Roadmaps to green nephrology: a mediterranean point of view.

PURPOSE OF REVIEW: Green nephrology is a movement whose aim is to find ways to reduce the environmental impact of kidney care. The question is of particular concern in this field since haemodialysis is one of the major contributors to waste generation, energy use and water consumption in healthcare. Although several ways for improving sustainability have been advocated, they are all context sensitive. This review aims to analyse the interventions that have been proposed to improve the ecologic sustainability and reduce the carbon footprint of nephrology care adapting to specific settings, and taking advantage of local expertise. RECENT FINDINGS: Green hospitals are becoming a reality in several high-income settings, thanks to new building guidelines, with greater awareness of climate change and users' demands. Water saving is feasible, and is increasingly done, in different ways (improving hardware, reducing and adapting dialysate flows). Recycling noncontaminated plastic waste is feasible, but is still rarely performed. However, ecological transition has been slow even in high-income countries, while in low and middle-income countries lack of resources limit the ability to cope with the planet's urgent needs. Conversely, where man-power cost is low, some time-consuming tasks, such as separation of various components for recycling may be affordable. Theoretically, implementation of all clinical tasks aiming to avoid or retard dialysis, should be a priority. SUMMARY: There is no single roadmap for achieving green nephrology. Each setting should start from those feasible interventions most in line with its specific needs and priorities.

Tacrolimus trough level and oxidative stress in Tunisian kidney transplanted patients.

BACKGROUND: The effect of tacrolimus (TAC) on oxidative stress after kidney transplantation (KT) is unclear. This study aimed to evaluate the influence of TAC trough levels of oxidative stress status in Tunisian KT patients during the post-transplantation period (PTP). METHODS: A prospective study including 90 KT patients was performed. TAC whole-blood concentrations were measured by the microparticle enzyme immunoassay method and adjusted according to the target range. Plasma levels of oxidants (malondialdehyde (MDA) and advanced oxidation protein products (AOPP)) and antioxidants (ascorbic acid, glutathione (GSH), glutathione peroxidase (GPx), and superoxide dismutase (SOD)) were measured using spectrophotometry. The subjects were subdivided according to PTP into three groups: patients with early, intermediate, and late PT. According to the TAC level, they were subdivided into LL-TAC, NL-TAC, and HL-TAC groups. RESULTS: A decrease in MDA levels, SOD activity, and an increase in GSH levels and GPx activity were observed in patients with late PT compared to those with early and intermediate PT (p < 0.05). Patients with LL-TAC had lower MDA levels and higher GSH levels and GPx activity compared with the NL-TAC and HL-TAC groups (p < 0.05). CONCLUSION: Our results have shown that in KT patients, despite the recovery of kidney function, the TAC reduced but did not normalize oxidative stress levels in long-term therapy, and the TAC effect significantly depends on the concentration used.

Water implications in dialysis therapy, threats and opportunities to reduce water consumption: a call for the planet.

Water is a dwindling natural resource, and potable water is wrongly considered an unlimited resource. Dialysis, particularly hemodialysis, is a water-hungry treatment that impacts the environment. The global annual water use of hemodialysis is approximately 265 million m3/yr. In this reference estimate, two-thirds of this water is represented by reverse osmosis reject water discharged into the drain. In this review, we would like to draw attention to the complexity and importance of water saving in hemodialysis. We propose that circular water management may comply with the "3R" concept: reduce (reduce dialysis need, reduce dialysate flow, and optimize reverse osmosis performance), reuse (reuse wastewater as potable water), and recycle (dialysis effluents for agriculture and aquaponic use). Awareness and sustainability should be integrated to create positive behaviors. Effective communication is crucial for water savings because local perspectives may lead to global opportunities. Besides the positive environmental impacts, planet-friendly alternatives may have significant financial returns. Innovative policies based on the transition from linear to circular water management may lead to a paradigm shift and establish a sustainable water management model. This review seeks to support policymakers in making informed decisions about water use, avoiding wasting, and finding solutions that may be planet friendly and patient friendly in dialysis, especially in hemodialysis treatments.

The presence of two light chain bands on immunofixation is associated with poor outcomes in newly diagnosed multiple myeloma patients.

