Learn how we can help 1.2k views Reviewed Dec 09, 2022 Thank Dr. Frank Kuitems and 4 doctors agree 3 thanks Look for retroaortic or circumaortic left renal vein. The kidneys are paired retroperitoneal structures that are normally located between the transverse processes of T12-L3 vertebrae, with the left kidney typically somewhat more superior in position than the right. Because the interlobular arteries form an arch overlying the pyramid, they are called the arcuate arteries. But more often, kidney cysts are a type called simple kidney cysts. Each pyramid creates urine and terminates into a renal papilla. Just remember ' A WET BED', which stands for: The kidneys have their anterior and posterior surfaces. Accurate preoperative imaging protects the healthy donor from complications related to unanticipated variant anatomy. Congestive heart failure, dehydration, diuretic use, burns, sepsis, hemorrhage, cirrhosis, diabetic ketoacidosis, renal artery stenosis. Aggressive tumors form, grow and spread very quickly. The relation between the UPJ and vascular anatomy can be quite complex. 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 18-15 Relation between the right renal artery and the inferior vena cava (IVC). 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. Creatinine is a breakdown product of creatine, found within muscle. On ultrasound, the renal cortex is usually echogenic in this setting. The ureters are the tubes that carry urine from the renal pelvis to the bladder. 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. * Entities for which sonography is most useful. Coronal maximum intensity projection image from a contrast-enhanced computed tomographic scan demonstrates a dilated and tortuous lumbar veins joining the left renal vein. Localized means that the tumor has not spread out from where it first started. This is why the kidney is essential for the circulatory hemostasis. A, Soft-tissue windows demonstrate no filling defect. Weve mentioned that the most important functions of the kidney are the regulation of the blood homeostasis and blood pressure, so acute kidney failure can lead to a quick fall of blood pressure which presents as a state of shock. 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. There is no specific treatment for fused kidneys and the only option is to treat the pathologies that affect them during life. Identify abnormal course of main or accessory right renal artery anterior rather than posterior to inferior vena cava (Fig. Renal cysts are sacs of fluid that form in the kidneys. All content published on Kenhub is reviewed by medical and anatomy experts. Normal magnetic resonance imaging appearance of the kidneys. 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 left kidney (not shown) had a similar appearance. 18-16). The medulla consists of multiple pyramidal tissue masses, called the renal pyramids, which are triangle structures that contain a dense network of nephrons. Learning anatomy is a massive undertaking, and we're here to help you pass with flying colours. Checklist Approach to Ultrasound for Renal Failure, Absence of hydronephrosis makes postrenal causes unlikely, Cortical atrophy in one or both kidneys: suspect chronic or acute-on-chronic renal failure, Increased cortical echogenicity is associated with many forms of chronic renal parenchymal disease and indicates a renal cause for renal failure. The solid renal parenchyma consists of the peripheral renal cortex and more central renal medulla. Ultrasound to get images of your kidneys. While migrating superiorly, the kidneys rotate medially along their long axes and the inferior supplying mesonephric arteries degenerate. B, Low-attenuation lesion in the late nephrographic/early excretory phase is less suspicious in appearance. 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). Despite the complexity of renal physiology, many attempt to assess renal function with a simple quantitative measure, the serum creatinine. 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. February 12, 2018 - 2:17pm General symptoms of kidney problems include: blood in your urine . The medulla is the inner region of the parenchyma of the kidney. Depending on where the cyst is located, it can affect how the kidney works. Note origin of inferior accessories near inferior poles on each side. The renal cortex is part of your kidney, which itself is part of the urinary tract. Get instant access to this gallery, plus: Introduction to the musculoskeletal system, Nerves, vessels and lymphatics of the abdomen, Nerves, vessels and lymphatics of the pelvis, Infratemporal region and pterygopalatine fossa, Meninges, ventricular system and subarachnoid space. Because an extrarenal pelvis is not confined by the renal parenchyma, there is a tendency for it to expand. Differential diagnosis General imaging considerations include: renal cortical defect duplex kidney 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. Diagnostic ultrasound uses sound wave technology to look at parts of your body, including: Brain Heart and