuolization and thrombotic microangiopathy are also recognized in this category. Intrarenal vasoconstriction and enhanced vascular reactivity become permanent and irreversible
after 3 months. The toxic effects of CSA-cyclophilincalcineurin complexes on tubular and endothelial cells play a
role in chronic toxicity. Significant interstitial fibrosis
and glomerular sclerosis is an indicator of irreversible
damage. By 10 years post-kidney transplantation, lesions
suggestive of chronic nephrotoxicity are seen in virtually all patients [2427, 18, 28]. In the present study,
late-onset chronic nephrotoxicity did not occur, given
the relatively short-term nature of the therapy and low
CsA dose used.
It is possible that concurrent oral medication with CSA
affects the development of renal dysfunction. The patients in
this study took aceclofenac for only 3 days immediately after
surgery. Short-term use of NSAIDs may result in acute kidney
toxicity and subsequent hypertension over hours to days [29].
In this study, however, no hypertension or serum creatinine
increase was observed within 1 month. As for the effect of oral
acyclovir on renal complication, we performed additional
analysis of the rate of renal complication in patients taking
cyclosporine only versus patients taking both cyclosporine
and acyclovir. Those who had taken acyclovir along with cyclosporine because of the herpes keratitis (n=33, Table 3; herpes keratitis without a previous history, n=20 + herpes keratitis with a previous history, n=13) did not show a higher
frequency of renal toxicity than those who had not taken acyclovir (n=55). There was no statistical difference in the frequency of serum creatinine increase between patients who had
taken acyclovir (3.0 %, 1/33) and those who had not (7.3 %,
4/55, chi-square test, Supplementary Table S1). Therefore,
adverse renal effects in the present study appear to be caused
by CsA.
Hypertrichosis is usually noted 2 months after initiation of
therapy in a dose-dependent manner [30, 31]. Because the

1118

activation of nuclear factor of activated T-cells (NFAT) is associated with follicular keratinocyte differentiation, the inhibition of NFAT by CsA causes enhanced hair growth [31].
Glucose intolerance may also occur, as calcineurin inhibitors
are toxic to pancreatic islets [24]. In this study, there were only
two patients with increased blood glucose concentration, and
no evidence of neurotoxicity was observed. ALT, a cytosolic
enzyme found predominantly in the liver, is a fairly specific
marker of hepatic injury, although it is also present in several
other organs including muscle. AST, a mitochondrial enzyme
affected by alcohol, is predominantly located in the liver,
heart, and skeletal muscles, in decreasing order of concentration. In rhabdomyolysis, the increase in AST levels is more
marked than the increase in ALT levels [32]. The elevation of
ALT and AST levels can be reversed by cessation of CsA
therapy. Because CsA is metabolized in the liver via CYP
3A4, care needs to be taken not to increase the concentrations
of co-administered drugs that share the same metabolic pathway [33, 34].
In our study, there was no statistically significant difference
in graft survival between the NCAE group (the group receiving oral CsA without adverse effects) and the CAE group (the
group showing adverse effects as a consequence of oral CsA
therapy). There were also no significant differences in the
duration and cumulative dose of CsA administered, regardless
of early cessation or dose reduction of CsA following adverse
events. As for efficacy, on the other hand, graft survival of
only 34.0 % suggests that CsA is not likely sufficient as a
single agent for high-risk PKPs, and combination with a second agent such as mycophenolate mofetil or azathioprine is
needed [13, 21, 3537].
In summary, reversible systemic adverse effects of CsA
administration can often occur (50 %) under a low-dose target
level (120150 ng/ml) following keratoplasty. The most common adverse effects of CsA administration that we observed
were herpes keratitis and hypertension. Therefore, continuous
monitoring is required, especially in the early stages, and prophylactic herpes treatment may be necessary during administration of CsA. In conclusion, the present study indicates that
the risk of irreversible toxicity of CsA is extremely low in the
concentration used here (serum trough levels of 120 to 150 ng/
mL), favoring the safety of CsA therapy, since all adverse
events were reversible with appropriate monitoring and cessation of CsA.

Conflict of interest All authors certify that they have no affiliations

with or involvement in any organization or entity with any financial
interest (including honoraria; educational grants; participation in
speakers bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing
arrangements), or non-financial interest (including personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

Graefes Arch Clin Exp Ophthalmol (2015) 253:11111119

References
1.

2.

3.

4.

