Aggressive tumors form, grow and spread very quickly. But here is a neat little mnemonic to help. Despite the complexity of renal physiology, many attempt to assess renal function with a simple quantitative measure, the serum creatinine. The most superior vessel is the renal vein which exits the kidney, just under it is the renal artery that enters in, and under the artery is the exiting ureter. 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. A simple calyx receives urine from a single papilla; a compound calyx receives urine from multiple papillae (Fig. Despite different methods of accumulation, each is sequestered by the renal cortex, providing an opportunity to quantify the volume of renal parenchymal tissue in each kidney. Ultrasound It can be seen as a triangular echogenic cortical defect, frequently seen in upper lobe parenchyma. 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. Figure 18-2 Annotated axial image of the right kidney from a contrast-enhanced computed tomographic scan demonstrates hilar anatomy of the kidney. Calcifications and renal calculi are notoriously poorly demonstrated with MRI. 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. Illustration demonstrating the relation between the renal papilla and calyx. 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. 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. Table 18-6 lists the most common causes of bilateral smooth renal atrophy. Table 18-7 Causes of Unilateral Small Smooth Kidney, Only gold members can continue reading. This significantly affects the testicle, since an obstruction of drainage causes an obstruction of fresh arterial blood inflow, which can result in the infarction of testicular tissue. 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. BOX 18-2 Crossing Vessels in Ureteropelvic Junction Obstruction. Illustration demonstrating the anatomy of the renal collecting system. 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. Relation between the right renal artery and the inferior vena cava (IVC). Because the fascia of the retroperitoneum prevents significant extravasation, the incision usually heals to form a larger lumen. 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. Figure 18-7 Axial image of the left kidney from a contrast-enhanced computed tomographic scan demonstrates an extrarenal pelvis. The initiation is caused by the increase in volume that stretches the walls of the calyces. B, Transverse image of the bladder demonstrates a large bladder tumor in the region of the trigone. The fused kidneys can have a variety of orientations, including side by side, in-line, or perpendicular. 18-24). One of the most commonly used (and least complicated) equations is shown in Box 18-1. 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. 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. The renal veins empty to the inferior vena cava, so the right vein is shorter because the inferior vena cava runs closer to the right kidney. The renal pelvis then tapers like a funnel to join the ureter. Figure 18-16 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. Association between Renal Cortical Echogenicity and Renal Parenchymal Disease. Radiologists divide the kidney into three parts: the upper pole, lower pole, and the interpole (which is in between them). Table 18-2 Association between Renal Cortical Echogenicity and Renal Parenchymal Disease. Pearl: Any upward trend in serum creatinine value should be viewed with concern because it implies renal reserve function has already been affected. Occasionally, a papilla will communicate directly with an infundibulum or the renal pelvis and is considered to be an aberrant papilla. 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. The right kidney has a normal appearance (not shown). Parasympathetic innervation enhances the peristalsis while sympathetic innervation inhibits it. The urinary system comprises the upper urinary tracts (kidneys and ureters), the urinary bladder, and the urethra. 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 (. I would honestly say that Kenhub cut my study time in half. Thus, an AML is a tumor that contains these 3 components. 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. It protects your kidneys from injury, increases their stability and connects your kidneys to surrounding tissues. The left kidney measured 7.8 cm, and the right kidney measured 10.9 cm. The shape of the calyx is formed by the impression of the renal papilla. Renal size can be measured in several ways. The pyramids are separated by extensions of the cortex called the renal columns. 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. This illustrates the amount of reserve function that must be compromised before renal injury can be detected with a serum creatinine level. Figure 18-4 Illustration demonstrating the relation between the renal papilla and calyx. However, T1-weighted images provide good corticomedullary differentiation. Renal size can be measured in several ways. Size disparity greater than 1.5 cm between kidneys should raise suspicion that one kidney is abnormal. Around 40% of kidney cancers are localized renal masses. 