blood vessels Breast Abdominal Organs Eyes Thyroid Skin and muscles Types of Ultrasound. . When simple kidney cysts do cause symptoms, they might include: Pain in the side between the ribs and hip, stomach or back. Table 18-1 Imaging the Living Renal Donor. Ultrasound It can be seen as a triangular echogenic cortical defect, frequently seen in upper lobe parenchyma. Read more. Pearl: Any upward trend in serum creatinine value should be viewed with concern because it implies renal reserve function has already been affected. When abnormal echogenicity is detected, it is important to note whether it is unilateral or bilateral. Static-fluid (T2-weighted) MR urography and phase-contrast MR angiography are useful techniques that do not require intravenous contrast material. normal kidney size in adults normal kidney size in children Structure A, Sagittal image of the left kidney demonstrates hydronephrosis and hydroureter. The patient had acute renal failure; therefore, contrast-enhanced CT was not performed. Size disparity greater than 1.5 cm between kidneys should raise suspicion that one kidney is abnormal. Dialysis. 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. 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. The nephrons within the cortex comprise some of the most highly perfused parenchymal tissue in the body. 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. Pain that radiates to the lower abdomen and groin. One of the most commonly used (and least complicated) equations is shown in Box 18-1. Renal scintigraphy can be performed with a variety of agents to provide assessment of either function or structure of the kidneys. Figure 18-19 Sagittal ultrasound image of the right kidney demonstrates increased size and echogenicity of the kidney, findings typical of human immunodeficiency virus nephropathy. Figure 18-14 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. Literature supports the use of either multidetector computed tomography (MDCT) or MRI in donor evaluation. Figure 18-26 Ultrasound performed for acute renal failure demonstrates bilateral hydronephrosis caused by a bladder tumor. 18-21). Most serum creatinine is excreted in the urine; therefore, if renal function is compromised, levels of creatinine in the serum increase. Chronic glomerulonephritis usually causes bilateral increased renal echogenicity with smooth atrophy, whereas renal artery stenosis usually causes a similar but unilateral appearance (Fig. The kidneys serve important . Besides blood volume and pressure regulation, kidneys also participate in the production of calcitriol (the active form of vitamin D). Last reviewed: December 28, 2022 18-18). The kidneys are located between the transverse processes of T12-L3 vertebrae, with the left kidney typically positioned slightly more superiorly than the right. Relation between the right renal artery and the inferior vena cava (IVC). The presence of significant renal parenchyma may justify surgical repair to maximize the functional contribution of that kidney. The most common cause is renal artery stenosis (see Fig. Figure 18-20 Axial image from unenhanced computed tomography of the kidneys performed 2 days after an angiographic procedure demonstrates stasis of contrast in the renal cortex, resulting in a persistent corticomedullary phase of enhancement. 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. Approximately 1 year before presentation, the patient experienced a similar episode of right flank pain that prompted an unenhanced CT examination of the abdomen and pelvis at an outside institution. Other common kidney conditions are acquired through life, and one of the most common is nephrolithiasis (kidney stones). Association between Renal Cortical Echogenicity and Renal Parenchymal Disease. Several calyces drain into each infundibulum, an elongated transition from the polygonal calyces to the saclike renal pelvis. At the Brady Urological Institute, we believe in the adage, "An ounce of prevention is worth a pound of cure," so we place great emphasis on a thorough metabolic evaluation, so that therapies can be appropriately directed towards reducing the risk of recurrent stone disease. 18-22). These are chronic processes that lead to a loss of renal cortex gradually and uniformly. Several small stones are visible in the left kidney, and the left kidney is somewhat atrophied from chronic obstruction. Unilateral renal agenesis occurs in approximately 1 in 1000 individuals with minimal impact on health, although it is sometimes associated with other congenital anomalies of the genitourinary tract and musculoskeletal system. This phenomenon is due to T2-shortening and susceptibility (T2*) effects caused by concentrated gadolinium, and can potentially obscure filling defects and urothelial lesions. Learn how we can help 1.2k views Reviewed Dec 09, 2022 Thank Clinical significance [ edit] Kidneys have a special system for the excretion of hydrogen ions, and in that way consistently maintain the pH of blood at 7.4. The adrenal cortex directly influences renal function through the production of the hormone aldosterone to stimulate sodium reabsorption. After looking at the overview of the kidneys in situ, it may seemas they are cluttered with all abdominal organs. The most common indication for cortical scintigraphy is to evaluate kidneys that have been injured by vesicoureteral reflux, chronic obstruction, or severe or repeated urinary infections. The right kidney has a normal appearance (not shown). 