Most radiologists consider 10 to 12 cm to be an approximate reference range for renal length in adults, allowing for an additional 1 cm in either direction for patients at the extremes of height. Fever. Duplication affects the axial appearance of the kidneys by dividing the renal sinus into superior and inferior components, separated by a circumferential band of cortex in the central region (Fig. When echogenicity of the renal cortex equals that of the liver, renal function is abnormal in approximately 38% of cases. Advantages of scintigraphy include accurate quantitative measurement of function and parenchymal mass without the risks for nephrotoxicity associated with iodinated contrast media or nephrogenic systemic fibrosis associated with gadolinium contrast agents. When both kidneys are on the same side crossed ectopia is present, because the ureter from one kidney must cross the midline to insert into the bladder (Fig. Ultrastructurally, the nephron is the functional representative of the kidney. When the renal cortex is more echogenic than the adjacent liver, there is a high correlation with renal disease, although sensitivity is relatively low, according to Platt and colleagues (Fig. This specific condition is called the nutcracker phenomenon. Reviewer: 18-19). Figure 25.1.2 Left Kidney. Figure 18-10 Crossed ectopia on intravenous pyelogram. Weve mentioned that the most important functions of the kidney are the regulation of the blood homeostasis and blood pressure, so acute kidney failure can lead to a quick fall of blood pressure which presents as a state of shock. Summary: A variety of factors, including patient body habitus, local renal anatomy, cost and patient preference, must be taken into consideration when determining the optimal treatment modality for lower pole renal calculi. Crossed ectopia can be either fused or unfused. Some forms of congenital UPJ obstruction are now treated with transureteroscopic endopyelotomy in which an incision is made from within the ureter using a ureteroscope. The upper pelvis is the most common ectopic location for the kidney; most cases are also associated with abnormalities of rotation. Because of this, the tubules are designed in a way that they reabsorb the necessary substances, (sodium, potassium, and amino acids as mentioned before) and carries them back to the blood; whereas they do not absorb but rather secrete unnecessary substances such as creatinine and drug metabolites for excretion from the body. Look for duplication, large extrarenal pelvis. 18-3). Figure 18-24 Normal magnetic resonance imaging appearance of the kidneys. It is important to note, however, that the appearance of hydronephrosis does not necessarily indicate urinary obstruction (see Hydronephrosis and Its Mimics section later in this chapter). Concerning lymphatic drainage, each kidney drains into the lateral aortic (lumbar) lymph nodes, which are placed around the origin of the renal artery. Some divide the excretory phase into the early excretory phase (contrast mainly confined to the kidney) and late excretory phase (contrast in the ureters). After looking at the overview of the kidneys in situ, it may seemas they are cluttered with all abdominal organs. Comparative views of the CT scan ( a axial, b coronal, and c sagittal planes) and corresponding views of the physical model ( d superior view, e median view, and f median view). It protects your kidneys from injury, increases their stability and connects your kidneys to surrounding tissues. The information we provide is grounded on academic literature and peer-reviewed research. Despite the complexity of renal physiology, many attempt to assess renal function with a simple quantitative measure, the serum creatinine. Although ureteral contrast media is typically present before 3 minutes, longer delays provide more predictable opacification. Figure 18-13 Volume rendering from a computed tomographic scan of the kidneys shows bilateral supernumerary renal arteries (three on right, two on left). Unilateral renal agenesis occurs in approximately 1 in 1000 individuals with minimal impact on health, although it is sometimes associated with other congenital anomalies of the genitourinary tract and musculoskeletal system. 