We aimed to describe the clinical and biological characteristics and the prognosis of patients presenting with an additional light chain (LC) band along with a complete monoclonal protein on immunofixation (IF).An 8-year descriptive study was conducted to assess all cases with confirmed monoclonal gammopathies (MG). We studied those with an entire M-protein with 2 bands of LC of the same isotype based on the results of IF. Data were collected from patients' files.Among 548 cases of MG, we found 32 cases (5.8%) with an additional LC band. We included 28 patients (5%) with a confirmed diagnosis of multiple myeloma (MM). The m/f ratio was 2.5 with a median age of 63 years [32-80 years]. All MM patients had anemia, 16 (57%) had renal failure, 14 (50%) had lytic lesions, 9 (32%) received hemodialysis, and 7 (25%) had hypercalcemia. The free-kappa-lambda ratio was abnormal in all cases: median = 0.07 [0.002-58.57]. The mean overall survival (OS) was 22 months ± 38.76.Fifteen MM patients (48%) received chemotherapy, and 7 (22%) autologous stem cell transplants (SCT). Patients who received SCT had an OS higher than those who received other treatments (p = 0.038). OS was low in patients with high ß2microglobulin levels (rho = -0.791; p = 0.001), and abnormally low free-kappa-lambda ratio (rho = -0.852;p = 0.04).The presence of an additional LC band with a complete monoclonal protein seems to identify newly diagnosed MM patients with poor outcomes and frequent renal impairment.

ePHex: a phase 3, double-blind, placebo-controlled, randomized study to evaluate long-term efficacy and safety of Oxalobacter formigenes in patients with primary hyperoxaluria.

BACKGROUND: Primary hyperoxalurias (PHs) are rare genetic diseases that increase the endogenous level of oxalate, a waste metabolite excreted predominantly by the kidneys and also the gut. Treatments aim to improve oxalate excretion, or reduce oxalate generation, to prevent kidney function deterioration. Oxalobacter formigenes is an oxalate metabolizing bacterium. This Phase III, double-blind, placebo-controlled randomized trial investigated the effectiveness of orally administered Oxabact™, a lyophilized O. formigenes formulation, at reducing plasma oxalate levels in patients suffering from PH. METHODS: Subjects (≥ 2 years of age) with a diagnosis of PH and maintained but suboptimal kidney function (mean estimated glomerular filtration rate at baseline < 90 mL/min/1.73 m2) were eligible to participate. Subjects were randomized to receive Oxabact or placebo twice daily for 52 weeks. Change from baseline in plasma oxalate concentration at Week 52 was the primary study endpoint. RESULTS: Forty-three subjects were screened, 25 were recruited and one was discontinued. At Week 52, O. formigenes was established in the gut of subjects receiving Oxabact. Despite decreasing plasma oxalate level in subjects treated with Oxabact, and stable/increased levels with placebo, there was no significant difference between groups in the primary outcome (Least Squares mean estimate of treatment difference was - 3.80 µmol/L; 95% CI: - 7.83, 0.23; p-value = 0.064). Kidney function remained stable in both treatments. CONCLUSIONS: Oxabact treatment may have stabilized/reduced plasma oxalate versus a rise with placebo, but the difference over 12 months was not statistically significant (p = 0.06). A subtle effect observed with Oxabact suggests that O. formigenes may aid in preventing kidney stones. A higher resolution version of the Graphical abstract is available as Supplementary information.

Next-generation sequencing in patients with familial FSGS: first report of collagen gene mutations in Tunisian patients.

Focal segmental glomerulosclerosis (FSGS) is a histological lesion with many causes, including inherited genetic defects, with significant proteinuria being the predominant clinical finding at presentation. FSGS is considered as a podocyte disease due to the fact that in the majority of patients with FSGS, the lesion results from defects in the podocyte structure. However, FSGS does not result exclusively from podocyte-associated genes. In this study, we used a genetic approach based on targeted next-generation sequencing (NGS) of 242 genes to identify the genetic cause of FSGS in seven Tunisian families. The sequencing results revealed the presence of eight distinct mutations including seven newly discovered ones: the c.538G>A (p.V180M) in NPHS2, c.5186G>A (p.R1729Q) in PLCE1 and c.232A>C (p.I78L) in PAX2 and five novel mutations in COL4A3 and COL4A4 genes. Four mutations (c.209G>A (p.G70D), c.725G>A (p.G242E), c.2225G>A (p.G742E), and c. 1681_1698del) were detected in COL4A3 gene and one mutation (c.1424G>A (p.G475D)) was found in COL4A4. In summary, NGS of a targeted gene panel is an ideal approach for the genetic testing of FSGS with multiple possible underlying etiologies. We have demonstrated that not only podocyte genes but also COL4A3/4 mutations should be considered in patients with FSGS.

