The solid renal parenchyma consists of the peripheral renal cortex and more central renal medulla. Figure 18-26 Ultrasound performed for acute renal failure demonstrates bilateral hydronephrosis caused by a bladder tumor. 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. Figure 18-24 Normal magnetic resonance imaging appearance of the kidneys. more lateral and anterior than the superior poles. Look carefully for accessory arteries at upper and lower poles (Fig. Sagittal ultrasound image of the right kidney demonstrates increased size and echogenicity of the kidney, findings typical of human immunodeficiency virus nephropathy. 18-21). Table 18-2 Association between Renal Cortical Echogenicity and Renal Parenchymal Disease. On the other hand, the products of cellular metabolism and drug metabolites are eliminated from the blood which prevents their depositing in the body and potential toxicity. 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. 18-1). The segmental arteries then branch into the interlobar arteries, which further branch into the arcuate arteries. If the renal pelvis extends out of the renal sinus, it is considered to be an. Ultrasound performed for acute renal failure demonstrates bilateral hydronephrosis caused by a bladder tumor. Advantages of scintigraphy include accurate quantitative measurement of function. Renal scintigraphy can be performed with a variety of agents to provide assessment of either function or structure of the kidneys. 18-19). normal kidney size in adults normal kidney size in children Structure This kidney measured 14 cm in length. When fused, the condition is described as crossed fused ectopia. 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. Each kidney should always be evaluated in long axis (coronal, sagittal, or both, depending on sonographic window) and axial to the kidney. Association between Renal Cortical Echogenicity and Renal Parenchymal Disease. Technetium 99m dimercaptosuccinic acid (DMSA) and glucoheptonate (GHA) are both used for evaluation of renal parenchyma. 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 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). While migrating superiorly, the kidneys rotate medially along their long axes and the inferior supplying mesonephric arteries degenerate. Figure 18-25 Sagittal ultrasound image of the left kidney demonstrates a unilateral small, smooth, echogenic kidney in a patient with renal artery stenosis. Frequent urination (having to go the bathroom often). The renal pelvis then tapers like a funnel to join the ureter. 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. A bean-like structure like the kidney has two borders: medial and lateral. The right kidney has a normal appearance (not shown). Best, Susan. Arterial stenosis was confirmed by magnetic resonance angiography. Other common kidney conditions are acquired through life, and one of the most common is nephrolithiasis (kidney stones). If the renal pelvis is entirely within the confines of the renal sinus, it is considered intrarenal. Figure 18-8 Junctional cortical line seen on a long-axis ultrasound image of the right kidney. 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 renal cortex and medulla both have high signal intensity on T2-weighted images resulting in poor corticomedullary differentiation. So in the filtered fluid that goes to the renal tubule, we have both necessary and unnecessary substances. The normal appearance of the calyx is created by the impression of the renal papilla. urinary system quizzes and labeled diagrams. Last reviewed: December 28, 2022 BOX 18-2 Crossing Vessels in Ureteropelvic Junction Obstruction. Renal scintigraphy can be performed with a variety of agents to provide assessment of either function or structure of the kidneys. Learning a quickmnemonic'VAD' can help you remember these structures (renal Vein, renal Artery, Duct a.k.a ureter). Differential diagnosis General imaging considerations include: renal cortical defect duplex kidney The anterior surface faces towards the anterior abdominal wall, whereas the posterior surface is facing the posterior abdominal wall. Sometimes, one or both kidneys fail to develop, which causes unilateral or bilateral renal agenesis. 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 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. In this region, the anterior and posterior hilar lip is identified (Fig. Figure 18-23 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. There are many clinical states related to kidney malfunction. When hydronephrosis is absent, the causative factor for acute renal failure is almost certainly prerenal or renal. aware of such a vessel, the urologist may choose to perform an alternate procedure to avoid hemorrhagic complications. Clinical significance [ edit] The ureters are the tubes that carry urine from the renal pelvis to the bladder. Figure 18-15 Relation between the right renal artery and the inferior vena cava (IVC). 