The renal pelvis then tapers like a funnel to join the ureter. It's not clear what causes simple kidney cysts. Because production of creatinine is affected by sex, age, muscle mass, protein intake, and liver function, the serum creatinine can be an inaccurate predictor of renal function, particularly in those at the extremes of age and body weight. 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. A potential benefit of MRI is the lack of exposure to ionizing radiation, although unenhanced CT would still be required to detect stones (the presence of stones increases the donors risk for renal insufficiency later in life and could disqualify them as a donor candidate). Yet, the relations of the kidneys with other organs are often found in Anatomy tests. The phases of nephrogram development and contrast excretion parallel those seen on contrast-enhanced CT with one notable exception (Fig. B, A curved planar reformation of the crossing vein demonstrates its course. 18-4). A bean-like structure like the kidney has two borders: medial and lateral. Global insult to one kidney may result in unilateral atrophy that is uniform and smooth. 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. In this region, the anterior and posterior hilar lip is identified (Fig. The causes of renal failure can be categorized as prerenal, renal, and postrenal (Table 18-4). Renal scintigraphy can be performed with a variety of agents to provide assessment of either function or structure of the kidneys. Increasing pressure within the lumen initially distends the fornices (acutely angled portions of the calyx along the sides of the papillae), whereas the central portion of the papillary impression is preserved. In cases of unilateral obstruction with acute renal failure, sonographic evaluation may show evidence of chronic renal parenchymal disease in the unobstructed kidney. Size disparity greater than 1.5 cm between kidneys should raise suspicion that one kidney is abnormal. Computed Tomographic Appearance of the Kidneys, Utility of Different Phases of Renal Contrast Enhancement. Table 18-7 Causes of Unilateral Small Smooth Kidney, Only gold members can continue reading. This causes them to fire impulses which stimulate rhythmical contraction and relaxation, called peristalsis. Urine that is concentrated in the renal papilla is subsequently excreted into a lumen lined with transitional epithelium. 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. Figure 18-21 Axial images from contrast-enhanced computed tomography demonstrate transient enhancement of a small renal cell carcinoma. B, A small calyceal defect is seen when the same image is viewed using bone windows. 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. Author: Clinical significance [ edit] Each segmental branch of the renal artery divides into multiple interlobar arteries that course along the periphery of the medullary pyramids and causes small interlobular branches (Fig. The main parts of your kidney anatomy include: Kidney capsule (renal capsule) The renal capsule consists of three layers of connective tissue or fat that cover your kidneys. The right kidney has a normal appearance (not shown). Other symptoms can include abnormal urine color, blood in your urine, fever, chills, nausea, and vomiting. BOX 18-3 Causes of Bilateral Hydronephrosis. 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. Technetium 99m dimercaptosuccinic acid (DMSA) and glucoheptonate (GHA) are both used for evaluation of renal parenchyma. The pyramids are separated by extensions of the cortex called the renal columns. 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. Anatomy Where is the renal cortex? In addition to the renal artery, accessory renal arteries are present too. Register now B, Low-attenuation lesion in the late nephrographic/early excretory phase is less suspicious in appearance. Although each kidney is about the size of a fist, the approximately one million nephrons per kidney require nearly 20% of the total cardiac output to perform this multitude of functions. Perhaps of even greater importance, serum creatinine is not a sensitive test for minor insults to the kidney in otherwise healthy individuals. Ultrasound permits real-time optimization of imaging relative to the axis of each kidney. In some cases, two separate kidneys drain into a bifid renal pelvis, ultimately drained by a common ureter. BOX 18-2 Crossing Vessels in Ureteropelvic Junction Obstruction. Because the interlobular arteries form an arch overlying the pyramid, they are called the arcuate arteries. Supernumerary kidneys are quite rare and have been associated with aortic coarctation, vaginal atresia, and urethral duplications. Because the fascia of the retroperitoneum prevents significant extravasation, the incision usually heals to form a larger lumen. There is no specific treatment for fused kidneys and the only option is to treat the pathologies that affect them during life. The Modification of Diet in Renal Disease (MDRD) is another method for estimating renal function that yields a value often called estimated glomerular filtration rate (eGFR). Note that the left renal vein receives blood from the left suprarenal and left testicular veins. While migrating superiorly, the kidneys rotate medially along their long axes and the inferior supplying mesonephric arteries degenerate. 18-23). More tenuous vascular supply to the renal medulla makes it more susceptible to ischemia. Right-sided pain was related to crossed renal ectopia. Renal Cysts. 18-25). 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. more lateral and anterior than the superior poles. 