Kidney cysts can occur with disorders that may impair kidney function. In other cases, both kidneys can be fused, usually at the inferior poles, which is a congenital state called the horseshoe kidney. The anteromedial, aspect of the interpolar region is interrupted by the renal hilum to make a C shape. The kidneys are located between the transverse processes of T12-L3 vertebrae, with the left kidney typically positioned slightly more superiorly than the right. Advantages of scintigraphy include accurate quantitative measurement of function. The anterior surface faces towards the anterior abdominal wall, whereas the posterior surface is facing the posterior abdominal wall. 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. The vascularity of some tumors may be most apparent during this phase (Fig. Crossed ectopia can be either fused or unfused. and grab your free ultimate anatomy study guide! Table 18-1 provides a quick guide itemizing key imaging findings in the potential renal donor. 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. Note that there is no contrast in the aorta. A, Tips of the fornices are sharply defined. Ultrastructurally, the nephron is the functional representative of the kidney. Because the interlobular arteries form an arch overlying the pyramid, they are called the. The portion of the kidney between the poles is called the interpolar region and contains the renal hilum (Fig. On the other hand, babies with bilateral agenesis cannot survive without an immediate kidney transplant. Anterior components of circumaortic vein can be small. 18-13). 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. B, Transverse image of the bladder demonstrates a large bladder tumor in the region of the trigone. The left kidney appeared unremarkable. 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. 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). 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 cortex of a normal kidney is usually less echogenic than the adjacent normal liver. However, T1-weighted images provide good corticomedullary differentiation. Anatomical Position of the Kidneys Kidney Structure A simple calyx receives urine from a single papilla; a compound calyx receives urine from multiple papillae (Fig. Just remember ' A WET BED', which stands for: The kidneys have their anterior and posterior surfaces. 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 presence of contour irregularity usually indicates scarring, suggesting prior infection, reflux, or infarction. 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). The most common cause is renal artery stenosis (see, Delayed but increasingly dense nephrogram, Delayed but hyperconcentrated contrast excretion, Imaging Evaluation of Acute Abdominal Pain, A Multidimensional Approach to Abdominal Imaging. When hydronephrosis is absent, the causative factor for acute renal failure is almost certainly prerenal or renal. This is called the nutcracker phenomenon. A, Sagittal image of the left kidney demonstrates hydronephrosis and hydroureter. Maintaining kidney health. Each pyramid creates urine and terminates into a renal papilla. 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. C, More severe hydronephrosis results in more pronounced shortening of the papilla. 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. Dimitrios Mytilinaios MD, PhD This phenomenon is due to T2-shortening and susceptibility (T2*) effects caused by concentrated gadolinium, and can potentially obscure filling defects and urothelial lesions. 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. 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. When. When multiple clefts in the renal cortex are present throughout the kidney, it is described as fetal lobulation. The renal cortex is part of your kidney, which itself is part of the urinary tract. Normal magnetic resonance imaging appearance of the kidneys. The parenchyma of the kidney consists of the outer renal cortex, and inner renal medulla. This specific condition is called the nutcracker phenomenon. Each kidney should always be evaluated in long axis (coronal, sagittal, or both, depending on sonographic window) and axial to the kidney. Extraaortic origin of the renal arteries and accessory renal arteries are common. Table 18-5 summarizes a checklist approach to the ultrasound examination. The region where the renal pelvis joins the ureter is called the ureteropelvic junction (UPJ). The urinary system comprises the upper urinary tracts (kidneys and ureters), the urinary bladder, and the urethra. You can test yourself on the renal arteries with our quiz. 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. Note that there is no contrast in the aorta. 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. 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 (Table 18-2). 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). Look carefully for accessory arteries at upper and lower poles (Fig. The minor calyces unite to form a major calyx. An increased amount of hydrogen ions can acidify the blood and cause a state called acidosis. An interpolar (an area of the kidney) solid mass of the kidney means there is a growth that needs to be examined. Computed Tomographic Appearance of the Kidneys, Utility of Different Phases of Renal Contrast Enhancement. Aggressive tumors form, grow and spread very quickly. 18-19). BOX 18-2 Crossing Vessels in Ureteropelvic Junction Obstruction. Thus, the ureter is seen paravertebrally starting from the L2 and going downwards. Literature supports the use of either multidetector computed tomography (MDCT) or MRI in donor evaluation. 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. Figure 18-12 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. As the lobules of metanephric blastema coalesce to form each kidney, they do not always result in a smooth, uniform band of cortex. Localized means that the tumor has not spread out from where it first started. Angiomyolipoma or AML for short, is a benign tumor that arises in the kidney. 2023 The renal corpuscle has two components: the glomerular (Bowmans) capsule in which sits the glomerulus. 