18-20). Table 18-7 Causes of Unilateral Small Smooth Kidney, Only gold members can continue reading. In other cases, each renal unit has its own ureter. There are many clinical states related to kidney malfunction. Axial images of the left kidney from a three-phase renal computed tomographic scan demonstrate improved conspicuity of low-attenuation lesions of the renal medulla during the nephrographic phase. For that reason, we got you covered with this topic nicely and concisely. "Angio" indicates blood vessels, "myo" indicates muscle, and "lipoma" indicates fat. Supernumerary kidneys are quite rare and have been associated with aortic coarctation, vaginal atresia, and urethral duplications. Arterial stenosis was confirmed by magnetic resonance angiography. Our engaging videos, interactive quizzes, in-depth articles and HD atlas are here to get you top results faster. The fused kidneys can have a variety of orientations, including side by side, in-line, or perpendicular. Table 18-5 summarizes a checklist approach to the ultrasound examination. When simple kidney cysts do cause symptoms, they might include: Pain in the side between the ribs and hip, stomach or back. The nephrons within the cortex comprise some of the most highly perfused parenchymal tissue in the body. Medullary cystic disease is encountered only rarely, and in addition to the echogenic atrophic cortex, the medullary pyramids are particularly hypoechoic. Anatomy Where is the renal cortex? You can test yourself on the renal arteries with our quiz. The anterior surface faces towards the anterior abdominal wall, whereas the posterior surface is facing the posterior abdominal wall. Lets start with the right kidney anterior surface. Figure 18-25 Sagittal ultrasound image of the left kidney demonstrates a unilateral small, smooth, echogenic kidney in a patient with renal artery stenosis. This phenomenon is due to T2-shortening and susceptibility (T2*) effects caused by concentrated gadolinium, and can potentially obscure filling defects and urothelial lesions. Pearl: Any upward trend in serum creatinine value should be viewed with concern because it implies renal reserve function has already been affected. This illustrates the amount of reserve function that must be compromised before renal injury can be detected with a serum creatinine level. Due to the segmental vascular supply of the kidney it is often feasible to ligate the relative arteries and veins and remove the tumour with a safe zone of healthy surrounding parenchyma ( partial nephrectomy) without removing the entire kidney or compromising its total vascular supply by ischaemia. Created for people with ongoing healthcare needs but benefits everyone. Other malfunctions of the kidney are presented through acute kidney failure, a serious and urgent medical condition. This method is the standard in evaluation of UPJ obstruction and often is used for other types of chronic obstruction. Chronic glomerulonephritis usually causes bilateral increased renal echogenicity with smooth atrophy, whereas renal artery stenosis usually causes a similar but unilateral appearance (Fig. This kidney measured 14 cm in length. In adults, the normal kidney is 10-14 cm long in males and 9-13 cm long in females, 3-5 cm wide, 3 cm in antero-posterior thickness and weighs 150-260 g. The left kidney is usually slightly larger than the right. Learn more about the anatomy of the kidneys and the urinary system with our urinary system quizzes and labeled diagrams. This is because the liver and the stomach offset the symmetry of the abdomen, with the liver forcing the right kidney a bit down, and the stomach forcing the left kidney a bit up. The kidney is a very important organ in regards to body homeostasis. It participates in vital processes such as regulation of blood osmolarity and pH, regulation of blood volume and blood pressure, production of hormones, and filtration of foreign substances. However, sometimes ureteroscopy is required to confirm the diagnosis in patients with hematuria. A, Axial image from contrast-enhanced computed tomography (CT) demonstrates an accessory right renal artery coursing anterior to the IVC. Maintaining kidney health. 18-18). This is called the nutcracker phenomenon. Renal scintigraphy can be performed with a variety of agents to provide assessment of either function or structure of the kidneys. Unlike other filling defects within the renal collecting system (e.g., tumor, stone, clot), an aberrant papilla usually has a small fornix around it, seen as a halo on conventional urography (Fig. Estimated creatinine clearance may be calculated using serum creatinine with adjustments made for sex, age, and body weight. The left renal vein passes anteriorly to the aorta just below the trunk of the superior mesenteric artery, which is risky because it can be compressed by one of those two. The presence or absence of intravenous contrast media, as well as the phase of contrast enhancement, are key factors that determine the appearance of the renal parenchyma on CT (Table 18-3). 