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. The vascularity of some tumors may be most apparent during this phase (Fig. In other cases, both kidneys can be fused, usually at the inferior poles, which is a congenital state called the horseshoe kidney. C, More severe hydronephrosis results in more pronounced shortening of the papilla. Last reviewed: December 28, 2022 A frontal section through the kidney reveals an outer region called the renal cortex and an inner region called the renal medulla (Figure 25.1.2). Internal Anatomy. Hydronephrosis is important to detect, because obstructive uropathy is often reversible if identified early. All content published on Kenhub is reviewed by medical and anatomy experts. Radiologists divide the kidney into three parts: the upper pole, lower pole, and the interpole (which is in between them). The cortex of a normal kidney is usually less echogenic than the adjacent normal liver. The phases of nephrogram. Axial sections of the right kidney from contrast-enhanced computed tomography demonstrate a bar of renal parenchyma separating renal hila in the superior and inferior poles, consistent with duplication. Renal cysts are sacs of fluid that form in the kidneys. Ultrasound is usually used in the initial evaluation of the patient with newly diagnosed renal failure. The kidneys serve important . Chronic glomerulonephritis usually causes bilateral increased renal echogenicity with smooth atrophy, whereas renal artery stenosis usually causes a similar but unilateral appearance (Fig. Kidney cysts can occur with disorders that may impair kidney function. The renal cortex and medulla both have high signal intensity on T2-weighted images resulting in poor corticomedullary differentiation. This is just a peek into the kidney physiology. It can be caused by a variety of factors, but most often arises because of the ischemia of the kidney and the toxic effect of some medications, resulting in the failure of all kidney functions. An interpolar (an area of the kidney) solid mass of the kidney means there is a growth that needs to be examined. 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. The kidneys are located between the transverse processes of T12-L3 vertebrae, with the left kidney typically positioned slightly more superiorly than the right. The left kidney appeared unremarkable. Ultrastructurally, the nephron is the functional representative of the kidney. 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. The muscular relations of the inferior half are easy to remember by dividing the kidney surface into three vertical stripes, where the medial stripe represents the impression of the psoas major muscle, the central stripe the quadratus lumborum, and the lateral stripe the transversus abdominis muscle. The glomerulus is actually a web of arterioles and capillaries, with a special filter which filters the blood that runs through the capillaries, the glomerular membrane. Blood in the urine, or dark urine. RENAL ANATOMY Renal Parenchyma The kidneys can be divided into three main regions from cranial to caudal. Each kidney should always be evaluated in long axis (coronal, sagittal, or both, depending on sonographic window) and axial to the kidney. 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. However, T1-weighted images provide good corticomedullary differentiation. Parasympathetic innervation enhances the peristalsis while sympathetic innervation inhibits it. Ultrasound permits real-time optimization of imaging relative to the axis of each kidney. 18-19). Right-sided pain was related to crossed renal ectopia. In clinical practice, it is probably best to categorize the renal cortex as hypoechoic, isoechoic, or hyperechoic compared with normal liver, and then state a correlative risk for associated renal parenchymal disease (. B, Axial CT image from a different patient demonstrates the more common location of the right renal artery posterior to the IVC. The pyramids contain the functional units of the kidney, the nephrons, which filter blood in order to produce urine which then is transported through a system of the structures called calyces which then transport the urine to the ureter. Curated learning paths created by our anatomy experts, 1000s of high quality anatomy illustrations and articles. BOX 18-1 Cockroft and Gault Equation for Calculating Estimated Creatinine Clearance. Read More Created for people with ongoing healthcare needs but benefits everyone. The portion of the kidney between the poles is called the interpolar region and contains the renal hilum (Fig. An acute change in renal cortical echogenicity is occasionally seen with pyelonehritis. 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. Figure 18-11 Three-dimensional volume rendering from contrast-enhanced multidetector computed tomography examination of the kidneys demonstrates typical orientation of a horseshoe kidney. This specific condition is called the nutcracker phenomenon. Learn how we can help 1.2k views Reviewed Dec 09, 2022 Thank A, Axial image from contrast-enhanced computed tomography (CT) demonstrates an accessory right renal artery coursing anterior to the IVC. The corticomedullary phase is prolonged in the presence of ureteral or venous obstruction and can persist for days in cases of acute tubular necrosis (ATN; Fig. The anterior surface of the left kidney, has the following anatomical relations: The posterior surfaces of both kidneys are related to certain neurovascular structures and muscles: You can easily remember these with the mnemonic: 1-2-3-4 All Boys Need Muscle. Renal artery At the Brady Urological Institute, we believe in the adage, "An ounce of prevention is worth a pound of cure," so we place great emphasis on a thorough metabolic evaluation, so that therapies can be appropriately directed towards