5.
6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

Hamrah P, Mantopoulos D, Akhtar J, Djalilian AR (2011)

Immunologically high-risk penetrating keratoplasty. In: Krachmer
JH, Mannis MJ, Holland EJ (eds) Cornea, vol 2, 3rd edn. Elsevier/
Mosby, Philadelphia, pp 14951509
Reis A, Reinhard T (2010) New developments in topical and systemic immunomodulation following penetrating keratoplasty. In:
Reinhard T, Larkin F (eds) Cornea and external eye disease.
Springer, Germany, pp 2537
Uusitalo RJ, Mahlberg K, Krootila K, Ruusuvaara P (1996)
Systemic cyclosporin treatment for high-risk corneal transplantation. Ocul Immunol Inflamm 4(1):1524. doi:10.3109/
09273949609069123
Hill JC (1995) Systemic cyclosporine in high-risk keratoplasty:
long-term results. Eye (Lond) 9(Pt 4):422428. doi:10.1038/eye.
1995.99
Hill JC (1994) Systemic cyclosporine in high-risk keratoplasty.
Short- versus long-term therapy. Ophthalmology 101(1):128133
Chong EM, Dana MR (2008) Graft failure IV. Immunologic mechanisms of corneal transplant rejection. Int Ophthalmol 28(3):209
222. doi:10.1007/s10792-007-9099-9
Reinhard T, Sundmacher R, Heering P (1996) Systemic ciclosporin
A in high-risk keratoplasties. Graefes Arch Clin Exp Ophthalmol
234(Suppl 1):S115S121
Poon AC, Forbes JE, Dart JK, Subramaniam S, Bunce C, Madison
P, Ficker LA, Tuft SJ, Gartry DS, Buckley RJ (2001) Systemic
cyclosporin A in high risk penetrating keratoplasties: a casecontrol study. Br J Ophthalmol 85(12):14641469
Inoue K, Kimura C, Amano S, Sato T, Fujita N, Kagaya F, Kaji Y,
Tsuru T, Araie M (2001) Long-term outcome of systemic cyclosporine treatment following penetrating keratoplasty. Jpn J
Ophthalmol 45(4):378382
Rumelt S, Bersudsky V, Blum-Hareuveni T, Rehany U (2002)
Systemic cyclosporin A in high failure risk, repeated corneal transplantation. Br J Ophthalmol 86(9):988992
Shimazaki J, Den S, Omoto M, Satake Y, Shimmura S, Tsubota K
(2011) Prospective, randomized study of the efficacy of systemic
cyclosporine in high-risk corneal transplantation. Am J Ophthalmol
152(1):3339. doi:10.1016/j.ajo.2011.01.019, e1
Djalilian AR, Bhasin AK, Holland EJ (2011) Postoperative management of ocular surface reconstruction. In: Krachmer JH, Mannis
MJ, Holland EJ (eds) Cornea, 3rd edn. Elsevier/Mosby,
Philadelphia, pp 17451753
Birnbaum F, Bohringer D, Sokolovska Y, Sundmacher R, Reinhard
T (2005) Immunosuppression with Cyclosporine A and mycophenolate mofetil after penetrating high-risk keratoplasty: a retrospective study. Transplantation 79(8):964968. doi:10.1097/01.tp.
0000158022.62059.f2
Maier AK, Ozlugedik S, Rottler J, Heussen FM, Klamann MK,
Huber KK, Joussen AM, Winterhalter S (2011) Efficacy of postoperative immunosuppression after keratoplasty in herpetic keratitis.
Cornea 30(12):13981405. doi:10.1097/ICO.0b013e31821e65b3
Garcia DD, Farjo Q, Musch DC, Sugar A (2007) Effect of prophylactic oral acyclovir after penetrating keratoplasty for herpes simplex keratitis. Cornea 26(8):930934. doi:10.1097/ICO.
0b013e3180e79b77
Jansen AF, Rijneveld WJ, Remeijer L, Volker-Dieben HJ, Eggink
CA, Geerards AJ, Mulder PG, van Rooij J (2009) Five-year followup on the effect of oral acyclovir after penetrating keratoplasty for
herpetic keratitis. Cornea 28(8):843845. doi:10.1097/ICO.
0b013e318198399a
Lomholt JA, Baggesen K, Ehlers N (1995) Recurrence and rejection rates following corneal transplantation for herpes simplex keratitis. Acta Ophthalmol Scand 73(1):2932

Graefes Arch Clin Exp Ophthalmol (2015) 253:11111119

18.

