The shape of the calyx is formed by the impression of the renal papilla. Literature supports the use of either multidetector computed tomography (MDCT) or MRI in donor evaluation. The normal appearance of the calyx is created by the impression of the renal papilla. 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). Typically, one kidney sits on either side of your spine. 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. The interpolar region is the middle of the kidney. As the lobules of metanephric blastema coalesce to form each kidney, they do not always result in a smooth, uniform band of cortex. 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. Frontal image of the left kidney from an intravenous urogram demonstrating an aberrant renal papilla in the lower pole infundibulum. Made. If this appearance were present bilaterally, chronic renal disease such as chronic glomerulonephritis would be a more likely explanation. B, The lesion becomes more conspicuous during the nephrographic phase. The solid renal parenchyma consists of the peripheral renal cortex and more central renal medulla. aware of such a vessel, the urologist may choose to perform an alternate procedure to avoid hemorrhagic complications. Figure 18-3 Illustration demonstrating basic intrarenal arterial anatomy. Learn how we can help 1.2k views Reviewed Dec 09, 2022 Thank Dr. Frank Kuitems and 4 doctors agree 3 thanks Urine that is concentrated in the renal papilla is subsequently excreted into a lumen lined with transitional epithelium. Besides blood volume and pressure regulation, kidneys also participate in the production of calcitriol (the active form of vitamin D). Alternatively, the anterior to posterior orientation follows the same pattern: renal vein, renal artery and ureter. Some divide the excretory phase into the early excretory phase (contrast mainly confined to the kidney) and late excretory phase (contrast in the ureters). Prominent extrarenal pelves are typically positioned anteriorly (Fig. 18-25). 18-18). Because repeat imaging does not expose the patient to additional radiation, multiple phases including delayed images may be obtained and allow the creation of quantitative curves that define the initial filling and then clearing of dilated collecting system structures. Grounded on academic literature and research, validated by experts, and trusted by more than 2 million users. 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. Arterial stenosis was confirmed by magnetic resonance angiography. 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. Each time a professor says 'nephron', a student gets a headache. 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. In most cases, the kidneys are situated with the inferior poles slightly more lateral and anterior than the superior poles. Duplication of the urinary tract is discussed in detail in Chapter 19. Blood supply is variable and often includes extraaortic and multiple vessel origins. Annotated axial image of the right kidney from a contrast-enhanced computed tomographic scan demonstrates hilar anatomy of the kidney. Overview. 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. Internal Anatomy. 18-25). Serum creatinine levels or other kidney function tests to check if the kidneys are getting rid of waste. When. 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. Although this dilatation of the renal pelvis may occasionally mimic hydronephrosis, delicate and sharply defined calyces and thin infundibula can be used to differentiate an extrarenal pelvis from obstruction. Figure 18-6 Frontal image of the left kidney from an intravenous urogram demonstrating an aberrant renal papilla in the lower pole infundibulum. 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). Learn more about the anatomy of the kidneys and the urinary system with our urinary system quizzes and labeled diagrams. You can test yourself on the renal arteries with our quiz. The kidneys have two functional areas that are managed and staged independently, the kidney parenchyma and the renal pelvis. Figure 18-7 Axial image of the left kidney from a contrast-enhanced computed tomographic scan demonstrates an extrarenal pelvis. Lets start with the right kidney anterior surface. 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 (. Usually, there are two to three major calyces in the kidney (superior, middle, and inferior), which again unite to form the renal pelvis from which the ureter emerges and leaves the kidney through the hilum. In cases of unilateral obstruction with acute renal failure, sonographic evaluation may show evidence of chronic renal parenchymal disease in the unobstructed kidney. Serum creatinine, however, is dependent not only on its disposal but also its production. This kidney measured 14 cm in length. Last reviewed: December 28, 2022 Size disparity greater than 1.5 cm between kidneys should raise suspicion that one kidney is abnormal. 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. 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. 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. Unenhanced MRI can also be used to diagnose obstruction and identify the source (Fig. Causes. A frontal section through the kidney reveals an outer region called the renal cortex and an inner region called the medulla. 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. This apical projection is called the renal papilla and it opens to the minor calyx. In the medulla, 5-8 renal pyramids are separated by connective tissue renal columns. B, Mild hydronephrosis results in rounding of the fornices with mild shortening of the papillary impression. The left kidney appeared unremarkable. The ureters are the tubes that carry urine from the renal pelvis to the bladder. 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. Note that there is no contrast in the aorta. Recent advances in MDCT and MRI permit cross-sectional vascular studies to replace conventional angiography before UPJ repair (Fig. The renal corpuscle has two components: the glomerular (Bowmans) capsule in which sits the glomerulus. Obstruction can cause renal failure if it is bilateral (Box 18-3) or if there is preexisting disease in the unobstructed kidney. 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. Thus, the ureter is seen paravertebrally starting from the L2 and going downwards. Kidney cysts can occur with disorders that may impair kidney function. If the renal pelvis is entirely within the confines of the renal sinus, it is considered intrarenal. This kidney measured 14 cm in length. In some cases, two separate kidneys drain into a bifid renal pelvis, ultimately drained by a common ureter. Maintaining kidney health. 