A healthy individual who donates a kidney is likely to maintain a normal serum creatinine despite the loss of 50% of parenchymal tissue. The apex of the pyramid projects medially toward the renal sinus. These kidney functions can sure seem overwhelming, especially if you have to memorise them! Read more. (Courtesy of Karl T. Rew, MD) Introduction Synonyms Epidemiology Look carefully for accessory arteries at upper and lower poles (Fig. Although less accurate than measured creatinine clearance, such methods provide an estimated creatinine clearance that is a better predictor of renal function than the serum creatinine alone. Table 18-1 Imaging the Living Renal Donor. Ultrasound permits real-time optimization of imaging relative to the axis of each kidney. The relation between the UPJ and vascular anatomy can be quite complex. This apical projection is called the renal papilla and it opens to the minor calyx. Note that the left renal vein receives blood from the left suprarenal and left testicular veins. Duplication of the urinary tract is discussed in detail in Chapter 19. This phenomenon is due to T2-shortening and susceptibility (T2*) effects caused by concentrated gadolinium, and can potentially obscure filling defects and urothelial lesions. 18-1). 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. The patient had right flank pain but had a solitary calcification in the left pelvis on plain radiograph (not shown). Pitfall: An extrarenal pelvis may be mistaken for hydronephrosis. The presence of contour irregularity usually indicates scarring, suggesting prior infection, reflux, or infarction. An acute change in renal cortical echogenicity is occasionally seen with pyelonehritis. Note number of veins by inspecting inferior vena cava along entire length of kidney. 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. The large left proximal ureteral stone seen in this image is only partially obstructing, causing mild dilation in the left kidney collecting system. CT and MR findings of renal artery stenosis parallel classic findings described on intravenous pyelogram, including one atrophic kidney with delayed nephrogram and excretion that can progress to a persistent nephrogram with hyperconcentrated excreted contrast media (Fig. 18-13). 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. 18-24). Each kidney has a single renal vein which conducts the blood out of the kidney and is positioned anterior to the artery. It's not clear what causes simple kidney cysts. If this appearance were present bilaterally, chronic renal disease such as chronic glomerulonephritis would be a more likely explanation. Creatinine is a breakdown product of creatine, found within muscle. The kidneys serve important . Several small stones are visible in the left kidney, and the left kidney is somewhat atrophied from chronic obstruction. AMLs can bleed and while not cancerous are still taken very seriously. In general, the amount of blood in the body is 5 liters. The kidneys are a pair of bean-shaped organs located below the rib cage, one on each side of the spine. Figure 25.1.2 Left Kidney. Prominent extrarenal pelves are typically positioned anteriorly (Fig. Figure 18-14 Axial maximum intensity projection image from the arterial phase of a contrast-enhanced computed tomographic scan from a prospective renal donor demonstrates early prehilar branching of the left renal artery. 3D printed model for a 53-year-old female presenting a 21 15 15 mm renal tumor located in the interpolar region of left kidney, treated by left partial nephrectomy. 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. The renal corpuscle has two components: the glomerular (Bowmans) capsule in which sits the glomerulus. 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 (. However, T1-weighted images provide good corticomedullary differentiation. The kidneys are bilateral organs placed retroperitoneally in the upper left and right abdominal quadrants and are part of the urinary system. February 12, 2018 - 2:17pm Blood supply is variable and often includes extraaortic and multiple vessel origins. 2023 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. Note origin of inferior accessories near inferior poles on each side. Renal scintigraphy can be performed with a variety of agents to provide assessment of either function or structure of the kidneys. Figure 18-9 Coronal computed tomographic image in the corticomedullary phase shows normal corticomedullary differentiation along the lobulated contour, consistent with fetal lobulation. The cortex of a normal kidney is usually less echogenic than the adjacent normal liver. The small portion of the lumen surrounding the papilla is called the. Maintaining kidney health. 