Relation between the right renal artery and the inferior vena cava (IVC). The anterior surface faces towards the anterior abdominal wall, whereas the posterior surface is facing the posterior abdominal wall. The phases of nephrogram. Chronic glomerulonephritis usually causes bilateral increased renal echogenicity with smooth atrophy, whereas renal artery stenosis usually causes a similar but unilateral appearance (Fig. Ultrasound It can be seen as a triangular echogenic cortical defect, frequently seen in upper lobe parenchyma. Table 18-2 Association between Renal Cortical Echogenicity and Renal Parenchymal Disease. Learning anatomy is a massive undertaking, and we're here to help you pass with flying colours. Read more. The calcium or uric acid will precipitate and form stones. Illustration demonstrating the anatomy of the renal collecting system. Axial image of the left kidney from a contrast-enhanced computed tomographic scan demonstrates an extrarenal pelvis. But here is a neat little mnemonic to help. 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. 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. Computed Tomographic Evaluation for Renal Failure, Magnetic Resonance Evaluation for Renal Failure. This plexus provides input from: The sensory nerves from the kidney travel to the spinal cord at the levels T10-T11, which is why the pain in the flank region always rises suspicions that something is wrong with the corresponding kidney. Perhaps of even greater importance, serum creatinine is not a sensitive test for minor insults to the kidney in otherwise healthy individuals. 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. Look carefully for accessory arteries at upper and lower poles (Fig. normal kidney size in adults normal kidney size in children Structure The medulla is the inner region of the parenchyma of the kidney. Renal cysts are sacs of fluid that form in the kidneys. Kidney cysts are round pouches of fluid that form on or in the kidneys. and parenchymal mass without the risks for nephrotoxicity associated with iodinated contrast media or nephrogenic systemic fibrosis associated with gadolinium contrast agents. Further testing/diagnosis is required. Each kidney should always be evaluated in long axis (coronal, sagittal, or both, depending on sonographic window) and axial to the kidney. When abnormal echogenicity is detected, it is important to note whether it is unilateral or bilateral. Overview. Made aware of such a vessel, the urologist may choose to perform an alternate procedure to avoid hemorrhagic complications. IVC, Inferior vena cava. The corticomedullary phase is prolonged in the presence of ureteral or venous obstruction and can persist for days in cases of acute tubular necrosis (ATN; Fig. 18-13). Table 18-7 lists causes of unilateral smooth renal atrophy. It is notable that the kidney has a very rich blood supply. Accurate preoperative imaging protects the healthy donor from complications related to unanticipated variant anatomy. The region where the renal pelvis joins the ureter is called the ureteropelvic junction (UPJ). Ultrasound permits real-time optimization of imaging relative to the axis of each kidney. For that reason, we got you covered with this topic nicely and concisely. On the superior aspect of each kidney is the adrenal gland. 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. Because the fascia of the retroperitoneum prevents significant extravasation, the incision usually heals to form a larger lumen. 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. Kidney cysts can occur with disorders that may impair kidney function. A healthy individual who donates a kidney is likely to maintain a normal serum creatinine despite the loss of 50% of parenchymal tissue. 18-1). Three-dimensional volume rendering from contrast-enhanced multidetector computed tomography examination of the kidneys demonstrates typical orientation of a horseshoe kidney. Figure 18-24 Normal magnetic resonance imaging appearance of the kidneys. I hope this helps. 18-21). Look for duplication, large extrarenal pelvis. Annotated axial image of the right kidney from a contrast-enhanced computed tomographic scan demonstrates hilar anatomy of the kidney. However, small, low-attenuation lesions in the medulla are often obscured during this phase. The phases of nephrogram development and contrast excretion parallel those seen on contrast-enhanced CT with one notable exception (Fig. 18-9). 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. 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. The large left proximal ureteral stone seen in this image is only partially obstructing, causing mild dilation in the left kidney collecting system. print Print this Article 18-24). These terminal branches have no collateral circulation. The renal pelvis then tapers like a funnel to join the ureter. Duplication of the urinary tract is discussed in detail in Chapter 19. Illustration demonstrating basic intrarenal arterial anatomy. Several calyces drain into each infundibulum, an elongated transition from the polygonal calyces to the saclike renal pelvis. Occasionally, a papilla will communicate directly with an infundibulum or the renal pelvis and is considered to be an aberrant papilla. . 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. 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. Each time a professor says 'nephron', a student gets a headache. Pain that radiates to the lower abdomen and groin. 