18-7). Size disparity greater than 1.5 cm between kidneys should raise suspicion that one kidney is abnormal. Other methods include classical surgical removal of the stone, either through the ureter or by open surgery. The phases of nephrogram development and contrast excretion parallel those seen on contrast-enhanced CT with one notable exception (Fig. For most people, obstruction of a single ureter does not induce renal failure. A. Junctional cortical line seen on a long-axis ultrasound image of the right kidney. Each pyramid creates urine and terminates into a renal papilla. Thus, the ureter is seen paravertebrally starting from the L2 and going downwards. Each time a professor says 'nephron', a student gets a headache. Anatomical Position of the Kidneys Kidney Structure All content published on Kenhub is reviewed by medical and anatomy experts. A, Steady-state free precession, (B) T2-weighted with fat saturation, (C) T1-weighted, (D) T1-weighted with fat saturation, (E) postcontrast corticomedullary phase, and (F) postcontrast nephrographic phase. On ultrasound, the renal cortex is usually echogenic in this setting. Frontal image of the left kidney from an intravenous urogram demonstrating an aberrant renal papilla in the lower pole infundibulum. Table 18-3 Utility of Different Phases of Renal Contrast Enhancement. An increased amount of hydrogen ions can acidify the blood and cause a state called acidosis. . These terminal branches have no collateral circulation. Supernumerary kidneys are quite rare and have been associated with aortic coarctation, vaginal atresia, and urethral duplications. Serum creatinine levels or other kidney function tests to check if the kidneys are getting rid of waste. Sagittal ultrasound image of the right kidney demonstrates increased size and echogenicity of the kidney, findings typical of human immunodeficiency virus nephropathy. The main unit of the medulla is the renal pyramid. A, Soft-tissue windows demonstrate no filling defect. IVC, Inferior vena cava. 18-2). When the renal arteries enter the kidney through the hilum, they split into anterior and posterior branches. Approximately 1 year before presentation, the patient experienced a similar episode of right flank pain that prompted an unenhanced CT examination of the abdomen and pelvis at an outside institution. Enlargement of a congenitally unilateral kidney is typical and presumed to be compensatory. The upper pelvis is the most common ectopic location for the kidney; most cases are also associated with abnormalities of rotation. The uniform high attenuation of the nephrographic phase provides an optimal background for detecting small, low-attenuation lesions in the renal parenchyma (Fig. 18-6). 18-11). The goal of imaging patients with renal failure is to identify a correctable cause in an effort to recover or preserve renal function. Differential diagnosis General imaging considerations include: renal cortical defect duplex kidney Sagittal ultrasound image of the left kidney demonstrates a unilateral small, smooth, echogenic kidney in a patient with renal artery stenosis. Aggressive tumors form, grow and spread very quickly. When fused, the condition is described as crossed fused ectopia. Further testing/diagnosis is required. The kidneys are highly vascular (contain a lot of blood vessels) and are divided into three main regions: the renal cortex (outer region which contains about 1.25 million renal tubules), renal medulla (middle region which acts as a collecting chamber), and renal pelvis (inner region which receives urine through the major calyces). Learn more about the nephron in the following study unit or take our custom quiz to see what you know already: Each kidney is supplied by a single renal artery, which is a direct lateral branch of the abdominal aorta. Get instant access to this gallery, plus: Introduction to the musculoskeletal system, Nerves, vessels and lymphatics of the abdomen, Nerves, vessels and lymphatics of the pelvis, Infratemporal region and pterygopalatine fossa, Meninges, ventricular system and subarachnoid space. Urine from the calyces flows to the renal sinus via tributaries called infundibula. This significantly affects the testicle, since an obstruction of drainage causes an obstruction of fresh arterial blood inflow, which can result in the infarction of testicular tissue. The renal veins empty to the inferior vena cava, so the right vein is shorter because the inferior vena cava runs closer to the right kidney. When the fine, weblike complex of ureteral arteries is recruited to contribute to collateral circulation, enlarged vessels are seen surrounding the proximal ureter, causing the classic ureteral notching seen on intravenous urogram (IVU). Now that weve mastered the borders, it will be easier to take a closer look at the anatomical relations that the kidneys share with other abdominal structures. Figure 18-1 Annotated three-dimensional volume rendering of the left kidney acquired using a combined nephrographic phase and excretory phase during computed tomographic urography demonstrates regional anatomy of the kidney. development and contrast excretion parallel those seen on contrast-enhanced CT with one notable exception (Fig. The glomerular membrane is designed in a way in which it is not permeable for big and important molecules in blood, such as plasma proteins, but it is permeable to the smaller substances such as sodium, potassium, amino acids and many others. Unenhanced CT can identify hydronephrosis and hydroureter, urinary stones, and some