The effect on renal function

Decreased urinary output with lowered renal sodium excretion and a positive water and sodium balance were first described in patients treated with prolonged mechanical ventilation in 1968. The addition of PEEP was shown to enhance this effect. Increases in intrathoracic pressure and decreases in venous return, transmural right atrial pressure, and mean arterial pressure initiate a cascade of interconnected regulatory mechanisms which ultimately reduce both diuresis and natriuresis. Mediation of the renal actions of PEEP is postulated to be by the following mechanisms:

1. a direct effect of decreased cardiac output and blood pressure on renal perfusion pressure, glomerular filtration rate, and tubular sodium reabsorption;

2. stimulation of neural mechanisms (stimulation of central sympathetic activity in response to decreased circulatory pressure; unloading of atrial and arterial baroreceptors with attenuation of tonic vagal activity as a consequence of elevated intrathoracic pressure);

3. hormonal changes induced by the hemodynamic and neural alterations mentioned above.

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