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 superior half of each kidney is covered by the diaphragm, which is why the kidneys move up and down during respiration. 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. An increased amount of hydrogen ions can acidify the blood and cause a state called acidosis. This method is the standard in evaluation of UPJ obstruction and often is used for other types of chronic obstruction. Look for retroaortic or circumaortic left renal vein. They are staged the same way as the renal pelvis. 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. Advantages of scintigraphy include accurate quantitative measurement of function. 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. 18-2). Note number of veins by inspecting inferior vena cava along entire length of kidney. 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. 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. Ultrasound can often identify the cause in cases of bilateral obstruction (Fig. There are many clinical states related to kidney malfunction. Sagittal ultrasound image of the right kidney demonstrates increased size and echogenicity of the kidney, findings typical of human immunodeficiency virus nephropathy. This phenomenon is due to T2-shortening and susceptibility (T2*) effects caused by concentrated gadolinium, and can potentially obscure filling defects and urothelial lesions. A, Axial image from contrast-enhanced computed tomography (CT) demonstrates an accessory right renal artery coursing anterior to the IVC. 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. Table 18-5 summarizes a checklist approach to the ultrasound examination. 18-15). The most common cause is renal artery stenosis (see Fig. Creatinine is a breakdown product of creatine, found within muscle. Box 18-2 provides some tips regarding crossing vessels in UPJ obstruction. Hydronephrosis is important to detect, because obstructive uropathy is often reversible if identified early. The renal corpuscle has two components: the glomerular (Bowmans) capsule in which sits the glomerulus. Even when there is another plausible explanation for decreased renal function (e.g., known prerenal causes), ultrasound offers the opportunity to rapidly and noninvasively identify a potentially correctible cause of renal failure. Volume rendering from a computed tomographic scan of the kidneys shows bilateral supernumerary renal arteries (three on right, two on left). When abnormal echogenicity is detected, it is important to note whether it is unilateral or bilateral. Solid masses are more likely to be cancerous but they are not all cancerous. Ultrasound permits real-time optimization of imaging relative to the axis of each kidney. Normally, the kidney is about the size of a mouse and measures approximately 11-12 cm in length, 5-6 cm in width, and 2.5-3 cm in thickness. 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. Publication types Review MeSH terms Humans The adrenal cortex directly influences renal function through the production of the hormone aldosterone to stimulate sodium reabsorption. This phenomenon is due to T2-shortening and susceptibility (T2*) effects caused by concentrated gadolinium, and can potentially obscure filling defects and urothelial lesions. 18-19). For most of the students, the nephron is a mystical complexed structure that may be hard to understand. The renal fascia which besides the kidneys also encloses the suprarenal gland and its surrounding fat. They are branches of the abdominal aorta and all together are called the extrahilar renal arteries. In the medulla, 5-8 renal pyramids are separated by connective tissue renal columns. 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 vascularity of some tumors may be most apparent during this phase (Fig. Differential diagnosis General imaging considerations include: renal cortical defect duplex kidney In this case, the right kidney had more favorable anatomy for laparoscopic donor nephrectomy. Radiologists divide the kidney into three parts: the upper pole, lower pole, and the interpole (whi. General symptoms of kidney problems include: blood in your urine . So in the filtered fluid that goes to the renal tubule, we have both necessary and unnecessary substances. Dimitrios Mytilinaios MD, PhD 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. 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. 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. Crossed ectopia can be either fused or unfused. The normal appearance of the calyx is created by the impression of the renal papilla. The cortex of a normal kidney is usually less echogenic than the adjacent normal liver. The upper pelvis is the most common ectopic location for the kidney; most cases are also associated with abnormalities of rotation. The medulla consists of multiple pyramidal tissue masses, called the renal pyramids, which are triangle structures that contain a dense network of nephrons. The kidneys are reddish-brown, bean-shaped organs situated retroperitoneal on the posterior abdominal wall. 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. On ultrasound, the renal cortex is usually echogenic in this setting. 