reducing the risk of recurrent stone disease. Always include unenhanced computed tomographic images to look for renal stones. There are many clinical states related to kidney malfunction. Annotated axial image of the right kidney from a contrast-enhanced computed tomographic scan demonstrates hilar anatomy of the kidney. Renal size can be measured in several ways. In most kidneys, the renal hilum faces more anteromedial in the upper half of the kidney and more directly medial in the lower half. The patient had acute renal failure; therefore, contrast-enhanced CT was not performed. The upper pelvis is the most common ectopic location for the kidney; most cases are also associated with abnormalities of rotation. chronic obstruction, or severe or repeated urinary infections. The adrenal cortex directly influences renal function through the production of the hormone aldosterone to stimulate sodium reabsorption. Fetal lobulation is best differentiated from renal scars during the corticomedullary phase of enhancement on computed tomography (CT) or magnetic resonance imaging (MRI) because cortex can be followed into the indentation that occurs between calyces (Fig. The upper poles are normally oriented more medially and posteriorly than the lower poles. The portion of the kidney between the poles is called the interpolar region and contains the renal hilum (Fig. Note that retroaortic components are usually near the inferior poles (Fig. The visible contrast seen in the excretory phase has been concentrated many-fold. The kidney also has endocrine functions, helping to control blood pressure, bone mineralization, and erythrocyte production. Other common kidney conditions are acquired through life, and one of the most common is nephrolithiasis (kidney stones). This article will discuss the anatomy and major functions of the kidney. Figure 18-20 Axial image from unenhanced computed tomography of the kidneys performed 2 days after an angiographic procedure demonstrates stasis of contrast in the renal cortex, resulting in a persistent corticomedullary phase of enhancement. Medullary cystic disease is encountered only rarely, and in addition to the echogenic atrophic cortex, the medullary pyramids are particularly hypoechoic. Supernumerary kidney describes the presence of more than two kidneys, each surrounded by its own renal capsule. Use of MR contrast agents in renal failure poses a lower risk than iodinated contrast material for exacerbating renal failure, but there is evidence that gadolinium-based MR contrast media pose some risk for systemic complications (nephrogenic systemic fibrosis) and should be used with caution in patients with severe or acute renal insufficiency. Chronic glomerulonephritis usually causes bilateral increased renal echogenicity with smooth atrophy, whereas renal artery stenosis usually causes a similar but unilateral appearance (Fig. Table 18-6 lists the most common causes of bilateral smooth renal atrophy. The left kidney measured 7.8 cm, and the right kidney measured 10.9 cm. Thus, an AML is a tumor that contains these 3 components. The right kidney has a normal appearance (not shown). The large left proximal ureteral stone seen in this image is only partially obstructing, causing mild dilation in the left kidney collecting system. Crossing Vessels in Ureteropelvic Junction Obstruction, Conventional surgery for congenital UPJ obstruction involves an open pyeloplasty, in which some tissue is removed from the wall of the saclike renal pelvis to form a more tapered, efficient, funnel-shaped renal pelvis. 18-25). Kidney stones are most often treated by ultrasound shock therapy, during which high-frequency radio waves break the stone into smaller pieces that can be passed naturally into the urine. Figure 18-19 Sagittal ultrasound image of the right kidney demonstrates increased size and echogenicity of the kidney, findings typical of human immunodeficiency virus nephropathy. Figure 18-27 T2-weighted maximum intensity projection image from a magnetic resonance urogram performed to evaluate urinary obstruction identified in a patient with an obstructing soft tissue mass in the pelvis on unenhanced computed tomography (CT). Illustration demonstrating basic intrarenal arterial anatomy. 18-1). Illustration demonstrating the anatomy of the renal collecting system. Sagittal ultrasound image of the left kidney demonstrates a unilateral small, smooth, echogenic kidney in a patient with renal artery stenosis. When multiple clefts in the renal cortex are present throughout the kidney, it is described as fetal lobulation. Other methods include classical surgical removal of the stone, either through the ureter or by open surgery. Most serum creatinine is excreted in the urine; therefore, if renal function is compromised, levels of creatinine in the serum increase. Table 18-6 Causes of Bilateral Small Smooth Kidneys. Figure 18-24 Normal magnetic resonance imaging appearance of the kidneys. If, however, a vessel crosses the UPJ at the level of obstruction, a blind incision made from the inside of the ureteral lumen can result in severe hemorrhage. Learn more about the anatomy of the kidneys and the urinary system with our urinary system quizzes and labeled diagrams. People with unilateral agenesis often are unaware that they lack one kidney until an accidental discovery, since the one kidney that they have is able to functionally compensate for the other. General symptoms of kidney problems include: blood in your urine . The left kidney (not shown) had a similar appearance. 18-6). 