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. BOX 18-1 Cockroft and Gault Equation for Calculating Estimated Creatinine Clearance. Curated learning paths created by our anatomy experts, 1000s of high quality anatomy illustrations and articles. Perhaps of even greater importance, serum creatinine is not a sensitive test for minor insults to the kidney in otherwise healthy individuals. The patient had acute renal failure; therefore, contrast-enhanced CT was not performed. Ultrasound permits real-time optimization of imaging relative to the axis of each kidney. This kidney measured 14 cm in length. After looking at the overview of the kidneys in situ, it may seemas they are cluttered with all abdominal organs. Chronic obstruction, however, results in damage to the papilla, evident in the clubbed calyx of papillary necrosis (Fig. A furosemide challenge is often administered after initial excretion is observed to measure the impact of diuresis on the clearance of radiotracer from the renal pelvis. I hope this helps. The apex of the pyramid projects medially toward the renal sinus. A second similar finely granular mass was present in the interpolar region, and it also contained . 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 defect proved to be blood clot from papillary necrosis. 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. 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. 18-16). The patient had right flank pain but had a solitary calcification in the left pelvis on plain radiograph (not shown). 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. Renal scintigraphy can be performed with a variety of agents to provide assessment of either function or structure of the kidneys. Supernumerary kidneys are quite rare and have been associated with aortic coarctation, vaginal atresia, and urethral duplications. All content published on Kenhub is reviewed by medical and anatomy experts. Best, Susan. The uniform high attenuation of the nephrographic phase provides an optimal background for detecting small, low-attenuation lesions in the renal parenchyma (Fig. 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. 18-3). Ultrasound It can be seen as a triangular echogenic cortical defect, frequently seen in upper lobe parenchyma. The information we provide is grounded on academic literature and peer-reviewed research. Cells in our body constantly produce hydrogen ions. Internal Anatomy. This is just a peek into the kidney physiology. 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. Bilateral echogenic kidneys with renal hypertrophy can be seen associated with human immunodeficiency virus disease (see Fig. Pain that radiates to the lower abdomen and groin. Renal artery In most cases, the kidneys are situated with the inferior poles slightly more lateral and anterior than the superior poles. 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. 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. Occasionally, a papilla will communicate directly with an infundibulum or the renal pelvis and is considered to be an aberrant papilla. The renal cortex and medulla both have high signal intensity on T2-weighted images resulting in poor corticomedullary differentiation. There is no specific treatment for fused kidneys and the only option is to treat the pathologies that affect them during life. A, Axial image demonstrates the dilated renal pelvis and crossing vessel. Each end of the kidney is commonly called a pole. Small renal shadows may be seen on radiographs, and reniform shape is preserved on cross-sectional imaging. Yet, the relations of the kidneys with other organs are often found in Anatomy tests. Table 18-3 Utility of Different Phases of Renal Contrast Enhancement. For most people, obstruction of a single ureter does not induce renal failure. 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. 18-15). Surgery was successful and the surgeon confirmed the anatomic survey was correct. The anteromedial aspect of the interpolar region is interrupted by the renal hilum to make a C shape. 18-4). Most serum creatinine is excreted in the urine; therefore, if renal function is compromised, levels of creatinine in the serum increase. It doesn't have to be that way. Learning anatomy is a massive undertaking, and we're here to help you pass with flying colours. Our engaging videos, interactive quizzes, in-depth articles and HD atlas are here to get you top results faster. There are many clinical states related to kidney malfunction. The kidneys are innervated by the renal plexus. Reading time: 23 minutes. More tenuous vascular supply to the renal medulla makes it more susceptible to ischemia. 18-22). Medullary cystic disease is encountered only rarely, and in addition to the echogenic atrophic cortex, the medullary pyramids are particularly hypoechoic. Renal cysts are sacs of fluid that form in the kidneys. Axial image of the left kidney from a contrast-enhanced computed tomographic scan demonstrates an extrarenal pelvis. When this happens, the stones can block the flow of urine out of your kidneys. However, T1-weighted images provide good corticomedullary differentiation. Computed Tomographic Evaluation for Renal Failure, Magnetic Resonance Evaluation for Renal Failure. The fused kidneys can have a variety of orientations, including side by side, in-line, or perpendicular. The calyces, however, will have a normal appearance with an unobstructed extrarenal pelvis but will be dilated in cases of urinary obstruction. Because the fascia of the retroperitoneum prevents significant extravasation, the incision usually heals to form a larger lumen. 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. The kidneys serve important . Right-sided pain was related to crossed renal ectopia. 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. Learn how we can help 1.2k views Reviewed Dec 09, 2022 Thank 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. Grounded on academic literature and research, validated by experts, and trusted by more than 2 million users. 18-10). Since the abdominal organs are not paired, the left kidney is not related to the same organs as the right kidney. 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. Causes. The right kidney has a normal appearance (not shown). Copyright Read more. This phenomenon is due to T2-shortening and susceptibility (T2*) effects caused by concentrated gadolinium, and can potentially obscure filling defects and urothelial lesions. The renal fascia which besides the kidneys also encloses the suprarenal gland and its surrounding fat. 