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. Most serum creatinine is excreted in the urine; therefore, if renal function is compromised, levels of creatinine in the serum increase. However, this individual is more likely to show a decline in renal function from an additional insult. Let's see what is nephron and how it is structured,so you can remember it for good. Because they rarely cause symptoms, renal cysts are most often found during . Also, in situations with notable blood losses, kidneys release a hormone called erythropoietin, which stimulates bone marrow to produce more blood cells. Figure 18-15 Relation between the right renal artery and the inferior vena cava (IVC). Crossed ectopia can be either fused or unfused. Further testing/diagnosis is required. Some tumors can be slow to grow while some can be aggressive. B, Mild hydronephrosis results in rounding of the fornices with mild shortening of the papillary impression. 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. As the lobules of metanephric blastema coalesce to form each kidney, they do not always result in a smooth, uniform band of cortex. Axial image of the left kidney from a contrast-enhanced computed tomographic scan demonstrates an extrarenal pelvis. This refers to the forming of the stones within the system of calyces because of too much calcium or uric acid into the filtrate. Global insult to one kidney may result in unilateral atrophy that is uniform and smooth. Radiologists divide the kidney into three parts: the upper pole, lower pole, and the interpole (whi. B, A small calyceal defect is seen when the same image is viewed using bone windows. The pyramids are separated by extensions of the cortex called the renal columns. The ureters are the tubes that carry urine from the renal pelvis to the bladder. 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. Their shape resembles a bean, where we can describe the superior and inferior poles, as well as the major convexity pointed laterally, and the minor concavity pointed medially. Table 18-6 Causes of Bilateral Small Smooth Kidneys. Chronic obstruction, however, results in damage to the papilla, evident in the clubbed calyx of papillary necrosis (Fig. The calyces, however, will have a normal appearance with an unobstructed extrarenal pelvis but will be dilated in cases of urinary obstruction. 18-7). Right-sided pain was related to crossed renal ectopia. A, A low-attenuation lesion is difficult to identify during the corticomedullary phase. Relation between the right renal artery and the inferior vena cava (IVC). 18-18). Since they are located deep retroperitoneally, the easiest way to examine them is from the patients back. The kidney tissue is protected by three layers that entirely surround the kidney: Outside the fascia is the most superficial layer a layer of fat tissue called the paranephric fat. 18-27). Lets start with the right kidney anterior surface. The isthmus connecting the kidneys is variable, ranging from normal renal cortex to a thin fibrous band. If the renal pelvis is entirely within the confines of the renal sinus, it is considered intrarenal. 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. Axial maximum intensity projection image from the arterial phase of a contrast-enhanced computed tomographic scan from a prospective renal donor demonstrates early prehilar branching of the left renal artery. All content published on Kenhub is reviewed by medical and anatomy experts. Figure 18-2 Annotated axial image of the right kidney from a contrast-enhanced computed tomographic scan demonstrates hilar anatomy of the kidney. 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. Each end of the kidney is commonly called a pole. The left testicular vein must ascend higher and it drains to the left renal vein at a right angle, unlike the right testicular vein which joins the inferior vena cava directly. The information we provide is grounded on academic literature and peer-reviewed research. Besides blood volume and pressure regulation, kidneys also participate in the production of calcitriol (the active form of vitamin D). Enlargement of a congenitally unilateral kidney is typical and presumed to be compensatory. Pancake kidney describes a more severe fusion anomaly with a single, flat kidney positioned low in the pelvis with an anterior collecting system drained by either one or two ureters. 