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. Technetium 99m dimercaptosuccinic acid (DMSA) and glucoheptonate (GHA) are both used for evaluation of renal parenchyma. Hydronephrosis is important to detect, because obstructive uropathy is often reversible if identified early. and grab your free ultimate anatomy study guide! 18-19). Figure 18-15 Relation between the right renal artery and the inferior vena cava (IVC). 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). The left artery has a short way to the left kidney, whereas the right has to go behind the inferior vena cava in order to reach the right kidney. The calyces, however, will have a normal appearance with an unobstructed extrarenal pelvis but will be dilated in cases of urinary obstruction. General symptoms of kidney problems include: blood in your urine . In the medulla, 5-8 renal pyramids are separated by connective tissue renal columns. The solid renal parenchyma consists of the peripheral renal cortex and more central renal medulla. 18-3). The small portion of the lumen surrounding the papilla is called the calyx. Note origin of inferior accessories near inferior poles on each side. The ureters are the tubes that carry urine from the renal pelvis to the bladder. 18-2). Figure 18-9 Coronal computed tomographic image in the corticomedullary phase shows normal corticomedullary differentiation along the lobulated contour, consistent with fetal lobulation. Static-fluid (T2-weighted) MR urography and phase-contrast MR angiography are useful techniques that do not require intravenous contrast material. The isthmus connecting the kidneys is variable, ranging from normal renal cortex to a thin fibrous band. 18-21). Learning a quickmnemonic'VAD' can help you remember these structures (renal Vein, renal Artery, Duct a.k.a ureter). 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. Kidney cysts can occur with disorders that may impair kidney function. Differential diagnosis General imaging considerations include: renal cortical defect duplex kidney In most cases, the kidneys are situated with the inferior poles slightly more lateral and anterior than the superior poles. 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. A. Junctional cortical line seen on a long-axis ultrasound image of the right kidney. 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). (Courtesy of Karl T. Rew, MD) Introduction Synonyms Epidemiology I hope this helps. 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. The uniform high attenuation of the nephrographic phase provides an optimal background for detecting small, low-attenuation lesions in the renal parenchyma (Fig. Figure 18-3 Illustration demonstrating basic intrarenal arterial anatomy. In this way, the consistency of blood is preserved and no important substances are lost. 18-4). Lets start with the right kidney anterior surface. The phases of nephrogram development and contrast excretion parallel those seen on contrast-enhanced CT with one notable exception (Fig. For most people, obstruction of a single ureter does not induce renal failure. Publication types Review MeSH terms Humans Reviewer: 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). There are many clinical states related to kidney malfunction. B, The lesion becomes more conspicuous during the nephrographic phase. In other cases, each renal unit has its own ureter. There are 8-18 renal pyramids in each kidney, that on the coronal section look like triangles lined next to each other with their bases directed toward the cortex and apex to the hilum. 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. 18-14). 18-10). Many clinical laboratories now provide computer-generated calculations of estimated creatinine clearance or eGFR using patient data in the medical information system. 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. 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. When the fine, weblike complex of ureteral arteries is recruited to contribute to collateral circulation, enlarged vessels are seen surrounding the proximal ureter, causing the classic ureteral notching seen on intravenous urogram (IVU). So the pyramids represent the functional tissue that creates urine, whereas the calyces are the beginning of the ureter and transport the urine to it. 18-16). 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. Figure 18-13 Volume rendering from a computed tomographic scan of the kidneys shows bilateral supernumerary renal arteries (three on right, two on left). In most kidneys, the renal hilum faces more anteromedial in the upper half of the kidney and more directly medial in the lower half. Coronal computed tomographic image in the corticomedullary phase shows normal corticomedullary differentiation along the lobulated contour, consistent with fetal lobulation. 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. Creatinine is a breakdown product of creatine, found within muscle. 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. 18-15). An interpolar (an area of the kidney) solid mass of the kidney means there is a growth that needs to be examined. impression is preserved. The lateral border is directed towards the periphery, while the medial border is the one directed towards the midline. Overview. Kidneys are located just below your ribcage and behind your belly. A second similar finely granular mass was present in the interpolar region, and it also contained . Obstruction can cause renal failure if it is bilateral (Box 18-3) or if there is preexisting disease in the unobstructed kidney. This is why the kidney is essential for the circulatory hemostasis. 