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 renal corpuscle has two components: the glomerular (Bowmans) capsule in which sits the glomerulus. The kidney is a very important organ in regards to body homeostasis. The kidneys help remove waste products from the . These are chronic processes that lead to a loss of renal cortex gradually and uniformly. Coronal computed tomographic image in the corticomedullary phase shows normal corticomedullary differentiation along the lobulated contour, consistent with fetal lobulation. Kidney cysts are round pouches of fluid that form on or in the kidneys. 18-3). The kidneys are positioned retroperitoneally, meaning that they are not wrapped with the peritoneal layers the way most abdominal organs are, but rather are placed behind it. 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. Concerning lymphatic drainage, each kidney drains into the lateral aortic (lumbar) lymph nodes, which are placed around the origin of the renal artery. Figure 18-15 Relation between the right renal artery and the inferior vena cava (IVC). 18-11). It protects your kidneys from injury, increases their stability and connects your kidneys to surrounding tissues. and parenchymal mass without the risks for nephrotoxicity associated with iodinated contrast media or nephrogenic systemic fibrosis associated with gadolinium contrast agents. On the other hand, babies with bilateral agenesis cannot survive without an immediate kidney transplant. Note origin of inferior accessories near inferior poles on each side. Besides blood volume and pressure regulation, kidneys also participate in the production of calcitriol (the active form of vitamin D). Further testing/diagnosis is required. Bone scan and chest x-ray to find out if the cancer has spread. A second similar finely granular mass was present in the interpolar region, and it also contained . If the renal pelvis extends out of the renal sinus, it is considered to be an extrarenal pelvis (Fig. 18-16). 18-2). A, A low-attenuation lesion is difficult to identify during the corticomedullary phase. Any excessive amount of fluid will increase the pressure on the arterial wall and cause the blood pressure to rise (hypertension). Alternatively, the anterior to posterior orientation follows the same pattern: renal vein, renal artery and ureter. Some divide the excretory phase into the early excretory phase (contrast mainly confined to the kidney) and late excretory phase (contrast in the ureters). The upper pelvis is the most common ectopic location for the kidney; most cases are also associated with abnormalities of rotation. 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 scintigraphy can be performed with a variety of agents to provide assessment of either function or structure of the kidneys. Kenhub. The kidneys are bilateral organs placed retroperitoneally in the upper left and right abdominal quadrants and are part of the urinary system. 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. However, sometimes ureteroscopy is required to confirm the diagnosis in patients with hematuria. Renal function is better evaluated by measured creatinine clearance, which takes into account not only the amount of creatinine in the blood but also the amount of creatinine within a specified volume of urine over a given period. Some tumors can be slow to grow while some can be aggressive. The kidneys play a central role in homeostasis. The renal fascia which besides the kidneys also encloses the suprarenal gland and its surrounding fat. This can cause varicocele of the left testicle because gravity works against the column of the blood in the left testicular vein. 18-20). Small renal shadows may be seen on radiographs, and reniform shape is preserved on cross-sectional imaging. 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. A frontal section through the kidney reveals an outer region called the renal cortex and an inner region called the medulla. D, If pressure on the papilla persists, the ischemic papilla undergoes necrosis, allowing the calyx to protrude outward toward the cortex. On the other hand, kidneys do have relations with peritoneum, or precisely with the specific organs that are covered with peritoneum which are placed directly adjacent to the kidneys. The genital system consists of the testes, epididymides, deferent ducts, seminal vesicles, ejaculatory ducts, the prostate, and the penis in males; and the ovaries, uterine tubes, uterus, and vagina in females. 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). The patient had acute renal failure; therefore, contrast-enhanced CT was not performed. 18-25). If the renal pelvis extends out of the renal sinus, it is considered to be an. Calculation of the estimated renal volume is considered by some to be the most accurate assessment of renal size available with ultrasound, although renal length alone is more commonly reported. 18-4). Even when there is another plausible explanation for decreased renal function (e.g., known prerenal causes), ultrasound offers the opportunity to rapidly and noninvasively identify a potentially correctible cause of renal failure. Each time a professor says 'nephron', a student gets a headache. Figure 18-3 Illustration demonstrating basic intrarenal arterial anatomy. Surgery was successful and the surgeon confirmed the anatomic survey was correct. Renal size can be measured in several ways. Of the kidney ; most interpolar region of kidney anatomy are also associated with aortic coarctation, vaginal atresia, in! A second similar finely granular mass was present in the unobstructed kidney color blood... Outward toward the cortex created for people with ongoing healthcare needs but benefits everyone of development. Methods include classical surgical removal of the kidneys demonstrates typical orientation of a horseshoe kidney area the. 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