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. Other symptoms can include abnormal urine color, blood in your urine, fever, chills, nausea, and vomiting. The normal appearance of the calyx is created by the impression of the renal papilla. The lateral border is directed towards the periphery, while the medial border is the one directed towards the midline. Single-detector computed tomographic images from ureteropelvic junction deformity in the right side of a horseshoe kidney. In most cases, the kidneys are situated with the inferior poles slightly more lateral and anterior than the superior poles. The center of the minor concavity is marked as the hilum of the kidney where the renal artery enters the kidney, and the renal vein and ureter leave the kidney. RENAL ANATOMY Renal Parenchyma The kidneys can be divided into three main regions from cranial to caudal. Recent advances in MDCT and MRI permit cross-sectional vascular studies to replace conventional angiography before UPJ repair (Fig. A, Soft-tissue windows demonstrate no filling defect. Size and Contour of Diffuse Renal Disease, The bilateral small smooth kidney pattern describes most of what is often diagnosed on sonography as medical renal disease, although the authors prefer the term, Global insult to one kidney may result in unilateral atrophy that is uniform and smooth. 18-2). Angiomyolipoma or AML for short, is a benign tumor that arises in the kidney. The renal cortex and medulla both have high signal intensity on T2-weighted images resulting in poor corticomedullary differentiation. Caliectasis doesn't cause any symptoms on its own. The anterior surface faces towards the anterior abdominal wall, whereas the posterior surface is facing the posterior abdominal wall. 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. The minor calyces unite to form a major calyx. If a kidney stone becomes lodged in the ureters, it may block the flow of urine and cause the kidney to swell and the ureter to spasm, which can be very painful. In order to understand the functions of the kidney, we must first learn its anatomy. 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. On the superior aspect of each kidney is the adrenal gland. Normal magnetic resonance imaging appearance of the kidneys. A, Sagittal image of the left kidney demonstrates hydronephrosis and hydroureter. On the other hand, the products of cellular metabolism and drug metabolites are eliminated from the blood which prevents their depositing in the body and potential toxicity. Look for retroaortic or circumaortic left renal vein. On axial sections, the polar regions of the kidney typically form a closed circle or donut shape, with the hole formed by renal sinus fat. Thus, an AML is a tumor that contains these 3 components. When abnormal echogenicity is detected, it is important to note whether it is unilateral or bilateral. Renal size and cortical thickness can be assessed in a manner similar to ultrasound. 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. The patient had right flank pain but had a solitary calcification in the left pelvis on plain radiograph (not shown). "Angio" indicates blood vessels, "myo" indicates muscle, and "lipoma" indicates fat. On axial sections, the polar regions of the kidney typically form a closed circle or donut shape, with the hole formed by renal sinus fat. Figure 18-13 Volume rendering from a computed tomographic scan of the kidneys shows bilateral supernumerary renal arteries (three on right, two on left). Renal cysts become fairly common as people age and usually do not cause symptoms or harm. Each time a professor says 'nephron', a student gets a headache. 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 superior poles (extremities) (T12) of both kidneys are more medially pointed towards the spine than the inferior poles (extremities) (L3). If the renal pelvis extends out of the renal sinus, it is considered to be an extrarenal pelvis (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. Because an extrarenal pelvis is not confined by the renal parenchyma, there is a tendency for it to expand. Each kidney should always be evaluated in long axis (coronal, sagittal, or both, depending on sonographic window) and axial to the kidney. A, Enhancement of the mass is conspicuous in the corticomedullary phase. 18-20). Internal Anatomy. This article will discuss the anatomy and major functions of the kidney. Because the fascia of the retroperitoneum prevents significant extravasation, the incision usually heals to form a larger lumen. 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. Bone scan and chest x-ray to find out if the cancer has spread. The kidneys are bilateral organs placed retroperitoneally in the upper left and right abdominal quadrants and are part of the urinary system. Computed Tomographic Appearance of the Kidneys, Utility of Different Phases of Renal Contrast Enhancement. Finally, the arcuate arteries branch into the interlobular arteries which branch off even further by giving afferent arterioles to run blood past the glomerulus for blood filtration. 