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. a bifid renal pelvis, ultimately drained by a common ureter. Caliectasis doesn't cause any symptoms on its own. RENAL ANATOMY Renal Parenchyma The kidneys can be divided into three main regions from cranial to caudal. Anatomy of the Kidney and Ureter Parenchyma Cortex Medulla Perirenal fat Capsule Ureter The left kidney (not shown) had a similar appearance. . This article will discuss the anatomy and major functions of the kidney. The interpolar region is the middle of the kidney. D, If pressure on the papilla persists, the ischemic papilla undergoes necrosis, allowing the calyx to protrude outward toward the cortex. Illustration demonstrating basic intrarenal arterial anatomy. 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. Learn how we can help 1.2k views Reviewed Dec 09, 2022 Thank Figure 18-11 Three-dimensional volume rendering from contrast-enhanced multidetector computed tomography examination of the kidneys demonstrates typical orientation of a horseshoe kidney. In general, the amount of blood in the body is 5 liters. So in the filtered fluid that goes to the renal tubule, we have both necessary and unnecessary substances. Several small stones are visible in the left kidney, and the left kidney is somewhat atrophied from chronic obstruction. The early excretory phase begins as early as 120 seconds after injection. This is why the kidney is essential for the circulatory hemostasis. In adults, the normal kidney is 10-14 cm long in males and 9-13 cm long in females, 3-5 cm wide, 3 cm in antero-posterior thickness and weighs 150-260 g. The left kidney is usually slightly larger than the right. The 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. Right-sided pain was related to crossed renal ectopia. 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. Table 18-1 Imaging the Living Renal Donor. The phases of nephrogram. Table 18-3 Utility of Different Phases of Renal Contrast Enhancement. Note diameter of arteries because small accessory arteries may be sacrificed in many cases. Renal size can be measured in several ways. 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. A, Steady-state free precession, (B) T2-weighted with fat saturation, (C) T1-weighted, (D) T1-weighted with fat saturation, (E) postcontrast corticomedullary phase, and (F) postcontrast nephrographic phase. 18-21). 18-24). 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. Obstruction can cause renal failure if it is bilateral (Box 18-3) or if there is preexisting disease in the unobstructed kidney. If the renal pelvis extends out of the renal sinus, it is considered to be an extrarenal pelvis (Fig. Retrograde urogram shows a calculus in the left ureter. Depending on where the cyst is located, it can affect how the kidney works. Ultrasound can often identify the cause in cases of bilateral obstruction (Fig. BOX 18-2 Crossing Vessels in Ureteropelvic Junction Obstruction. IVC, Inferior vena cava. 18-4). In this region, the anterior and posterior hilar lip is identified (Fig. However, small, low-attenuation lesions in the medulla are often obscured during this phase. A. Junctional cortical line seen on a long-axis ultrasound image of the right kidney. 18-11). 18-27). All content published on Kenhub is reviewed by medical and anatomy experts. chronic obstruction, or severe or repeated urinary infections. When echogenicity of the renal cortex equals that of the liver, renal function is abnormal in approximately 38% of cases. The initiation is caused by the increase in volume that stretches the walls of the calyces. This layer sits posteriorly and posterolaterally to each kidney and separates it from the muscles of the abdominal wall. Pearl: Any upward trend in serum creatinine value should be viewed with concern because it implies renal reserve function has already been affected. 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. Several calyces drain into each infundibulum, an elongated transition from the polygonal calyces to the saclike renal pelvis. Kidney cysts are round pouches of fluid that form on or in 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. Increased cortical echogenicity is associated with many forms of chronic renal parenchymal disease and indicates a renal cause for renal failure. normal kidney size in adults normal kidney size in children Structure 18-19). 18-4). 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. During the 6th to 9th weeks of life, the kidneys begin to ascend from their position in the pelvis to the level of T12-L1, inferior to the adrenal glands. 18-26). A, Tips of the fornices are sharply defined. The presence of contour irregularity usually indicates scarring, suggesting prior infection, reflux, or infarction. In this case, the right kidney had more favorable anatomy for laparoscopic donor nephrectomy. BOX 18-3 Causes of Bilateral Hydronephrosis. Jana Vaskovi MD Renal artery Although less accurate than measured creatinine clearance, such methods provide an estimated creatinine clearance that is a better predictor of renal function than the serum creatinine alone. A, A low-attenuation lesion is difficult to identify during the corticomedullary phase. Because they rarely cause symptoms, renal cysts are most often found during . 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. 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). 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. 18-23). The upper poles are normally oriented more medially and posteriorly than the lower poles. Because the fascia of the retroperitoneum prevents significant extravasation, the incision usually heals to form a larger lumen. and parenchymal mass without the risks for nephrotoxicity associated with iodinated contrast media or nephrogenic systemic fibrosis associated with gadolinium contrast agents. The most common cause is renal artery stenosis (see Fig. 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. 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. Learning a quickmnemonic'VAD' can help you remember these structures (renal Vein, renal Artery, Duct a.k.a ureter). At that point, you may experience these symptoms: Severe, sharp pain in the side and back, below the ribs. 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. Frequent urination (having to go the bathroom often). The patient had right flank pain but had a solitary calcification in the left pelvis on plain radiograph (not shown). 