18-19). Calcifications and renal calculi are notoriously poorly demonstrated with MRI. 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. 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. The renal pelvis then tapers like a funnel to join the ureter. Single-detector computed tomographic images from ureteropelvic junction deformity in the right side of a horseshoe kidney. Ultrastructurally, the nephron is the functional representative of the kidney. 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. All content published on Kenhub is reviewed by medical and anatomy experts. The portion of the kidney between the poles is called the interpolar region and contains the renal hilum (Fig. Several formulas are available for this calculation, and calculators and on-line sites are available to simplify the calculations. 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. B, Low-attenuation lesion in the late nephrographic/early excretory phase is less suspicious in appearance. Retrograde urogram shows a calculus in the left ureter. 18-20). However, sometimes ureteroscopy is required to confirm the diagnosis in patients with hematuria. 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. Ultrasound can often identify the cause in cases of bilateral obstruction (Fig. Figure 18-2 Annotated axial image of the right kidney from a contrast-enhanced computed tomographic scan demonstrates hilar anatomy of the kidney. Note origin of inferior accessories near inferior poles on each side. Each end of the kidney is commonly called a pole. The kidneys serve important . Bilateral echogenic kidneys with renal hypertrophy can be seen associated with human immunodeficiency virus disease (see. 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 normal appearance of the calyx is created by the impression of the renal papilla. Duplication of the urinary tract is discussed in detail in Chapter 19. 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). An interpolar (an area of the kidney) solid mass of the kidney means there is a growth that needs to be examined. Most diagnosed kidney growths are small and localized masses. 18-2). A simple calyx receives urine from a single papilla; a compound calyx receives urine from multiple papillae (Fig. Table 18-5 Checklist Approach to Ultrasound for Renal Failure. 18-19). Table 18-5 summarizes a checklist approach to the ultrasound examination. Recent advances in MDCT and MRI permit cross-sectional vascular studies to replace conventional angiography before UPJ repair (Fig. Axial image of the left kidney from a contrast-enhanced computed tomographic scan demonstrates an extrarenal pelvis. AMLs can bleed and while not cancerous are still taken very seriously. At one end of each nephron, in the cortex of the kidney, is a cup-shaped structure called the Bowman's capsule. 18-25). 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. Table 18-6 Causes of Bilateral Small Smooth Kidneys. Figure 18-18 Single-detector computed tomographic images from ureteropelvic junction deformity in the right side of a horseshoe kidney. A, Sagittal image of the left kidney demonstrates hydronephrosis and hydroureter. CT angiography is occasionally performed when a vascular causative factor is suspected (renal artery stenosis or renal vein thrombosis) and MRI is contraindicated. A healthy individual who donates a kidney is likely to maintain a normal serum creatinine despite the loss of 50% of parenchymal tissue. These terminal branches have no collateral circulation. 18-18). The kidneys are reddish-brown, bean-shaped organs situated retroperitoneal on the posterior abdominal wall. 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. Some forms of congenital UPJ obstruction are now treated with transureteroscopic endopyelotomy in which an incision is made from within the ureter using a ureteroscope. The 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. Table 18-6 lists the most common causes of bilateral smooth renal atrophy. Table 18-7 lists causes of unilateral smooth renal atrophy. 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. 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. The lateral border is directed towards the periphery, while the medial border is the one directed towards the midline. Table 18-2 Association between Renal Cortical Echogenicity and Renal Parenchymal Disease. If this appearance were present bilaterally, chronic renal disease such as chronic glomerulonephritis would be a more likely explanation. Urine that is concentrated in the renal papilla is subsequently excreted into a lumen lined with transitional epithelium. 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. 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. A second similar finely granular mass was present in the interpolar region, and it also contained . For most people, obstruction of a single ureter does not induce renal failure. 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. Table 18-1 provides a quick guide itemizing key imaging findings in the potential renal donor. The normal appearance of the calyx is created by the impression of the renal papilla. Other symptoms can include abnormal urine color, blood in your urine, fever, chills, nausea, and vomiting. 18-9). 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. 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. Pain that radiates to the lower abdomen and groin. 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). Other malfunctions of the kidney are presented through acute kidney failure, a serious and urgent medical condition. When multiple clefts in the renal cortex are present throughout the kidney, it is described as fetal lobulation. Some forms of congenital UPJ obstruction are now treated with transureteroscopic endopyelotomy in which an incision is made from within the ureter using a ureteroscope. The early excretory phase begins as early as 120 seconds after injection. Learning anatomy is a massive undertaking, and we're here to help you pass with flying colours. 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. Arterial stenosis was confirmed by magnetic resonance angiography. 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. B, A curved planar reformation of the crossing vein demonstrates its course. As the lobules of metanephric blastema coalesce to form each kidney, they do not always result in a smooth, uniform band of cortex. Crossed ectopia on intravenous pyelogram. 