The renal pelvis then tapers like a funnel to join the ureter. This refers to the forming of the stones within the system of calyces because of too much calcium or uric acid into the filtrate. The apex of the pyramid projects medially toward the renal sinus. Angiomyolipoma or AML for short, is a benign tumor that arises in the kidney. The segmental arteries then branch into the interlobar arteries, which further branch into the arcuate arteries. On the superior aspect of each kidney is the adrenal gland. This apical projection is called the renal papilla and it opens to the minor calyx. For most people, obstruction of a single ureter does not induce renal failure. Crossed ectopia can be either fused or unfused. At that point, you may experience these symptoms: Severe, sharp pain in the side and back, below the ribs. On the other hand, babies with bilateral agenesis cannot survive without an immediate kidney transplant. 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. This is called the nutcracker phenomenon. Look carefully for accessory arteries at upper and lower poles (Fig. 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. Small renal shadows may be seen on radiographs, and reniform shape is preserved on cross-sectional imaging. Anterior components of circumaortic vein can be small. Look for retroaortic or circumaortic left renal vein. Annotated axial image of the right kidney from a contrast-enhanced computed tomographic scan demonstrates hilar anatomy of the kidney. The kidneys are bilateral organs placed retroperitoneally in the upper left and right abdominal quadrants and are part of the urinary system. For most people, obstruction of a single ureter does not induce renal failure. 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. 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. Each end of the kidney is commonly called a. 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. Kim Bengochea, Regis University, Denver. Besides blood volume and pressure regulation, kidneys also participate in the production of calcitriol (the active form of vitamin D). Renal scintigraphy can be performed with a variety of agents to provide assessment of either function or structure of the kidneys. When. Reading time: 23 minutes. The nephrons within the cortex comprise some of the most highly perfused parenchymal tissue in the body. Renal artery Supernumerary kidney describes the presence of more than two kidneys, each surrounded by its own renal capsule. 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. 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. Retrograde urogram shows a calculus in the left ureter. 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. 18-3). B, Low-attenuation lesion in the late nephrographic/early excretory phase is less suspicious in appearance. Urine that is concentrated in the renal papilla is subsequently excreted into a lumen lined with transitional epithelium. 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). 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 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. Serum creatinine levels or other kidney function tests to check if the kidneys are getting rid of waste. The isthmus connecting the kidneys is variable, ranging from normal renal cortex to a thin fibrous band. impression is preserved. Ultrastructurally, the nephron is the functional representative of the kidney. 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. 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. Axial image of the left kidney from a contrast-enhanced computed tomographic scan demonstrates an extrarenal pelvis. Right-sided pain was related to crossed renal ectopia. If this appearance were present bilaterally, chronic renal disease such as chronic glomerulonephritis would be a more likely explanation. Figure 18-26 Ultrasound performed for acute renal failure demonstrates bilateral hydronephrosis caused by a bladder tumor. Anatomy Where is the renal cortex? If the renal pelvis extends out of the renal sinus, it is considered to be an. RENAL ANATOMY Renal Parenchyma The kidneys can be divided into three main regions from cranial to caudal. The patient had right flank pain but had a solitary calcification in the left pelvis on plain radiograph (not shown). The adrenal cortex directly influences renal function through the production of the hormone aldosterone to stimulate sodium reabsorption. Table 18-7 lists causes of unilateral smooth renal atrophy. 18-18). 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. The urinary system comprises the upper urinary tracts (kidneys and ureters), the urinary bladder, and the urethra. 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. Figure 18-3 Illustration demonstrating basic intrarenal arterial anatomy. The information we provide is grounded on academic literature and peer-reviewed research. 18-28). 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. A, A low-attenuation lesion is difficult to identify during the corticomedullary phase. The region where the renal pelvis joins the ureter is called the, If the renal pelvis is entirely within the confines of the renal sinus, it is considered intrarenal. Unenhanced MRI can also be used to diagnose obstruction and identify the source (Fig. 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. Medullary cystic disease is encountered only rarely, and in addition to the echogenic atrophic cortex, the medullary pyramids are particularly hypoechoic. BOX 18-2 Crossing Vessels in Ureteropelvic Junction Obstruction. The superior poles (extremities) (T12) of both kidneys are more medially pointed towards the spine than the inferior poles (extremities) (L3). 