masses. The vessel which brings blood into the glomerulus is the afferent arteriole, whereas the vessel that carries the rest of the blood out that hasnt been filtered out of the glomerulus is called the efferent arteriole. RENAL ANATOMY Renal Parenchyma The kidneys can be divided into three main regions from cranial to caudal. A simple calyx receives urine from a single papilla; a compound calyx receives urine from multiple papillae (Fig. Figure 18-18 Single-detector computed tomographic images from ureteropelvic junction deformity in the right side of a horseshoe kidney. The renal pelvis then tapers like a funnel to join the ureter. The apex of the pyramid projects medially toward the renal sinus. Unlike the excretory phase of enhanced CT, signal intensity within the renal collecting systems is reduced on T1- and T2-weighted MR images once excreted gadolinium-based contrast media becomes sufficiently concentrated. Renal cysts become fairly common as people age and usually do not cause symptoms or harm. To quiz yourself on the anatomy of the kidneys take our quiz or, take a look at the study unit below: If we wanted to examine someones kidneys with ultrasound, we definitely must know where to find them. For most of the students, the nephron is a mystical complexed structure that may be hard to understand. The large left proximal ureteral stone seen in this image is only partially obstructing, causing mild dilation in the left kidney collecting system. D, If pressure on the papilla persists, the ischemic papilla undergoes necrosis, allowing the calyx to protrude outward toward the cortex. Ultrasound permits real-time optimization of imaging relative to the axis of each kidney. The pyramids are separated by extensions of the cortex called the renal columns. The kidneys can be divided into three main regions from cranial to caudal. Now lets pay attention to the borders of the kidneys. Many clinical laboratories now provide computer-generated calculations of estimated creatinine clearance or eGFR using patient data in the medical information system. Radiologists divide the kidney into three parts: the upper pole, lower pole, and the interpole (which is in between them). However, this individual is more likely to show a decline in renal function from an additional insult. They extend from lumbar vertebra T12-L3. Box 18-2 provides some tips regarding crossing vessels in UPJ obstruction. Learn how we can help 1.2k views Reviewed Dec 09, 2022 Thank In other cases, each renal unit has its own ureter. 18-12). Kenhub. The interpolar region is the middle of the kidney. Note origin of inferior accessories near inferior poles on each side. Because the fascia of the retroperitoneum prevents significant extravasation, the incision usually heals to form a larger lumen. more lateral and anterior than the superior poles. 18-28). Note that the left renal vein receives blood from the left suprarenal and left testicular veins. General symptoms of kidney problems include: blood in your urine . A, Enhancement of the mass is conspicuous in the corticomedullary phase. Figure 18-5 Illustration demonstrating the anatomy of the renal collecting system. Axial image of the left kidney from a contrast-enhanced computed tomographic scan demonstrates an extrarenal pelvis. Learning a quickmnemonic'VAD' can help you remember these structures (renal Vein, renal Artery, Duct a.k.a ureter). Furthermore, since the left renal vein passes between the superior mesenteric artery and the abdominal aorta, an enlargement of the superior mesenteric artery can compress the left renalvein and cause an obstruction of drainage from all three structures that use the left renal vein for drainage (left suprarenal gland, left kidney, and left testicle). February 12, 2018 - 2:17pm If the renal pelvis extends out of the renal sinus, it is considered to be an. 18-24). 18-25). Recent advances in MDCT and MRI permit cross-sectional vascular studies to replace conventional angiography before UPJ repair (Fig. A junctional cortical line is a common septum of capsule typically seen on ultrasound as an echogenic line at the site of fusion between the superior pole and middle third of the kidney (Fig. and grab your free ultimate anatomy study guide! AMLs can bleed and while not cancerous are still taken very seriously. Poorly functioning kidneys with little residual parenchymal volume may be removed because preservation offers opportunities for future complications (infection, hypertension) without contributing significantly to renal function. Technetium 99m-mercaptoacetyltriglycin (MAG3) is excreted by the kidneys (mainly through secretion by proximal tubules) and provides evaluation of renal function, particularly in cases of suspected obstruction. Since the abdominal organs are not paired, the left kidney is not related to the same organs as the right kidney. The portion of the kidney between the poles is called the interpolar region and contains the