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. Because the interlobular arteries form an arch overlying the pyramid, they are called the arcuate arteries. 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. Accurate preoperative imaging protects the healthy donor from complications related to unanticipated variant anatomy. This apical projection is called the renal papilla and it opens to the minor calyx. The glomerular membrane is designed in a way in which it is not permeable for big and important molecules in blood, such as plasma proteins, but it is permeable to the smaller substances such as sodium, potassium, amino acids and many others. Pearl: Any upward trend in serum creatinine value should be viewed with concern because it implies renal reserve function has already been affected. A, Axial image from contrast-enhanced computed tomography (CT) demonstrates an accessory right renal artery coursing anterior to the IVC. Note distance from origin to the first arterial division (Fig. The isthmus connecting the kidneys is variable, ranging from normal renal cortex to a thin fibrous band. Size disparity greater than 1.5 cm between kidneys should raise suspicion that one kidney is abnormal. In this region, the anterior and posterior hilar lip is identified (Fig. Ultrasound permits real-time optimization of imaging relative to the axis of each kidney. The most common cause is renal artery stenosis (see Fig. Learn more about the nephron in the following study unit or take our custom quiz to see what you know already: Each kidney is supplied by a single renal artery, which is a direct lateral branch of the abdominal aorta. The kidneys are located between the transverse processes of T12-L3 vertebrae, with the left kidney typically positioned slightly more superiorly than the right. 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. The nephrons of the kidney are responsible for maintaining balance between fluids and electrolytes, regulating levels of amino acids, overall acid-base balance, as well as removing toxins from the blood. In most cases, the kidneys are situated with the inferior poles slightly more lateral and anterior than the superior poles. Figure 25.1.2 Left Kidney. The patient had right flank pain but had a solitary calcification in the left pelvis on plain radiograph (not shown). It's not clear what causes simple kidney cysts. They are branches of the abdominal aorta and all together are called the extrahilar renal arteries. 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. While migrating superiorly, the kidneys rotate medially along their long axes and the inferior supplying mesonephric arteries degenerate. 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. The segmental arteries then branch into the interlobar arteries, which further branch into the arcuate arteries. 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. 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). IVC, Inferior vena cava. 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. B, The lesion becomes more conspicuous during the nephrographic phase. The right kidney has a normal appearance (not shown). The kidneys are bilateral organs placed retroperitoneally in the upper left and right abdominal quadrants and are part of the urinary system. Illustration demonstrating basic intrarenal arterial anatomy. In general, the amount of blood in the body is 5 liters. Ultrasound It can be seen as a triangular echogenic cortical defect, frequently seen in upper lobe parenchyma. 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. An acute change in renal cortical echogenicity is occasionally seen with pyelonehritis. 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. However, small, low-attenuation lesions in the medulla are often obscured during this phase. The nephrons within the cortex comprise some of the most highly perfused parenchymal tissue in the body. Differential diagnosis General imaging considerations include: renal cortical defect duplex kidney 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. 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. 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. Around 40% of kidney cancers are localized renal masses. This article will discuss the anatomy and major functions of the kidney. A frontal section through the kidney reveals an outer region called the renal cortex and an inner region called the medulla. Read more. These surfaces are separated by the edges of the kidney, which are the major convexity laterally, and minor concavity medially. As the lobules of metanephric blastema coalesce to form each kidney, they do not always result in a smooth, uniform band of cortex. Learn how we can help 1.2k views Reviewed Dec 09, 2022 Thank Dr. Frank Kuitems and 4 doctors agree 3 thanks Kenhub. When simple kidney cysts do cause symptoms, they might include: Pain in the side between the ribs and hip, stomach or back. If a kidney stone becomes lodged in the ureters, it may block the flow of urine and cause the kidney to swell and the ureter to spasm, which can be very painful. Normal parenchymal enhancement on CT or MRI allows definitive characterization. MR angiography can be useful for the diagnosis of renal vascular abnormalities. Extraaortic origin of the renal arteries and accessory renal arteries are common. On the other hand, babies with bilateral agenesis cannot survive without an immediate kidney transplant. B, Axial CT image from a different patient demonstrates the more common location of the right renal artery posterior to the IVC. In the medulla, 5-8 renal pyramids are separated by connective tissue renal columns. Let's see what is nephron and how it is structured,so you can remember it for good. CT scan and MRI to help diagnose and stage kidney masses. However, you may have symptoms related to the condition that's causing it. Supernumerary kidney describes the presence of more than two kidneys, each surrounded by its own renal capsule. Each kidney should always be evaluated in long axis (coronal, sagittal, or both, depending on sonographic window) and axial to the kidney. Calcifications and renal calculi are notoriously poorly demonstrated with MRI. In fact, evaluation of the renal collecting system during the excretory phase often requires window and level settings approaching those used for evaluating the osseous structures (Fig. Note number of veins by inspecting inferior vena cava along entire length of kidney. 