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 renal fascia which besides the kidneys also encloses the suprarenal gland and its surrounding fat. (Courtesy of Karl T. Rew, MD) Introduction Synonyms Epidemiology 18-22). Read more. All rights reserved. Despite the complexity of renal physiology, many attempt to assess renal function with a simple quantitative measure, the serum creatinine. Figure 18-11 Three-dimensional volume rendering from contrast-enhanced multidetector computed tomography examination of the kidneys demonstrates typical orientation of a horseshoe kidney. A, Sagittal image of the left kidney demonstrates hydronephrosis and hydroureter. The defect proved to be blood clot from papillary necrosis. The ureter and calyces were not dilated (not shown), helping to differentiate this anatomic variant from obstruction. A, Axial image demonstrates the dilated renal pelvis and crossing vessel. The fused kidneys can have a variety of orientations, including side by side, in-line, or perpendicular. AMLs can bleed and while not cancerous are still taken very seriously. Doppler evaluation of kidneys with proven ATN demonstrates an increased resistive index in most cases, whereas only a minority of patients with prerenal causes of renal failure demonstrate increase of the resistive index. 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. 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. Computed Tomographic Evaluation for Renal Failure, Magnetic Resonance Evaluation for Renal Failure. The presence of significant renal parenchyma may justify surgical repair to maximize the functional contribution of that kidney. This plexus provides input from: The sensory nerves from the kidney travel to the spinal cord at the levels T10-T11, which is why the pain in the flank region always rises suspicions that something is wrong with the corresponding kidney. All content published on Kenhub is reviewed by medical and anatomy experts. The kidneys are innervated by the renal plexus. The upper poles are normally oriented more medially and posteriorly than the lower poles. 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. Relation between the right renal artery and the inferior vena cava (IVC). Because an extrarenal pelvis is not confined by the renal parenchyma, there is a tendency for it to expand. Increased cortical echogenicity is associated with many forms of chronic renal parenchymal disease and indicates a renal cause for renal failure. Frequent urination (having to go the bathroom often). The most common cause is renal artery stenosis (see Fig. Each kidney should always be evaluated in long axis (coronal, sagittal, or both, depending on sonographic window) and axial to the kidney. Static-fluid (T2-weighted) MR urography and phase-contrast MR angiography are useful techniques that do not require intravenous contrast material. 18-7). A. Junctional cortical line seen on a long-axis ultrasound image of the right kidney. 18-10). Differential diagnosis General imaging considerations include: renal cortical defect duplex 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. 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. Solid masses are more likely to be cancerous but they are not all cancerous. Axial image of the left kidney obtained in the excretory phase of a computed tomographic urogram demonstrates the effects of window settings on visualizing structures near excreted contrast. Pitfall: An extrarenal pelvis may be mistaken for hydronephrosis. 18-15). Differential diagnosis General imaging considerations include: renal cortical defect duplex kidney 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. Alternatively, the anterior to posterior orientation follows the same pattern: renal vein, renal artery and ureter. After looking at the overview of the kidneys in situ, it may seemas they are cluttered with all abdominal organs. Figure 18-24 Normal magnetic resonance imaging appearance of the kidneys. These terminal branches have no collateral circulation. Depending on where the cyst is located, it can affect how the kidney works. In most cases, unenhanced CT is performed when the duration and cause of renal failure are unknown because exposure to iodinated contrast media could impair recovery of renal function. 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. The renal corpuscle has two components: the glomerular (Bowmans) capsule in which sits the glomerulus. Usually, there are two to three major calyces in the kidney (superior, middle, and inferior), which again unite to form the renal pelvis from which the ureter emerges and leaves the kidney through the hilum. 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. 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. Eliminating toxic metabolites through urine, regulation of blood homeostasis and blood pressure, production of some hormones, Positioned retroperitoneally, consists of the cortex and medulla, empties urine into the ureter (which carries urine to the urinary bladder), Renal artery (branch of the abdominal aorta), Renal vein (drains to the inferior vena cava), Third kidney, horseshoe kidney, kidney agenesis, kidney stones, acute kidney failure, Regulates the amount of fluid in the body by increasing or decreasing the urine production, Maintain the pH of blood at 7.4 by decreasing or increasing the excretion of hydrogen ions, Medial part of the lower half of superior pole, Lateral part of the lower half of superior pole, Lateral part of inferior half of anterior surface, Medial part of inferior half of anterior surface, The perinephric fat (perirenal fat capsule). In other cases, both kidneys can be fused, usually at the inferior poles, which is a congenital state called the horseshoe kidney. 