18-3). Reviewer: Obstruction can cause renal failure if it is bilateral (Box 18-3) or if there is preexisting disease in the unobstructed kidney. The goal of imaging patients with renal failure is to identify a correctable cause in an effort to recover or preserve renal function. I would honestly say that Kenhub cut my study time in half. Urine that is concentrated in the renal papilla is subsequently excreted into a lumen lined with transitional epithelium. You can test yourself on the renal arteries with our quiz. 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. The left kidney (not shown) had a similar appearance. The parenchyma of the kidney consists of the outer renal cortex, and inner renal medulla. In this case, the right kidney had more favorable anatomy for laparoscopic donor nephrectomy. The superior half of each kidney is covered by the diaphragm, which is why the kidneys move up and down during respiration. The renal fascia which besides the kidneys also encloses the suprarenal gland and its surrounding fat. Table 18-7 Causes of Unilateral Small Smooth Kidney, Only gold members can continue reading. BOX 18-1 Cockroft and Gault Equation for Calculating Estimated Creatinine Clearance. When hydronephrosis is absent, the causative factor for acute renal failure is almost certainly prerenal or renal. The kidneys play a central role in homeostasis. BOX 18-2 Crossing Vessels in Ureteropelvic Junction Obstruction. Recent advances in MDCT and MRI permit cross-sectional vascular studies to replace conventional angiography before UPJ repair (Fig. All rights reserved. Ultrasound It can be seen as a triangular echogenic cortical defect, frequently seen in upper lobe parenchyma. Literature supports the use of either multidetector computed tomography (MDCT) or MRI in donor evaluation. Renal scintigraphy can be performed with a variety of agents to provide assessment of either function or structure of the kidneys. 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. 18-25). Table 18-3 Utility of Different Phases of Renal Contrast Enhancement. Kidney cysts can occur with disorders that may impair kidney function. The ureter and calyces were not dilated (not shown), helping to differentiate this anatomic variant from obstruction. The right kidney has a normal appearance (not shown). The upper poles are normally oriented more medially and posteriorly than the lower poles. CT scan and MRI to help diagnose and stage kidney masses. A, Tips of the fornices are sharply defined. Although ureteral contrast media is typically present before 3 minutes, longer delays provide more predictable opacification. Renal Cysts. Thus, any upward trend in the serum creatinine value should be viewed with concern when considering the administration of potentially nephrotoxic or renally excreted intravenous contrast media. Kidneys have a special system for the excretion of hydrogen ions, and in that way consistently maintain the pH of blood at 7.4. Other common kidney conditions are acquired through life, and one of the most common is nephrolithiasis (kidney stones). 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. Ultrasound It can be seen as a triangular echogenic cortical defect, frequently seen in upper lobe parenchyma. Although this dilatation of the renal pelvis may occasionally mimic hydronephrosis, delicate and sharply defined calyces and thin infundibula can be used to differentiate an extrarenal pelvis from obstruction. They are usually characterized as "simple" cysts, meaning they have a thin wall and contain water-like fluid. 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). After looking at the overview of the kidneys in situ, it may seemas they are cluttered with all abdominal organs. Duplication of the urinary tract is discussed in detail in Chapter 19. The causes of renal failure can be categorized as prerenal, renal, and postrenal (Table 18-4). More tenuous vascular supply to the renal medulla makes it more susceptible to ischemia. Accurate preoperative imaging protects the healthy donor from complications related to unanticipated variant anatomy. Frequent urination (having to go the bathroom often). The portion of the kidney between the poles is called the interpolar region and contains the renal hilum (Fig. Aggressive tumors form, grow and spread very quickly. Illustration demonstrating the anatomy of the renal collecting system. 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). These surfaces are separated by the edges of the kidney, which are the major convexity laterally, and minor concavity medially. Made. Anatomy of the Kidney and Ureter Parenchyma Cortex Medulla Perirenal fat Capsule Ureter Other malfunctions of the kidney are presented through acute kidney failure, a serious and urgent medical condition. Cells in our body constantly produce hydrogen ions. Kenhub. This can cause varicocele of the left testicle because gravity works against the column of the blood in the left testicular vein. 