Effects of intradialytic exercise in combination with melatonin supplementation on functional capacity, postural balance, and quality of life in hemodialysis patients.

INTRODUCTION: We evaluated the effect of intradialytic concurrent (resistance-endurance) training combined with melatonin (MEL) supplementation on functional capacity, muscle strength, postural balance, and quality of life (QoL) in hemodialysis (HD) patients. METHODS: Thirty-three HD patients were randomized into three groups: Exercise (EX)-MEL (n = 11); EX-Placebo (PLA) (n = 11) and Control (C)-PLA (n = 11). Participants included in the EX-MEL and EX-PLA groups were submitted to concurrent training for 12 weeks. RESULTS: EX-MEL and EX-PLA improved functional capacity, muscle strength, QoL, and postural balance parameters in eyes open and eyes closed conditions. Parameters of postural balance in the dual task condition were improved only in EX-MEL. EX-MEL induced better results in some domains of QoL compared with EX-PLA. CONCLUSION: Intradialytic concurrent training induced beneficial effects on physical function, muscle strength, postural balance, and QoL in HD patients. MEL supplementation combined with intradialytic exercise lead to better improvements in postural balance and QoL.

Melatonin intake before intradialytic exercise reverses oxidative stress and improves antioxidant status in hemodialysis patients.

PURPOSE: The present study aimed to investigate for the first time the effects of melatonin (MEL) intake on oxidative stress and cellular damage during intradialytic exercise (IEX). METHODS: Thirteen hemodialysis (HD) patients volunteered to participate in the current randomized crossover trial. Participants performed four HD sessions in four different conditions: (Exercise (EX)-MEL), (EX-Placebo (PLA)), (Control (C)-MEL), and (C-PLA). 3 mg of MEL or PLA were taken 60 min before starting exercise, or at the equivalent time in the C conditions. Blood samples were taken before HD (T0), immediately after the end of IEX (T1), 60 min after IEX (T2), or at the corresponding times in the C conditions to measure free radicals damage, antioxidant biomarkers, as well as biomarkers of muscle and liver damage. RESULTS: Malondialdehyde and Advanced Oxidation Protein Products decreased in (C-MEL) (p < 0.05, d = 2.19; p < 0.01, d = 0.99, respectively) at T2 compared to T0. Catalase and total thiol levels increased in (C-MEL) (p < 0.01, d = 1.51; p < 0.01, d = 1.56, respectively) and in (EX-MEL) (p = 0.01, d = 1.28; p < 0.01, d = 1.52, respectively) at T1 compared to T0. Total bilirubin levels increased in (EX-MEL) and (C-MEL) at T2 compared to T0 (p < 0.001, d = 2.77; p < 0.001, d = 1.36, respectively), but only at T2 compared to T1 in (EX-MEL) (p < 0.001, d = 1.67). In all conditions, uric acid levels decreased at T1 compared to T0 and at T2 compared to T1, while biomarkers of muscle and liver damage remained unchanged. CONCLUSION: This pilot study is the first to show that MEL ingestion, alone or combined with IEX, could improve oxidant-antioxidant balance during HD.

Biclonal Gammopathies in South Tunisia: Clinical and Biological Characteristics.

OBJECTIVE: Biclonal gammopathies (BGs) are rare situations characterized by the production of 2 monoclonal proteins. There are no available data on BGs in North Africa. We aimed to estimate the prevalence of BGs in our population and describe their clinical and laboratory features. METHODS: We conducted a 31-year retrospective study including patients with persistent double monoclonal bands based on the results of immunofixation/immunoelectrophoresis. RESULTS: A total of 35 patients with available clinical data (sex ratio, M/F = 1.53; mean age, 70 ±â€…10.87 years [range, 45-90 years]) were included. The main associated conditions were multiple myeloma (MM) (40%), BG of undetermined significance (BGUS) (34%), and lymphoproliferative diseases (23%). Only one-third of the patients had 2 monoclonal spikes on serum protein electrophoresis. The most common paraprotein combinations were immunoglobulin (Ig)G-IgG (25%) and IgG-IgA (23%) with different light chains in one-half of the cases. The mean follow-up was 25.6 months (median, 12 months). No BGUS evolved into a malignant disease. CONCLUSION: BGs are rare in clinical laboratory routine but must be accurately identified by the pathologist. Our cohort is characterized by a high prevalence of BGUS compared with MM.