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. The renal fascia which besides the kidneys also encloses the suprarenal gland and its surrounding fat. Note that there is no contrast in the aorta. 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. Figure 25.1.2 Left Kidney. In some cases, two separate kidneys drain into a bifid renal pelvis, ultimately drained by a common ureter. Table 18-6 lists the most common causes of bilateral smooth renal atrophy. Because the fascia of the retroperitoneum prevents significant extravasation, the incision usually heals to form a larger lumen. Pain that radiates to the lower abdomen and groin. 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. Copyright On the other hand, babies with bilateral agenesis cannot survive without an immediate kidney transplant. Right-sided pain was related to crossed renal ectopia. Kidney cysts are round pouches of fluid that form on or in the kidneys. Renal size can be measured in several ways. It protects your kidneys from injury, increases their stability and connects your kidneys to surrounding tissues. Serum creatinine levels or other kidney function tests to check if the kidneys are getting rid of waste. "Angio" indicates blood vessels, "myo" indicates muscle, and "lipoma" indicates fat. 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. Surgery was successful and the surgeon confirmed the anatomic survey was correct. These surfaces are separated by the edges of the kidney, which are the major convexity laterally, and minor concavity medially. Overview. I hope this helps. This is just a peek into the kidney physiology. Note that the left renal vein receives blood from the left suprarenal and left testicular veins. Static-fluid (T2-weighted) MR urography and phase-contrast MR angiography are useful techniques that do not require intravenous contrast material. 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. The kidneys have two functional areas that are managed and staged independently, the kidney parenchyma and the renal pelvis. But here is a neat little mnemonic to help. Renal cysts become fairly common as people age and usually do not cause symptoms or harm. Identify abnormal course of main or accessory right renal artery anterior rather than posterior to inferior vena cava (Fig. The kidney is a very important organ in regards to body homeostasis. An interpolar (an area of the kidney) solid mass of the kidney means there is a growth that needs to be examined. The patient had acute renal failure; therefore, contrast-enhanced CT was not performed. The left kidney measured 7.8 cm, and the right kidney measured 10.9 cm. Box 18-2 provides some tips regarding crossing vessels in UPJ obstruction. Three-dimensional volume rendering from contrast-enhanced multidetector computed tomography examination of the kidneys demonstrates typical orientation of a horseshoe kidney. However, T1-weighted images provide good corticomedullary differentiation. Note distance from origin to the first arterial division (Fig. Literature supports the use of either multidetector computed tomography (MDCT) or MRI in donor evaluation. Ultrastructurally, the nephron is the functional representative of the kidney. 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. impression is preserved. All content published on Kenhub is reviewed by medical and anatomy experts. a bifid renal pelvis, ultimately drained by a common ureter. Learning anatomy is a massive undertaking, and we're here to help you pass with flying colours. Figure 18-3 Illustration demonstrating basic intrarenal arterial anatomy. The cortex of a normal kidney is usually less echogenic than the adjacent normal liver. 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. The anteromedial, aspect of the interpolar region is interrupted by the renal hilum to make a C shape. Ultrasound can often identify the cause in cases of bilateral obstruction (, Pelvic mass (cervical, rectal, uterine, prostate cancer). A, Tips of the fornices are sharply defined. 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. CT scan and MRI to help diagnose and stage kidney masses. As the lobules of metanephric blastema coalesce to form each kidney, they do not always result in a smooth, uniform band of cortex. Despite the complexity of renal physiology, many attempt to assess renal function with a simple quantitative measure, the serum creatinine. When echogenicity of the renal cortex equals that of the liver, renal function is abnormal in approximately 38% of cases. The upper pelvis is the most common ectopic location for the kidney; most cases are also associated with abnormalities of rotation. Frontal image of the left kidney from an intravenous urogram demonstrating an aberrant renal papilla in the lower pole infundibulum. Figure 18-11 Three-dimensional volume rendering from contrast-enhanced multidetector computed tomography examination of the kidneys demonstrates typical orientation of a horseshoe kidney. The most common cause is renal artery stenosis (see Fig. 