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. Copyright In the medulla, 5-8 renal pyramids are separated by connective tissue renal columns. Log In or, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), Estimated Creatinine Clearance and Glomerular Filtration Rate, Cockroft and Gault Equation for Calculating Estimated Creatinine Clearance, The Modification of Diet in Renal Disease (MDRD) is another method for estimating renal function that yields a value often called, The kidneys can be divided into three main regions from cranial to caudal. Note diameter of arteries because small accessory arteries may be sacrificed in many cases. This layer sits posteriorly and posterolaterally to each kidney and separates it from the muscles of the abdominal wall. Anatomy Where is the renal cortex? There are many clinical states related to kidney malfunction. Blood in the urine, or dark urine. The kidneys can be divided into three main regions from cranial to caudal. Renal artery 18-21). Always include unenhanced computed tomographic images to look for renal stones. Note that there is no contrast in the aorta. 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. Box 18-2 provides some tips regarding crossing vessels in UPJ obstruction. 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. Learn how we can help 1.2k views Reviewed Dec 09, 2022 Thank Dr. Frank Kuitems and 4 doctors agree 3 thanks Causes. 18-19). In fact, evaluation of the renal collecting system during the excretory phase often requires window and level settings approaching those used for evaluating the osseous structures (Fig. When echogenicity of the renal cortex equals that of the liver, renal function is abnormal in approximately 38% of cases. 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. Overview. Figure 18-6 Frontal image of the left kidney from an intravenous urogram demonstrating an aberrant renal papilla in the lower pole infundibulum. The fused kidneys can have a variety of orientations, including side by side, in-line, or perpendicular. A second similar finely granular mass was present in the interpolar region, and it also contained . Since the abdominal organs are not paired, the left kidney is not related to the same organs as the right kidney. The kidneys are located between the transverse processes of T12-L3 vertebrae, with the left kidney typically positioned slightly more superiorly than the right. Unenhanced CT can identify hydronephrosis and hydroureter, urinary stones, and some masses. 18-24). Renal cysts are sacs of fluid that form in the kidneys. The kidneys are innervated by the renal plexus. The most common cause is renal artery stenosis (see Fig. The kidneys help remove waste products from the . Thoracic kidneys are the least common form of renal ectopia. The upper pelvis is the most common ectopic location for the kidney; most cases are also associated with abnormalities of rotation. This kidney measured 14 cm in length. 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). But more often, kidney cysts are a type called simple kidney cysts. These terminal branches have no collateral circulation. Figure 18-17 Coronal maximum intensity projection image from a contrast-enhanced computed tomographic scan demonstrates a dilated and tortuous lumbar veins joining the left renal vein. On the other hand, babies with bilateral agenesis cannot survive without an immediate kidney transplant. In this region, the anterior and posterior hilar lip is identified (Fig. Because the interlobular arteries form an arch overlying the pyramid, they are called the arcuate arteries. 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Views reviewed Dec 09, 2022 Thank Dr. Frank Kuitems and 4 doctors agree 3 thanks.! Present before 3 minutes, longer delays provide more predictable opacification of papillary necrosis Fig. Be aggressive has spread posteriorly than the superior poles survive without an immediate kidney transplant an... Is reviewed by medical and anatomy experts, 5-8 renal pyramids are separated by extensions of the stones within confines! Abnormal in approximately 38 % of cases vascular anatomy can be assessed in a manner similar ultrasound... Almost certainly prerenal or renal tendency for it to expand and posterior hilar lip is identified ( Fig system... Cortex, and it opens to the forming of the kidney and separates it from the patients back a lesion!, is a benign tumor that arises in the left kidney typically anteriorly! Is created by the impression of the right kidney chronic obstruction, if renal function abnormal. Medulla makes it more susceptible to ischemia laterally, and postrenal ( 18-4. 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