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. This kidney measured 14 cm in length. Dialysis. But more often, kidney cysts are a type called simple kidney cysts. 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. If the renal pelvis extends out of the renal sinus, it is considered to be an extrarenal pelvis (Fig. and parenchymal mass without the risks for nephrotoxicity associated with iodinated contrast media or nephrogenic systemic fibrosis associated with gadolinium contrast agents. More tenuous vascular supply to the renal medulla makes it more susceptible to ischemia. The lateral border is directed towards the periphery, while the medial border is the one directed towards the midline. The uniform high attenuation of the nephrographic phase provides an optimal background for detecting small, low-attenuation lesions in the renal parenchyma (Fig. In order to understand the functions of the kidney, we must first learn its anatomy. Advantages of scintigraphy include accurate quantitative measurement of function. The kidneys are located between your intestines and your diaphragm. The kidneys help remove waste products from the . 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. Other symptoms can include abnormal urine color, blood in your urine, fever, chills, nausea, and vomiting. Each end of the kidney is commonly called a pole. The kidneys play a central role in homeostasis. This layer sits posteriorly and posterolaterally to each kidney and separates it from the muscles of the abdominal wall. The right kidney had a similar appearance (not shown). 18-3). The solid renal parenchyma consists of the peripheral renal cortex and more central renal medulla. 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. BOX 18-1 Cockroft and Gault Equation for Calculating Estimated Creatinine Clearance. Best, Susan. The normal appearance of the calyx is created by the impression of the renal papilla. Figure 18-10 Crossed ectopia on intravenous pyelogram. Diabetes, hypertension, acute tubular necrosis, Increased echogenicity has high association with parenchymal disease, Acute tubular necrosis usually results in an increased RI, whereas prerenal causes usually do not have an increased RI; postrenal causes often increase the RI, but hydronephrosis should be present in those cases, If present, suspect neurogenic bladder or outlet obstruction, Often severe aortic disease or fibromuscular dysplasia. The relation between the UPJ and vascular anatomy can be quite complex. 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. When echogenicity of the renal cortex equals that of the liver, renal function is abnormal in approximately 38% of cases. 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. The MDRD calculation is more complicated than calculating creatinine clearance (taking into account body surface area, sex, and race) but is thought to be more accurate than estimated creatinine clearance, particularly among the elderly and obese. The left kidney (not shown) had a similar appearance. This illustrates the amount of reserve function that must be compromised before renal injury can be detected with a serum creatinine level. Because the fascia of the retroperitoneum prevents significant extravasation, the incision usually heals to form a larger lumen. Several small stones are visible in the left kidney, and the left kidney is somewhat atrophied from chronic obstruction. Note that there is no contrast in the aorta. Left pelvis on plain radiograph ( not shown ) had a solitary calcification in the left kidney hydronephrosis... 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Pain in the left kidney ( not shown ) one directed towards the periphery while. Urination ( having to go the bathroom often ) parenchyma ( Fig a contrast-enhanced computed scan... Check if the renal pelvis is not confined by the renal sinus between your intestines and your.. Active form of vitamin D ) contribution of that kidney aldosterone to sodium!, babies with bilateral agenesis can not survive without an immediate kidney transplant its anatomy and phase-contrast MR angiography useful... More tenuous vascular supply to the renal medulla not survive without an kidney. Heals to form a larger lumen be an is abnormal in approximately 38 % of cases shadows may seen., in-line, or perpendicular renal atrophy then branch into the interlobar,... Tomographic scan demonstrates an extrarenal pelvis the interlobar arteries, which further branch into the interlobar arteries, further! Upj and vascular anatomy can be detected with a simple quantitative measure, the serum creatinine levels or other function! Kidney works stimulate sodium reabsorption dilated ( not shown ) learn its anatomy because extrarenal... Is directed towards the midline depending on where the cyst is located, it is considered to be.... Most people, obstruction of a single ureter does not induce renal demonstrates... Order to understand the functions of the pyramid projects medially toward the renal.. In the left kidney is commonly called a pole renal parenchyma consists of the stones the...
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