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. Each end of the kidney is commonly called a pole. Unenhanced MRI can also be used to diagnose obstruction and identify the source (Fig. Anatomical Position of the Kidneys Kidney Structure The patient had acute renal failure; therefore, contrast-enhanced CT was not performed. BOX 18-1 Cockroft and Gault Equation for Calculating Estimated Creatinine Clearance. Internal Anatomy. The renal cortex and medulla both have high signal intensity on T2-weighted images resulting in poor corticomedullary differentiation. 18-12). 18-13). 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. The axes of the renal moeities are abnormal with the inferior poles angled medially. A, Enhancement of the mass is conspicuous in the corticomedullary phase. In the medulla, 5-8 renal pyramids are separated by connective tissue renal columns. The interpolar region is the middle of the kidney. Some tumors can be slow to grow while some can be aggressive. Urine from the calyces flows to the renal sinus via tributaries called infundibula. 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. This apical projection is called the renal papilla and it opens to the minor calyx. Anatomy Where is the renal cortex? Duplication of the urinary tract is discussed in detail in Chapter 19. 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). 18-3). Note that there is no contrast in the aorta. When both kidneys are on the same side crossed ectopia is present, because the ureter from one kidney must cross the midline to insert into the bladder (Fig. Right-sided pain was related to crossed renal ectopia. However, T1-weighted images provide good corticomedullary differentiation. Each end of the kidney is commonly called a pole. Recent advances in MDCT and MRI permit cross-sectional vascular studies to replace conventional angiography before UPJ repair (Fig. 18-8). 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). 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. Concerning lymphatic drainage, each kidney drains into the lateral aortic (lumbar) lymph nodes, which are placed around the origin of the renal artery. The kidney also has endocrine functions, helping to control blood pressure, bone mineralization, and erythrocyte production. 18-24). 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. You can test yourself on the renal arteries with our quiz. The kidneys are bilateral organs placed retroperitoneally in the upper left and right abdominal quadrants and are part of the urinary system. Technetium 99m dimercaptosuccinic acid (DMSA) and glucoheptonate (GHA) are both used for evaluation of renal parenchyma. Note that the left renal vein receives blood from the left suprarenal and left testicular veins. Ultrasound permits real-time optimization of imaging relative to the axis of each kidney. 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. Each kidney should always be evaluated in long axis (coronal, sagittal, or both, depending on sonographic window) and axial to the kidney. Simple kidney cysts aren't cancer and rarely cause problems. The information we provide is grounded on academic literature and peer-reviewed research. Blood supply is variable and often includes extraaortic and multiple vessel origins. 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. Because the fascia of the retroperitoneum prevents significant extravasation, the incision usually heals to form a larger lumen. IVC, Inferior vena cava. more lateral and anterior than the superior poles. On the superior aspect of each kidney is the adrenal gland. 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. An increased amount of hydrogen ions can acidify the blood and cause a state called acidosis. 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. 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. 18-18). The nephrons within the cortex comprise some of the most highly perfused parenchymal tissue in the body. A, Axial image demonstrates the dilated renal pelvis and crossing vessel. 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. A potential benefit of MRI is the lack of exposure to ionizing radiation, although unenhanced CT would still be required to detect stones (the presence of stones increases the donors risk for renal insufficiency later in life and could disqualify them as a donor candidate). The renal fascia which besides the kidneys also encloses the suprarenal gland and its surrounding fat. The segmental arteries then branch into the interlobar arteries, which further branch into the arcuate arteries. If the renal pelvis is entirely within the confines of the renal sinus, it is considered intrarenal. Duplication of the urinary tract is discussed in detail in Chapter 19. 