renal hilum (Fig. The small portion of the lumen surrounding the papilla is called the. Pain that radiates to the lower abdomen and groin. Luckily, the kidneys also feel this increase of pressure, and in cases when this happens, they increase the filtration rate of blood and production of urine, which subsequently leads to the increase fluid excretion and decrease of blood pressure. Simple kidney cysts aren't cancer and rarely cause problems. The kidneys are bilateral organs placed retroperitoneally in the upper left and right abdominal quadrants and are part of the urinary system. Dimitrios Mytilinaios MD, PhD The kidneys are reddish-brown, bean-shaped organs situated retroperitoneal on the posterior abdominal wall. Figure 18-2 Annotated axial image of the right kidney from a contrast-enhanced computed tomographic scan demonstrates hilar anatomy of the kidney. The initiation is caused by the increase in volume that stretches the walls of the calyces. Kim Bengochea, Regis University, Denver. Parasympathetic innervation enhances the peristalsis while sympathetic innervation inhibits it. In adults, the normal kidney is 10-14 cm long in males and 9-13 cm long in females, 3-5 cm wide, 3 cm in antero-posterior thickness and weighs 150-260 g. The left kidney is usually slightly larger than the right. Obstruction can cause renal failure if it is bilateral (Box 18-3) or if there is preexisting disease in the unobstructed kidney. Kidneys are located just below your ribcage and behind your belly. The lateral border is directed towards the periphery, while the medial border is the one directed towards the midline. Literature supports the use of either multidetector computed tomography (MDCT) or MRI in donor evaluation. 18-15). 18-8). The left kidney (not shown) had a similar appearance. Overview. This kidney measured 14 cm in length. Each end of the kidney is commonly called a pole. CT is occasionally used to evaluate patients with renal failure. The calcium or uric acid will precipitate and form stones. These kidney functions can sure seem overwhelming, especially if you have to memorise them! It is important to remember this order of vessels and ducts since this is the only thing that will make you able to orient the kidney and differentiate the left one from the right when they are outside of the cadaver. 18-19). The medial border of the kidney contains a very important landmark called the hilum of the kidney, which is the entry and exit point for the kidney vessels and ureter. The shape of the calyx is formed by the impression of the renal papilla. On the other hand, babies with bilateral agenesis cannot survive without an immediate kidney transplant. Bilateral echogenic kidneys with renal hypertrophy can be seen associated with human immunodeficiency virus disease (see Fig. There are 8-18 renal pyramids in each kidney, that on the coronal section look like triangles lined next to each other with their bases directed toward the cortex and apex to the hilum. The highest portion of the superior pole is covered with the, The superior one-half of the anterior surface is in contact with the layer of, At exactly the center of the anterior surface, imagine a horizontal stripe that extends from the medial concavity toward the center of the lateral convexity that is the area of the kidney that is directly touched by the retroperitoneal posterior wall of the, The lateral part of the inferior pole is directly contacted with the, The rest of the inferior pole is associated with the peritoneum of the, Just like the right kidney, the highest part of the superior pole of the left is also covered with the, The inferior portion of the superior pole contacts with the peritoneum of the, Just inferior to the stomach and spleen impression, is where the left kidney directly contacts, The lateral part of the inferior half of the anterior surface is directly associated with the left colic flexure (also known as the splenic flexure) and, The medial part of the inferior half and the inferior pole are contacted by the peritoneum of the, Kidney structure (overview) - Mohammed Albakkar, Kidneys in situ (overview) - Johannes Reiss, Internal anatomy of the kidney (overview) - Mohammed Albakkar, Arteries of the kidney (overview) - Abdulmalek Albakkar, Kidneys in a cadaver - Prof. Carlos Surez-Quian. Cells in our body constantly produce hydrogen ions. The axes of the renal moeities are abnormal with the inferior poles angled medially. So the pyramids represent the functional tissue that creates urine, whereas the calyces are the beginning of the ureter and transport the urine to it. Single-detector computed tomographic images from ureteropelvic junction deformity in the right side of a horseshoe kidney. Thoracic kidneys are the least common form of renal ectopia. Increased cortical echogenicity is associated with many forms of chronic renal parenchymal disease and indicates a renal cause for renal failure. During the 6th to 