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. Three-dimensional volume rendering from contrast-enhanced multidetector computed tomography examination of the kidneys demonstrates typical orientation of a horseshoe kidney. 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. C, More severe hydronephrosis results in more pronounced shortening of the papilla. 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 large left proximal ureteral stone seen in this image is only partially obstructing, causing mild dilation in the left kidney collecting system. 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. 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. 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. However, you may have symptoms related to the condition that's causing it. The anteromedial, aspect of the interpolar region is interrupted by the renal hilum to make a C shape. When the renal arteries enter the kidney through the hilum, they split into anterior and posterior branches. Made aware of such a vessel, the urologist may choose to perform an alternate procedure to avoid hemorrhagic complications. Also, in situations with notable blood losses, kidneys release a hormone called erythropoietin, which stimulates bone marrow to produce more blood cells. A, Enhancement of the mass is conspicuous in the corticomedullary phase. The renal cortex and medulla both have high signal intensity on T2-weighted images resulting in poor corticomedullary differentiation. I would honestly say that Kenhub cut my study time in half. (Courtesy of Karl T. Rew, MD) Introduction Synonyms Epidemiology Each kidney should always be evaluated in long axis (coronal, sagittal, or both, depending on sonographic window) and axial to the kidney. The calcium or uric acid will precipitate and form stones. The anteromedial aspect of the interpolar region is interrupted by the renal hilum to make a C shape. Now lets pay attention to the borders of the kidneys. Figure 18-25 Sagittal ultrasound image of the left kidney demonstrates a unilateral small, smooth, echogenic kidney in a patient with renal artery stenosis. Aggressive tumors form, grow and spread very quickly. There is no specific treatment for fused kidneys and the only option is to treat the pathologies that affect them during life. Coronal computed tomographic image in the corticomedullary phase shows normal corticomedullary differentiation along the lobulated contour, consistent with fetal lobulation. It is notable that the kidney has a very rich blood supply. Anatomy Where is the renal cortex? Reading time: 23 minutes. print Print this Article In this way, the consistency of blood is preserved and no important substances are lost. The ureter and calyces were not dilated (not shown), helping to differentiate this anatomic variant from obstruction. These surfaces are separated by the edges of the kidney, which are the major convexity laterally, and minor concavity medially. Illustration demonstrating the anatomy of the renal collecting system. 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. This can cause varicocele of the left testicle because gravity works against the column of the blood in the left testicular vein. Dialysis. 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. More tenuous vascular supply to the renal medulla makes it more susceptible to ischemia. urinary system quizzes and labeled diagrams. Congestive heart failure, dehydration, diuretic use, burns, sepsis, hemorrhage, cirrhosis, diabetic ketoacidosis, renal artery stenosis. Perhaps of even greater importance, serum creatinine is not a sensitive test for minor insults to the kidney in otherwise healthy individuals. These kidney functions can sure seem overwhelming, especially if you have to memorise them! Chronic obstruction, however, results in damage to the papilla, evident in the clubbed calyx of papillary necrosis (Fig. Volume rendering from a computed tomographic scan of the kidneys shows bilateral supernumerary renal arteries (three on right, two on left). The small portion of the lumen surrounding the papilla is called the. Other symptoms can include abnormal urine color, blood in your urine, fever, chills, nausea, and vomiting. 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. A, Axial image demonstrates the dilated renal pelvis and crossing vessel. 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. In this case, the right kidney had more favorable anatomy for laparoscopic donor nephrectomy. The calyces, however, will have a normal appearance with an unobstructed extrarenal pelvis but will be dilated in cases of urinary obstruction. 18-3). 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. When this happens, the stones can block the flow of urine out of your kidneys. The adrenal cortex directly influences renal function through the production of the hormone aldosterone to stimulate sodium reabsorption. Renal cysts are sacs of fluid that form in the kidneys. 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. In addition to the renal artery, accessory renal arteries are present too. This illustrates the amount of reserve function that must be compromised before renal injury can be detected with a serum creatinine level. 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. Publication types Review MeSH terms Humans more lateral and anterior than the superior poles. Bone scan and chest x-ray to find out if the cancer has spread. The lateral border is directed towards the periphery, while the medial border is the one directed towards the midline. 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. Figure 18-15 Relation between the right renal artery and the inferior vena cava (IVC). 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. Read more. An increased amount of hydrogen ions can acidify the blood and cause a state called acidosis. 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. Chills, nausea, and vomiting chronic glomerulonephritis would be a more likely explanation sacrificed in cases..., blood in your urine, fever, chills, nausea, and vomiting kidneys also participate in the calyx... Line seen on a long-axis ultrasound image of the calyx to protrude outward toward the cortex in otherwise healthy.... Stone seen in this case, the consistency of blood is preserved and no important substances are.. Appearance with an unobstructed extrarenal pelvis but will be dilated in cases of bilateral obstruction Fig! 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