Chronic Kidney Disease, Hypokalemia, and Appendicular Mucocele in a 66-Year-Old Man.

Appendicular mucocele (AM) is a rare and potentially malignant entity linked to obstructive dilatation of the appendix with an intraluminal accumulation of mucoid material. Most AM is asymptomatic or simulates acute appendicitis. We report an exceptional case of AM discovered in the face of hypokalemia and aggravation of chronic kidney disease (CKD) without diarrhea in an old man. Investigations led to the diagnosis of AM in its malignant form complicated by gelatinous ascites. We retained mucinous hypersecretion as the cause of hypokalemia and acute renal failure. Aggressive surgery and intraperitoneal chemotherapy corrected hydroelectrolyte imbalance.

Bone marrow aspirate: a diagnostic tool for primary hyperoxaluria type 1.

INTRODUCTION: Type1 primary hyperoxaluria is an infrequent autosomal recessive metabolic disease characterized by the accumulation of calcium oxalate in the kidney, which leads to end stage renal disease. In fact, the diagnosis of this disease is mandatory in order to avoid graft loss. AIM: To assess the incidence of primary hyperoxaluria and to develop the diagnostic value of bone marrow infiltration by calcium oxalate in uremic stone former patients. METHODS: This study was conducted on a cohort of stone former patients identified in the south of Tunisia over a period of 18 years. Baseline characteristics were recorded. Clinical and laboratory data were collected on chart review. Secondary forms of hyperoxaluria were excluded. Bone marrow aspirate was performed in uremic patients from this cohort because early hyperoxaluria was suspected. Diagnostic accuracy of this test relating to sensitivity, specificity, positive predictive value and negative predictive value were also calculated. RESULTS: A cohort of 31 patients comprising 17 male patients and 14 female patients were identified. During this time of diagnosis, the patient's ages ranged from 9 to 57 years old and 22 of them (70%) unfortunately died. Bone marrow aspirate was safely done in 16 uremic patients. It was positive in 12 patients and negative in 4 patients. Sensitivity, specificity, positive predictive value and negative predictive value were respectively 85%, 100%, 100% and 50%. CONCLUSION: The bone marrow examination represents both an easy and a worldwide feasible solution for the diagnosis of oxalosis, which affords an early diagnosis.

Acinetobacter lwoffi peritonitis in peritoneal dialysis: two cases report.

Peritonitis is an important cause of morbidity and technique failure in peritoneal dialysis. Herein, we report peritonitis related to Acinetobacter lwoffi in two patients on peritoneal dialysis. The first case is a 63-year-old patient treated by automated peritoneal dialysis admitted with abdominal pain. The peritoneal effluent White Blood Cells count consisted of 280 cells/mm3. Then culture identified a multisensitive Acinetobacter lwoffi. Treatment with ceftazidime and ciprofloxacin had been started. The control dialysate culture was sterile after three weeks. The second patient is a 59-year-old female admitted because of diffuse abdominal pain and cloudy dialysate. The peritoneal effluent White Blood Cells count consisted of countless leukocytes, with predominantly polynuclear and culture identified Acinetobacter lwoffi. He received intraperitoneal ceftazidim and amikacin for three weeks. The control dialysate was sterile. Acinetobacter lwoffi is a rare cause of peritonitis and it can be treated successfully with early recognition and appropriate antibiotic therapy based on culture instead of catheter removal.

Melatonin ingestion before intradialytic exercise improves immune responses in hemodialysis patients.