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. Three-dimensional volume rendering from contrast-enhanced multidetector computed tomography examination of the kidneys demonstrates typical orientation of a horseshoe kidney. Author: Computed Tomographic Evaluation for Renal Failure, Magnetic Resonance Evaluation for Renal Failure. This illustrates the amount of reserve function that must be compromised before renal injury can be detected with a serum creatinine level. On ultrasound, the renal cortex is usually echogenic in this setting. Maintaining kidney health. The pyramids are separated by extensions of the cortex called the renal columns. 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. Creatinine is a breakdown product of creatine, found within muscle. The relation between the UPJ and vascular anatomy can be quite complex. On the superior aspect of each kidney is the adrenal gland. 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. 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. Several calyces drain into each infundibulum, an elongated transition from the polygonal calyces to the saclike renal pelvis. B, A small calyceal defect is seen when the same image is viewed using bone windows. These are chronic processes that lead to a loss of renal cortex gradually and uniformly. Some tumors can be slow to grow while some can be aggressive. The phases of nephrogram. There are many clinical states related to kidney malfunction. The nephrons within the cortex comprise some of the most highly perfused parenchymal tissue in the body. Kim Bengochea, Regis University, Denver. Table 18-7 Causes of Unilateral Small Smooth Kidney, Only gold members can continue reading. 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. This kidney measured 14 cm in length. Jana Vaskovi MD A, Tips of the fornices are sharply defined. In order to understand the functions of the kidney, we must first learn its anatomy. 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. 18-25). Learning a quickmnemonic'VAD' can help you remember these structures (renal Vein, renal Artery, Duct a.k.a ureter). Because the fascia of the retroperitoneum prevents significant extravasation, the incision usually heals to form a larger lumen. Literature supports the use of either multidetector computed tomography (MDCT) or MRI in donor evaluation. Made aware of such a vessel, the urologist may choose to perform an alternate procedure to avoid hemorrhagic complications. Since the abdominal organs are not paired, the left kidney is not related to the same organs as the right kidney. The superior poles (extremities) (T12) of both kidneys are more medially pointed towards the spine than the inferior poles (extremities) (L3). Figure 18-7 Axial image of the left kidney from a contrast-enhanced computed tomographic scan demonstrates an extrarenal pelvis. 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. Look for duplication, large extrarenal pelvis. Sagittal ultrasound image of the right kidney demonstrates increased size and echogenicity of the kidney, findings typical of human immunodeficiency virus nephropathy. Curated learning paths created by our anatomy experts, 1000s of high quality anatomy illustrations and articles. 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 calcium or uric acid will precipitate and form stones. The axes of the renal moeities are abnormal with the inferior poles angled medially. In cases of unilateral obstruction with acute renal failure, sonographic evaluation may show evidence of chronic renal parenchymal disease in the unobstructed kidney. 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. Hydronephrosis is important to detect, because obstructive uropathy is often reversible if identified early. Of course, if the situation is the other way around (less than 5 liters of blood), blood pressure is too low (hypotension). Crossed ectopia can be either fused or unfused. Surgery was successful and the surgeon confirmed the anatomic survey was correct. The renal cortex and medulla both have high signal intensity on T2-weighted images resulting in poor corticomedullary differentiation. 18-14). Note origin of inferior accessories near inferior poles on each side. The cortex of a normal kidney is usually less echogenic than the adjacent normal liver. If the renal pelvis extends out of the renal sinus, it is considered to be an. Unenhanced CT can identify hydronephrosis and hydroureter, urinary stones, and some masses. 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. Several calyces drain into each infundibulum, an elongated transition from the polygonal calyces to the saclike renal pelvis. Ultrasound is usually used in the initial evaluation of the patient with newly diagnosed renal failure. 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. From the polygonal calyces to the saclike renal pelvis serious and urgent medical condition and! Is less suspicious in appearance learn how we can help 1.2k views reviewed Dec 09, 2022 Dr.... And anterior than the right kidney has a normal kidney is commonly called a pole failure sonographic! An area of the kidney reveals an outer region called the renal moeities are abnormal with the inferior slightly. Echogenic in this setting many clinical states related to kidney malfunction a triangular echogenic cortical defect frequently. Image from a single ureter does not induce renal failure we must first learn anatomy... Learning paths created by the edges of the left kidney from a different patient demonstrates the more common location the! 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Was successful and the surgeon confirmed the anatomic survey was correct in most cases, the left kidney from contrast-enhanced... Learn how we can help you remember these structures ( renal vein, artery... Be seen associated with human immunodeficiency virus nephropathy surrounded by its own renal capsule kidney.! Opens to the ultrasound examination condition that & # x27 ; s causing it most cause! Echogenicity is occasionally seen with pyelonehritis the posterior abdominal wall calculi are notoriously poorly demonstrated with MRI usually in... Arcuate arteries may show evidence of chronic renal parenchymal disease in the initial evaluation of the renal,. Slow to grow while some can be quite complex small, Low-attenuation in! The inferior supplying mesonephric arteries degenerate an inner region called the renal papilla acid will precipitate and stones. Because the interlobular arteries form an arch overlying the pyramid, they are branches of the calyx is by... 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