Graham RM (1994) Cyclosporine: mechanisms of action and toxicity. Cleve Clin J Med 61(4):308313
19. Johnson AJ, Chu CF, Milligan GN (2008) Effector CD4+ T-cell
involvement in clearance of infectious herpes simplex virus type 1
from sensory ganglia and spinal cords. J Virol 82(19):96789688.
doi:10.1128/JVI. 01159-08
20. Nakanishi Y, Lu B, Gerard C, Iwasaki A (2009) CD8(+) T lymphocyte mobilization to virus-infected tissue requires CD4(+) T-cell
help. Nature 462(7272):510513. doi:10.1038/nature08511
21. Reinhard T, Reis A, Bhringer D, Malinowski M, Voiculescu A,
Heering P, Godehardt E, Sundmacher R (2001) Systemic mycophenolate mofetil in comparison with systemic cyclosporin A in highrisk keratoplasty patients: 3 years results of a randomized prospective clinical trial. Graefes Arch Clin Exp Ophthalmol 239(5):367
372. doi:10.1007/s004170100285
22. Sander M, Lyson T, Thomas GD, Victor RG (1996) Sympathetic
neural mechanisms of cyclosporine-induced hypertension. Am J
Hypertens 9(11):121S138S
23. Taler SJ, Textor SC, Canzanello VJ, Schwartz L (1999)
Cyclosporin-induced hypertension: incidence, pathogenesis and
management. Drug Saf 20(5):437449
24. Gaston RS (2001) Maintenance immunosuppression in the renal
transplant recipient: an overview. Am J Kidney Dis 38(6 Suppl
6):S25S35
25. Isnard Bagnis C, Tezenas du Montcel S, Beaufils H, Jouanneau C,
Jaudon MC, Maksud P, Mallet A, LeHoang P, Deray G (2002)
Long-term renal effects of low-dose cyclosporine in uveitistreated patients: follow-up study. J Am Soc Nephrol 13(12):2962
2968
26. Naesens M, Kuypers DR, Sarwal M (2009) Calcineurin inhibitor
nephrotoxicity. Clin J Am Soc Nephrol 4(2):481508. doi:10.2215/
CJN.04800908
27. Tedesco D, Haragsim L (2012) Cyclosporine: a review. J Transplant
2012, 230386. doi:10.1155/2012/230386
28. Perez de Hornedo J, de Arriba G, Calvino M, Benito S, Parra T
(2007) Cyclosporin A causes oxidative stress and mitochondrial
dysfunction in renal tubular cells. Nefrologia 27(5):565573

1119
29.

Naughton CA (2008) Drug-induced nephrotoxicity. Am Fam

Physician 78(6):743750
30. Xu W, Fan W, Yao K (2012) Cyclosporine A stimulated hair growth
from mouse vibrissae follicles in an organ culture model. J Biomed
Res 26(5):372380. doi:10.7555/JBR.26.20110067
31. Gafter-Gvili A, Sredni B, Gal R, Gafter U, Kalechman Y (2003)
Cyclosporin A-induced hair growth in mice is associated with inhibition of calcineurin-dependent activation of NFAT in follicular
keratinocytes. Am J Physiol Cell Physiol 284(6):C15931603. doi:
10.1152/ajpcell.00537.2002
32. Weibrecht K, Dayno M, Darling C, Bird SB (2010) Liver aminotransferases are elevated with rhabdomyolysis in the absence of
significant liver injury. J Med Toxicol 6(3):294300. doi:10.1007/
s13181-010-0075-9
33. Lasocki A, Vote B, Fassett R, Zamir E (2007) Simvastatin-induced
rhabdomyolysis following cyclosporine treatment for uveitis. Ocul
Immunol Inflamm 15(4):345346. doi:10.1080/
09273940701375147
34. Maxa JL, Melton LB, Ogu CC, Sills MN, Limanni A (2002)
Rhabdomyolysis after concomitant use of cyclosporine, simvastatin, gemfibrozil, and itraconazole. Ann Pharmacother 36(5):820
823
35. Pleyer U (2003) Immunomodulation in penetrating keratoplasty.
Current status and perspectives. Ophthalmologe 100(12):1036
1044. doi:10.1007/s00347-003-0954-4
36. Birnbaum F, Mayweg S, Reis A, Bohringer D, Seitz B, Engelmann
K, Messmer EM, Reinhard T (2009) Mycophenolate mofetil
(MMF) following penetrating high-risk keratoplasty: long-term results of a prospective, randomised, multicentre study. Eye (Lond)
23(11):20632070. doi:10.1038/eye.2008.402
37. Chatel MA, Larkin DF (2010) Sirolimus and mycophenolate as
combination prophylaxis in corneal transplant recipients at high
rejection risk. Am J Ophthalmol 150(2):179184. doi:10.1016/j.
ajo.2010.03.010