PURPOSE: The present study aimed to investigate the effects of melatonin (MEL) intake on systemic inflammation and immune responses during intradialytic exercise. METHODS: Thirteen hemodialysis (HD) patients volunteered to participate in the current randomized-crossover study. Immunological responses were monitored in four HD sessions at different conditions: [Exercise (EX) + MEL], [EX + Placebo (PLA)], [Control (CON) + MEL] and [CON + PLA]. MEL (3 mg) or PLA was ingested 1 h before starting exercise or the equivalent time in CON condition. During all sessions, peripheral blood samples were collected to assess c-reactive protein, complete blood count, and immune cells phenotypes before HD (T0), immediately after exercise (T1) and 1 h after exercise (T2) or at corresponding times in the CON condition. RESULTS: HD therapy induced a significant decrease in natural killer (NK) (p = 0.001, d = 0.85; p < 0.001, d = 1.19, respectively) and CD8+ T-lymphocytes rates (p = 0.001, d = 0.57; p < 0.001, d = 0.75, respectively) at T1 and T2 compared to T0. MEL intake prevented the decrease in NK and CD8+ T-lymphocytes, increased the proportion of CD4+ T-lymphocytes at T1 and T2 compared to T0 (p = 0.002, d = 1.18; p = 0.001, d = 1.04, respectively) and decreased the proportion of CD14++CD16+ Monocytes at T2 compared to T0 (p = 0.02, d = 1.57) in peripheral blood during HD therapy. Similar results were found in [EX + MEL] and [EX + PLA] conditions. CONCLUSION: This pilot study provides the first evidence that MEL intake alone or associated with intradialytic exercise displays potential immunoregulatory and anti-inflammatory effects. The combination of MEL with intradialytic exercise may be an appropriate anti-inflammatory therapy for HD patients.

[Urolithiasis of the kidney transplanted patient in south Tunisia: A 17-year experience]. / La lithiase urinaire du transplanté rénal dans le sud tunisien : expérience de 17 ans.

INTRODUCTION: Urolithiasis in a kidney transplanted patient is an uncommon but complex urological complication. Its potential severity comes from its occurrence on a solitary kidney and on a field of immunosuppression. The aim of our study is to assess the incidence, characteristics and course of urolithiasis in our series. METHODS: A retrospective study was performed. We included kidney transplanted patients between November 2002 and November 2019 and presenting lithiasis during their follow-up. Clinical, biological and radiological data were collected as well as lithiasis disease related data. The management of and patient's evolution were also specified. RESULTS: Seven of 416 kidney transplanted patients developed lithiasis during their follow-up with an incidence of 1.6 %. The mean age at lithiasis diagnosis was 36.5 years [24-55 years], the sex ratio was 1.3. They developed stones after mean follow-up of 67 months [4-168 months]. The stones' size varied from 2 to 18mm. Treatment was alkalisation in 3 cases, extracorporeal lithotripsy in 2 cases, a double J stent in 3 cases and pyelolithotomy in 2 cases. Four patients had multiple treatments. Three patients had 1 residual stone during evolution (7mm average diameter), 1 microlithiasis, 1 lost to follow-up after treatment and only 2 (out of 7) were "stone free". Furthermore, lithiasis didn't damage the graft survival after a median follow-up of 62 months post-treatment. CONCLUSION: Urolithiasis in the kidney transplanted patient requires an adapted multidisciplinary management. Its skill is a challenge for both the nephrologist and urologist.

Wegener's granulomatosis presenting as multiple bilateral renal masses: case report and literature review.

Wegener's granulomatosis (WG) is a disease of unknown etiology characterized by necrotizing granulomatous vascularitis. The upper and lower respiratory tract and kidney involvements are very common; however, its presentation as bilateral renal masses is unusual. We report a case of a 59-year-old female patient who presented with multiple bilateral renal masses. The patient presented with sinusal and ocular symptoms suggestive of WG, and positive antineutrophil cytoplasmic antibodies (c-ANCA) with an anti-PR3 pattern. Histopathologic examination of the renal biopsy specimen revealed granulomatous inflammation with vasculitis and fibrinoid necrosis. The patient management, including prednisone and cyclophosphamid, induced a marked improvement of the renal masses. This case illustrates that WG should be considered in the differential diagnosis of renal masses.

[Adult Schönlein-Henoch purpura associated with epidermoid carcinoma of the lung]. / Association purpura rhumatoïde de l'adulte et carcinome épidermoïde du poumon.

INTRODUCTION: Association between Schönlein-Henoch purpura and neoplasm can suggest the responsibility of tumour antigens in the genesis of the vasculitis. We report a new case of squamous cell carcinoma associated with Schönlein-Henoch purpura and we discuss the reality of this association. CASE REPORT: We report the case of a 50-year-old man who presents Schönlein-Henoch purpura with a purpura of lower limbs, joint involvement, gastrointestinal lesions and IgA renal mesangial deposits. The patient received three intravenous methylprednisolone pulses followed with oral corticosteroids. Six months later, while the vasculitis was in remission, the patient presented a squamous cell lung carcinoma. He was treated by chemotherapy and local radiotherapy. At the late follow-up, the neoplasm was incompletely resolved. CONCLUSION: The neoplasm could be responsible of the development of the Schönlein-Henoch purpura. The discovery of this systemic vasculitis in an elderly patient should warrant a deep screening for an occult neoplasm.