9th weeks of life, the kidneys begin to ascend from their position in the pelvis to the level of T12-L1, inferior to the adrenal glands. Around 40% of kidney cancers are localized renal masses. This is why the kidney is essential for the circulatory hemostasis. Note diameter of arteries because small accessory arteries may be sacrificed in many cases. The left artery has a short way to the left kidney, whereas the right has to go behind the inferior vena cava in order to reach the right kidney. The renal corpuscle has two components: the glomerular (Bowmans) capsule in which sits the glomerulus. Note that retroaortic components are usually near the inferior poles (Fig. The kidneys are innervated by the renal plexus. The defect proved to be blood clot from papillary necrosis. Checklist Approach to Ultrasound for Renal Failure, Absence of hydronephrosis makes postrenal causes unlikely, Cortical atrophy in one or both kidneys: suspect chronic or acute-on-chronic renal failure, Increased cortical echogenicity is associated with many forms of chronic renal parenchymal disease and indicates a renal cause for renal failure. The left kidney measured 7.8 cm, and the right kidney measured 10.9 cm. If the renal pelvis is entirely within the confines of the renal sinus, it is considered intrarenal. The opposite situation is possible too, if the kidneys excrete too many hydrogen ions, the pH of blood becomes too alkaline, and leads to a state called alkalosis. Renal size can be measured in several ways. The early excretory phase begins as early as 120 seconds after injection. Read More Created for people with ongoing healthcare needs but benefits everyone. When. The nephrons of the kidney are responsible for maintaining balance between fluids and electrolytes, regulating levels of amino acids, overall acid-base balance, as well as removing toxins from the blood. The defect is the extension of sinus fat into the cortex, usually at the border of the upper pole and interpolar region of the kidney. The upper poles are normally oriented more medially and posteriorly than the lower poles. If this appearance were present bilaterally, chronic renal disease such as chronic glomerulonephritis would be a more likely explanation. Arterial stenosis was confirmed by magnetic resonance angiography. Table 18-6 lists the most common causes of bilateral smooth renal atrophy. Extraaortic origin of the renal arteries and accessory renal arteries are common. The main function of the kidney is to eliminate excess bodily fluid, salts and byproducts of metabolism this makes kidneys key in the regulation of acid-base balance, blood pressure, and many other homeostatic parameters. Frequent urination (having to go the bathroom often). Unenhanced MRI can also be used to diagnose obstruction and identify the source (Fig. The most common cause is renal artery stenosis (see Fig. Ultrasound It can be seen as a triangular echogenic cortical defect, frequently seen in upper lobe parenchyma. Coronal reformation from contrast-enhanced computed tomography performed for renal donation demonstrates a retroaortic left renal vein crossing the aorta well inferior to the level of the renal hila. Computed Tomographic Appearance of the Kidneys, Utility of Different Phases of Renal Contrast Enhancement. Advantages of scintigraphy include accurate quantitative measurement of function. Annotated axial image of the right kidney from a contrast-enhanced computed tomographic scan demonstrates hilar anatomy of the kidney. The posterior branch supplies the posterior part of the kidney, whereas the anterior branch arborizes into five segmental arteries, each supplying a different renal segment. B, A small calyceal defect is seen when the same image is viewed using bone windows. Entities for which sonography is most useful. Kidney cysts can occur with disorders that may impair kidney function. Typically, one kidney sits on either side of your spine. The dynamics of obstruction and quantification of relative renal function between the two kidneys may be important considerations in two general circumstances: (1) it is unclear whether obstruction is severe enough to warrant surgical intervention; or (2) significant parenchymal atrophy exists, and the relative merits of repair and nephrectomy are being compared. The right kidney needs but benefits everyone provide assessment of either multidetector computed tomography ( MDCT ) or MRI donor. Least common form of renal contrast Enhancement age and usually do not cause or. Papillary necrosis attention to the renal sinus, it is considered to an... Main unit of the students, the ischemic papilla undergoes necrosis, allowing calyx. Thoracic kidneys are the least common form of renal physiology, many attempt to assess renal function is.. The renal hilum ( Fig cm, and urethral duplications with bilateral agenesis can not survive without an immediate transplant... 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