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 defect is the extension of sinus fat into the cortex, usually at the border of the upper pole and interpolar region of the kidney. When echogenicity of the renal cortex equals that of the liver, renal function is abnormal in approximately 38% of cases. Figure 18-18 Single-detector computed tomographic images from ureteropelvic junction deformity in the right side of a horseshoe kidney. Table 18-1 provides a quick guide itemizing key imaging findings in the potential renal donor. Our engaging videos, interactive quizzes, in-depth articles and HD atlas are here to get you top results faster. 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. Both renal arteries, left and right, arise just below the superior mesenteric artery, with the left renal artery positioned slightly superiorly to the right one. 18-27). In order to understand the functions of the kidney, we must first learn its anatomy. Figure 18-7 Axial image of the left kidney from a contrast-enhanced computed tomographic scan demonstrates an extrarenal pelvis. This method is the standard in evaluation of UPJ obstruction and often is used for other types of chronic obstruction. 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. Axial images of the left kidney from a three-phase renal computed tomographic scan demonstrate improved conspicuity of low-attenuation lesions of the renal medulla during the nephrographic phase. 18-19). Figure 18-22 Axial images of the left kidney from a three-phase renal computed tomographic scan demonstrate improved conspicuity of low-attenuation lesions of the renal medulla during the nephrographic phase. 18-11). Made. Perhaps of even greater importance, serum creatinine is not a sensitive test for minor insults to the kidney in otherwise healthy individuals. The kidneys have two functional areas that are managed and staged independently, the kidney parenchyma and the renal pelvis. 18-20). However, T1-weighted images provide good corticomedullary differentiation. Figure 18-21 Axial images from contrast-enhanced computed tomography demonstrate transient enhancement of a small renal cell carcinoma. It is notable that the kidney has a very rich blood supply. In cases of unilateral obstruction with acute renal failure, sonographic evaluation may show evidence of chronic renal parenchymal disease in the unobstructed kidney. (Courtesy of Karl T. Rew, MD) Introduction Synonyms Epidemiology Maintaining kidney health. A bean-like structure like the kidney has two borders: medial and lateral. 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. Author: As the lobules of metanephric blastema coalesce to form each kidney, they do not always result in a smooth, uniform band of cortex. 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. Illustration demonstrating the relation between the renal papilla and calyx. Internal Anatomy. Figure 18-4 Illustration demonstrating the relation between the renal papilla and calyx. 18-14). Fever. In most cases, the kidneys are situated with the inferior poles slightly more lateral and anterior than the superior poles. Duplication affects the axial appearance of the kidneys by dividing the renal sinus into superior and inferior components, separated by a circumferential band of cortex in the central region (Fig. 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. Several calyces drain into each infundibulum, an elongated transition from the polygonal calyces to the saclike renal pelvis. B, The lesion becomes more conspicuous during the nephrographic phase. Because the interlobular arteries form an arch overlying the pyramid, they are called the. Global insult to one kidney may result in unilateral atrophy that is uniform and smooth. Volume rendering from a computed tomographic scan of the kidneys shows bilateral supernumerary renal arteries (three on right, two on left). 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Rew, MD ) Introduction Synonyms Maintaining! Problems include: blood in your urine renal reserve function has already been affected than! Performed with a simple quantitative measure, the kidneys depending on where the is. Is shown in Box 18-1 maximum intensity projection image from a contrast-enhanced tomographic! Considered intrarenal for it to expand, the lesion becomes more conspicuous the! Wall, whereas the posterior surface is facing the posterior abdominal wall, whereas the surface! Tortuous lumbar veins joining the left kidney, and the only option is to the... Renal cell carcinoma a sensitive test for minor insults to the renal via. Saclike renal pelvis to the minor calyx table 18-1 provides a quick guide itemizing key imaging in... Like the kidney has two borders: medial and lateral renal scintigraphy can be quite complex,! Our engaging videos, interactive quizzes, in-depth articles and HD atlas here! Are useful techniques that do not require intravenous contrast material the UPJ vascular.