[Renal biopsy findings in diabetes mellitus]. / La ponction biopsie renale chez le diabetique: interet et resultats.

BACKGROUND: The prevalence of diabetic patients with endstage renal disease is increased overall the word. Renal biopsy is sometimes necessary to precise the type of renal damage. AIM: To precise the type and the frequency of non diabetic nephropathy in diabetic patients. METHODS: We enrolled retrospectively during 17 years, 72 diabetic patients who had a renal biopsy. RESULTS: A non diabetic nephropathy was found in 69.5 % of them. Its presence was correlate to the presence of hematuria and the absence of diabetic retinopathy. We can successfully treated nine patients with minimal-change nephrotic syndrome and one patient with crescentic glomerulonephritis. CONCLUSION: Renal biopsy must be done in diabetic patient with hematuria or in the absence of diabetic retinopathy.

[Cutaneous manifestations of chronic hemodialysis. Prospective study of 363 cases]. / Manifestations cutanées chez les hémodialysés chroniques. Etude prospective de 363 cas.

OBJECTIVE: Chronic hemodialysis patients experience frequent and varied cutaneous manifestations, of often hypothetical pathogenesis. The aim of this work is to assess the prevalence and nature of these cutaneous lesions and discuss some pathogenic mechanisms. METHODS: This prospective study was conducted from 1 February through 30 April 1996. It included 363 hemodialysis patients in seven centers. Each patient was interviewed and examined. RESULTS: There were 210 men and 153 women. Their mean age was 50.6 years. The total duration of hemodialysis ranged from 1 to 192 months, with a mean of 52.4 months. 88% of the patients had cutaneous manifestations. Pruritus was reported by 44.8%. It appeared after hemodialysis began for 82.1% of them. Cutaneous xerosis was observed in 69%. Changes in pigmentation were observed in 17% of cases, primarily involving hyperpigmentation of photo-exposed areas. In 6 patients, skin, hair, and exoskeleton began to turn lighter 10 months to 8 years after hemodialysis. Follicular hyperkeratosis was observed in 15%. One patient had a confirmed case of perforating follicular dermatosis. Disorders of the exoskeleton (18.5% of cases) were represented mainly by thin nails and subungual hemorrhages. Other cutaneous manifestations included petechiae and ecchymoses (66%), folliculitis-type infections (9%), subcutaneous calcifications (2 cases), cutaneous pseudoporphyria (2 cases), and eczema around the fistula (11.5%), due essentially to locally-applied products. CONCLUSION: Cutaneous manifestations in chronic hemodialysis patients are frequent and polymorphous. While most have long been known, lightening of skin, in particular, others have been discovered more recently. Their pathogenesis is most often poorly elucidated. Treatment is often symptomatic. Dialysis and renal transplantation constitute the best treatment.

Trigeminal somatosensory evoked potentials in trichloroethylene-exposed workers.

OBJECTIVE: To assess the value of trigeminal somatosensory evoked potentials (TSEP) in evaluating toxicity of trichloroethylene to the trigeminal nerve. METHODS: Trichloroethylene (TCE), an excellent fat solvent largely used in industry, has a neurotoxic effect particularly on the trigeminal nerve. In March 2002, several TCE-exposed workers presented to Habib Bourguiba University Hospital, Sfax, Tunisia, for burned or numbness of the face. Twenty-three workers manipulating TCE underwent clinical, biological and toxicological assessment. Neurophysiologic study consisted of the measurement of the latencies and the amplitudes of TSEP in 23 exposed workers and 23 controls. RESULTS: Abnormal TSEP were observed in 6 workers with clinical evidence of trigeminal involvement and in 9 asymptomatic workers. We observed a significant positive correlation between duration of exposure and the N2 latency (r=0.5, p<0.01) and P2 latency (r=0.6, p<0.02). The sensitivity of TSEP was 65% and the specificity was 100%. CONCLUSION: Trigeminal somatosensory evoked potentials are a useful tool in the diagnosis and management of chronic neurological complications of TCE intoxication. Since alterations of TSEP precede clinical symptoms, trigeminal nerve involvement can be demonstrated at the infra-clinical stage.