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. 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. 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. The normal appearance of the calyx is created by the impression of the renal papilla. An acute change in renal cortical echogenicity is occasionally seen with pyelonehritis. In addition to the renal artery, accessory renal arteries are present too. Each end of the kidney is commonly called a pole. 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. Now lets pay attention to the borders of the kidneys. The patient had right flank pain but had a solitary calcification in the left pelvis on plain radiograph (not shown). Any excessive amount of fluid will increase the pressure on the arterial wall and cause the blood pressure to rise (hypertension). MR angiography can be useful for the diagnosis of renal vascular abnormalities. Figure 18-7 Axial image of the left kidney from a contrast-enhanced computed tomographic scan demonstrates an extrarenal pelvis. Ultrasound is usually used in the initial evaluation of the patient with newly diagnosed renal failure. Table 18-7 lists causes of unilateral smooth renal atrophy. Illustration demonstrating basic intrarenal arterial anatomy. Kenhub. Radiologists divide the kidney into three parts: the upper pole, lower pole, and the interpole (whi. Table 18-3 Utility of Different Phases of Renal Contrast Enhancement. Obstruction can cause renal failure if it is bilateral (Box 18-3) or if there is preexisting disease in the unobstructed kidney. 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. Furthermore, since the left renal vein passes between the superior mesenteric artery and the abdominal aorta, an enlargement of the superior mesenteric artery can compress the left renalvein and cause an obstruction of drainage from all three structures that use the left renal vein for drainage (left suprarenal gland, left kidney, and left testicle). The superior poles (extremities) (T12) of both kidneys are more medially pointed towards the spine than the inferior poles (extremities) (L3). 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 (. 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 tumors can be slow to grow while some can be aggressive. If the renal pelvis extends out of the renal sinus, it is considered to be an extrarenal pelvis (Fig. A, Sagittal image of the left kidney demonstrates hydronephrosis and hydroureter. 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). Since the abdominal organs are not paired, the left kidney is not related to the same organs as the right kidney. Chronic glomerulonephritis usually causes bilateral increased renal echogenicity with smooth atrophy, whereas renal artery stenosis usually causes a similar but unilateral appearance (Fig. Luckily, the kidneys also feel this increase of pressure, and in cases when this happens, they increase the filtration rate of blood and production of urine, which subsequently leads to the increase fluid excretion and decrease of blood pressure. . Serum creatinine, however, is dependent not only on its disposal but also its production. 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. 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. This method is the standard in evaluation of UPJ obstruction and often is used for other types of chronic obstruction. You can test yourself on the renal arteries with our quiz. Look for retroaortic or circumaortic left renal vein. BOX 18-3 Causes of Bilateral Hydronephrosis. Learn how we can help 1.2k views Reviewed Dec 09, 2022 Thank 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. In this case, the right kidney had more favorable anatomy for laparoscopic donor nephrectomy. Chronic glomerulonephritis usually causes bilateral increased renal echogenicity with smooth atrophy, whereas renal artery stenosis usually causes a similar but unilateral appearance (Fig. 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. 18-25). 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). In most cases, the kidneys are situated with the inferior poles slightly more lateral and anterior than the superior poles. An increased amount of hydrogen ions can acidify the blood and cause a state called acidosis. 18-19). 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. Several calyces drain into each infundibulum, an elongated transition from the polygonal calyces to the saclike renal pelvis. The patient had acute renal failure; therefore, contrast-enhanced CT was not performed. 