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. "Angio" indicates blood vessels, "myo" indicates muscle, and "lipoma" indicates fat. Look for retroaortic or circumaortic left renal vein. Each end of the kidney is commonly called a pole. But more often, kidney cysts are a type called simple kidney cysts. In this case, the right kidney had more favorable anatomy for laparoscopic donor nephrectomy. 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. Alternatively, the anterior to posterior orientation follows the same pattern: renal vein, renal artery and ureter. Normally, the kidney is about the size of a mouse and measures approximately 11-12 cm in length, 5-6 cm in width, and 2.5-3 cm in thickness. Pearl: Any upward trend in serum creatinine value should be viewed with concern because it implies renal reserve function has already been affected. Fever. The phases of nephrogram development and contrast excretion parallel those seen on contrast-enhanced CT with one notable exception (Fig. Relation between the right renal artery and the inferior vena cava (IVC). 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 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. 18-25). In the medulla, 5-8 renal pyramids are separated by connective tissue renal columns. 18-18). Frontal image of the left kidney from an intravenous urogram demonstrating an aberrant renal papilla in the lower pole infundibulum. 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. If the renal pelvis is entirely within the confines of the renal sinus, it is considered intrarenal. 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). 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. Because they rarely cause symptoms, renal cysts are most often found during . In addition to the renal artery, accessory renal arteries are present too. Renal size can be measured in several ways. Figure 18-15 Relation between the right renal artery and the inferior vena cava (IVC). These kidney functions can sure seem overwhelming, especially if you have to memorise them! Identify abnormal course of main or accessory right renal artery anterior rather than posterior to inferior vena cava (Fig. The initiation is caused by the increase in volume that stretches the walls of the calyces. So in the filtered fluid that goes to the renal tubule, we have both necessary and unnecessary substances. 18-5). 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. However, sometimes ureteroscopy is required to confirm the diagnosis in patients with hematuria. This apical projection is called the renal papilla and it opens to the minor calyx. The left kidney (not shown) had a similar appearance. The kidneys are bilateral organs placed retroperitoneally in the upper left and right abdominal quadrants and are part of the urinary system. Concerning lymphatic drainage, each kidney drains into the lateral aortic (lumbar) lymph nodes, which are placed around the origin of the renal artery. Figure 25.1.2 Left Kidney. 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. Anatomy Where is the renal cortex? 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. The ureter and calyces were not dilated (not shown), helping to differentiate this anatomic variant from obstruction. Note that the left renal vein receives blood from the left suprarenal and left testicular veins. Kenhub. Author: 18-3). Typically, one kidney sits on either side of your spine. 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). 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. 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. Each kidney has a single renal vein which conducts the blood out of the kidney and is positioned anterior to the artery. chronic obstruction, or severe or repeated urinary infections. 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). Figure 18-11 Three-dimensional volume rendering from contrast-enhanced multidetector computed tomography examination of the kidneys demonstrates typical orientation of a horseshoe kidney. Other common kidney conditions are acquired through life, and one of the most common is nephrolithiasis (kidney stones). Figure 18-5 Illustration demonstrating the anatomy of the renal collecting system. The phases of nephrogram. Increased cortical echogenicity is associated with many forms of chronic renal parenchymal disease and indicates a renal cause for renal failure. Ultrasound It can be seen as a triangular echogenic cortical defect, frequently seen in upper lobe parenchyma. The patient had acute renal failure; therefore, contrast-enhanced CT was not performed. 18-18). 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. A healthy individual who donates a kidney is likely to maintain a normal serum creatinine despite the loss of 50% of parenchymal tissue. Reviewer: It protects your kidneys from injury, increases their stability and connects your kidneys to surrounding tissues. 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. The left kidney measured 7.8 cm, and the right kidney measured 10.9 cm. 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. and parenchymal mass without the risks for nephrotoxicity associated with iodinated contrast media or nephrogenic systemic fibrosis associated with gadolinium contrast agents. Illustration demonstrating the relation between the renal papilla and calyx. 18-19). Figure 18-10 Crossed ectopia on intravenous pyelogram. 18-25). BOX 18-3 Causes of Bilateral Hydronephrosis. They are usually characterized as "simple" cysts, meaning they have a thin wall and contain water-like fluid. Ultrasound performed for acute renal failure demonstrates bilateral hydronephrosis caused by a bladder tumor. 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. This is why the kidney is essential for the circulatory hemostasis. 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. Addition to the kidney in otherwise healthy individuals severe or repeated urinary infections which! Acquired through life, and inner renal medulla makes it more susceptible ischemia. Surface is facing the posterior surface is facing the posterior surface is facing the posterior abdominal wall vena cava IVC. Perhaps of even greater importance, serum creatinine is excreted in the region the! Surgeon confirmed the anatomic survey was correct and one of the urinary system either! 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