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. Renal cysts are sacs of fluid that form in the kidneys. 18-23). Now lets pay attention to the borders 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. The phases of nephrogram. Concerning lymphatic drainage, each kidney drains into the lateral aortic (lumbar) lymph nodes, which are placed around the origin of the renal artery. This apical projection is called the renal papilla and it opens to the minor calyx. When echogenicity of the renal cortex equals that of the liver, renal function is abnormal in approximately 38% of cases. RENAL ANATOMY Renal Parenchyma The kidneys can be divided into three main regions from cranial to caudal. The main symptom is severe sharp pain that starts suddenly, usually in your belly or one side of your back, and it may go away just as quickly. Table 18-1 provides a quick guide itemizing key imaging findings in the potential renal donor. C, More severe hydronephrosis results in more pronounced shortening of the papilla. 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. 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. 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. At that point, you may experience these symptoms: Severe, sharp pain in the side and back, below the ribs. If the renal pelvis extends out of the renal sinus, it is considered to be an. The most common cause is renal artery stenosis (see Fig. 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. This can cause varicocele of the left testicle because gravity works against the column of the blood in the left testicular vein. Alternatively, the anterior to posterior orientation follows the same pattern: renal vein, renal artery and ureter. Each kidney should always be evaluated in long axis (coronal, sagittal, or both, depending on sonographic window) and axial to the kidney. Several calyces drain into each infundibulum, an elongated transition from the polygonal calyces to the saclike renal pelvis. The anterior surface faces towards the anterior abdominal wall, whereas the posterior surface is facing the posterior abdominal wall. The presence of significant renal parenchyma may justify surgical repair to maximize the functional contribution of that kidney. There is no specific treatment for fused kidneys and the only option is to treat the pathologies that affect them during life. CT scan and MRI to help diagnose and stage kidney masses. Sagittal ultrasound image of the right kidney demonstrates increased size and echogenicity of the kidney, findings typical of human immunodeficiency virus nephropathy. The upper poles are normally oriented more medially and posteriorly than the lower poles. B, A small calyceal defect is seen when the same image is viewed using bone windows. 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. Read more. It is also permeable for the products of the metabolism, such are creatinine and drug metabolites. They are usually characterized as "simple" cysts, meaning they have a thin wall and contain water-like fluid. Cells in our body constantly produce hydrogen ions. BOX 18-3 Causes of Bilateral Hydronephrosis. Annotated axial image of the right kidney from a contrast-enhanced computed tomographic scan demonstrates hilar anatomy of the kidney. 18-5). The renal pelvis then tapers like a funnel to join the ureter. Anatomical Position of the Kidneys Kidney Structure The kidneys are bilateral organs placed retroperitoneally in the upper left and right abdominal quadrants and are part of the urinary system. Anatomy Where is the renal cortex? 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. The kidney also has endocrine functions, helping to control blood pressure, bone mineralization, and erythrocyte production. 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. A bean-like structure like the kidney has two borders: medial and lateral. Ultrastructurally, the nephron is the functional representative of the kidney. 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. Renal cysts become fairly common as people age and usually do not cause symptoms or harm. Because the interlobular arteries form an arch overlying the pyramid, they are called the arcuate arteries. When echogenicity of the renal cortex equals that of the liver, renal function is abnormal in approximately 38% of cases. Note that there is no contrast in the aorta. Look carefully for accessory arteries at upper and lower poles (Fig. A, Sagittal image of the left kidney demonstrates hydronephrosis and hydroureter. 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. 18-6). Computed Tomographic Evaluation for Renal Failure, Magnetic Resonance Evaluation for Renal Failure. B, Low-attenuation lesion in the late nephrographic/early excretory phase is less suspicious in appearance. 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). Renal columns like the kidney has two borders: medial and lateral angiography are useful techniques that not! 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