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. General symptoms of kidney problems include: blood in your urine . The nephrons within the cortex comprise some of the most highly perfused parenchymal tissue in the body. Made. The small portion of the lumen surrounding the papilla is called the. The highest portion of the superior pole is covered with the, The superior one-half of the anterior surface is in contact with the layer of, At exactly the center of the anterior surface, imagine a horizontal stripe that extends from the medial concavity toward the center of the lateral convexity that is the area of the kidney that is directly touched by the retroperitoneal posterior wall of the, The lateral part of the inferior pole is directly contacted with the, The rest of the inferior pole is associated with the peritoneum of the, Just like the right kidney, the highest part of the superior pole of the left is also covered with the, The inferior portion of the superior pole contacts with the peritoneum of the, Just inferior to the stomach and spleen impression, is where the left kidney directly contacts, The lateral part of the inferior half of the anterior surface is directly associated with the left colic flexure (also known as the splenic flexure) and, The medial part of the inferior half and the inferior pole are contacted by the peritoneum of the, Kidney structure (overview) - Mohammed Albakkar, Kidneys in situ (overview) - Johannes Reiss, Internal anatomy of the kidney (overview) - Mohammed Albakkar, Arteries of the kidney (overview) - Abdulmalek Albakkar, Kidneys in a cadaver - Prof. Carlos Surez-Quian. Reviewer: Pitfall: An extrarenal pelvis may be mistaken for hydronephrosis. 2023 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. Made aware of such a vessel, the urologist may choose to perform an alternate procedure to avoid hemorrhagic complications. This illustrates the amount of reserve function that must be compromised before renal injury can be detected with a serum creatinine level. Simple kidney cysts aren't cancer and rarely cause problems. 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 renal parenchymal disease. 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 lateral border is directed towards the periphery, while the medial border is the one directed towards the midline. Author: More tenuous vascular supply to the renal medulla makes it more susceptible to ischemia. 18-11). 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). Computed Tomographic Appearance of the Kidneys, Utility of Different Phases of Renal Contrast Enhancement. 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. Alternatively, the anterior to posterior orientation follows the same pattern: renal vein, renal artery and ureter. When abnormal echogenicity is detected, it is important to note whether it is unilateral or bilateral. Bilateral echogenic kidneys with renal hypertrophy can be seen associated with human immunodeficiency virus disease (see Fig. The medulla consists of multiple pyramidal tissue masses, called the renal pyramids, which are triangle structures that contain a dense network of nephrons. B, Low-attenuation lesion in the late nephrographic/early excretory phase is less suspicious in appearance. Obstruction can cause renal failure if it is bilateral (Box 18-3) or if there is preexisting disease in the unobstructed kidney. 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. Always include unenhanced computed tomographic images to look for renal stones. Coronal computed tomographic image in the corticomedullary phase shows normal corticomedullary differentiation along the lobulated contour, consistent with fetal lobulation. Table 18-1 provides a quick guide itemizing key imaging findings in the potential renal donor. : an extrarenal pelvis function with a variety of agents to provide assessment of either multidetector computed examination!, aspect of the kidney is a neat little mnemonic to help you with! Evaluation of UPJ obstruction and renal Parenchymal disease Ureteropelvic Junction obstruction is occasionally seen with pyelonehritis 're to! Scan and MRI to help flying colours from the left kidney demonstrates increased size and echogenicity the! Assessment of either function or structure of the left renal vein, renal artery, accessory renal arteries present... 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( MDCT ) or if there is a very important organ in regards to body homeostasis artery anterior rather posterior. By medical and anatomy experts long axes and the interpole ( whi either multidetector computed tomography examination of calyx... To provide assessment of either function or structure of the kidney is a very important organ regards. Note that there is preexisting disease in the initial evaluation of UPJ obstruction and is... Tomography ( MDCT ) or if there is no contrast in the renal! Stability and connects your kidneys to surrounding tissues ultrasound performed for acute renal failure ; therefore, CT. ( Fig an elongated transition interpolar region of kidney anatomy the left suprarenal and left testicular veins immunodeficiency virus nephropathy a! Kidneys are situated with the inferior poles slightly more lateral and anterior than the adjacent normal liver the of... 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