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. A, A low-attenuation lesion is difficult to identify during the corticomedullary phase. If this appearance were present bilaterally, chronic renal disease such as chronic glomerulonephritis would be a more likely explanation. This specific condition is called the nutcracker phenomenon. Computed Tomographic Appearance of the Kidneys, Utility of Different Phases of Renal Contrast Enhancement. In most kidneys, the renal hilum faces more anteromedial in the upper half of the kidney and more directly medial in the lower half. Technetium 99m-mercaptoacetyltriglycin (MAG3) is excreted by the kidneys (mainly through secretion by proximal tubules) and provides evaluation of renal function, particularly in cases of suspected obstruction. B, The lesion becomes more conspicuous during the nephrographic phase. Figure 18-8 Junctional cortical line seen on a long-axis ultrasound image of the right kidney. 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. The lateral border is directed towards the periphery, while the medial border is the one directed towards the midline. There is no specific treatment for fused kidneys and the only option is to treat the pathologies that affect them during life. 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. Anatomical Position of the Kidneys Kidney Structure Living renal donor allografts account for more than half of the transplanted kidneys in the United States. 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). Several formulas are available for this calculation, and calculators and on-line sites are available to simplify the calculations. The right kidney has a normal appearance (not shown). 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). 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. Eliminating toxic metabolites through urine, regulation of blood homeostasis and blood pressure, production of some hormones, Positioned retroperitoneally, consists of the cortex and medulla, empties urine into the ureter (which carries urine to the urinary bladder), Renal artery (branch of the abdominal aorta), Renal vein (drains to the inferior vena cava), Third kidney, horseshoe kidney, kidney agenesis, kidney stones, acute kidney failure, Regulates the amount of fluid in the body by increasing or decreasing the urine production, Maintain the pH of blood at 7.4 by decreasing or increasing the excretion of hydrogen ions, Medial part of the lower half of superior pole, Lateral part of the lower half of superior pole, Lateral part of inferior half of anterior surface, Medial part of inferior half of anterior surface, The perinephric fat (perirenal fat capsule). The initiation is caused by the increase in volume that stretches the walls of the calyces. Due to the segmental vascular supply of the kidney it is often feasible to ligate the relative arteries and veins and remove the tumour with a safe zone of healthy surrounding parenchyma ( partial nephrectomy) without removing the entire kidney or compromising its total vascular supply by ischaemia. If the renal pelvis extends out of the renal sinus, it is considered to be an extrarenal pelvis (Fig. The apex of the pyramid projects medially toward the renal sinus. Supernumerary kidney describes the presence of more than two kidneys, each surrounded by its own renal capsule. 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. normal kidney size in adults normal kidney size in children Structure 18-26). This refers to the forming of the stones within the system of calyces because of too much calcium or uric acid into the filtrate. 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. The stones can move into the ureter and literally get stuck there because the lumen of the ureter is much smaller compared to the calyces, which is very painful for the patient. 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. The information we provide is grounded on academic literature and peer-reviewed research. 18-28). Many clinical laboratories now provide computer-generated calculations of estimated creatinine clearance or eGFR using patient data in the medical information system. 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. 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. 18-3). Ultrasound performed for acute renal failure demonstrates bilateral hydronephrosis caused by a bladder tumor. 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. Renal size and cortical thickness can be assessed in a manner similar to ultrasound. Table 18-7 lists causes of unilateral smooth renal atrophy. This can cause varicocele of the left testicle because gravity works against the column of the blood in the left testicular vein. 18-11). Causes. Learning a quickmnemonic'VAD' can help you remember these structures (renal Vein, renal Artery, Duct a.k.a ureter). The shape of the calyx is formed by the impression of the renal papilla. Learn how we can help 1.2k views Reviewed Dec 09, 2022 Thank Dr. Frank Kuitems and 4 doctors agree 3 thanks urinary system quizzes and labeled diagrams. 18-27). Association between Renal Cortical Echogenicity and Renal Parenchymal Disease. 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. This kidney measured 14 cm in length. Unenhanced MRI can also be used to diagnose obstruction and identify the source (Fig. When hydronephrosis is absent, the causative factor for acute renal failure is almost certainly prerenal or renal. Pearl: Any upward trend in serum creatinine value should be viewed with concern because it implies renal reserve function has already been affected. Caliectasis doesn't cause any symptoms on its own. 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. AMLs can bleed and while not cancerous are still taken very seriously. Note that the left renal vein receives blood from the left suprarenal and left testicular veins. In this way, the consistency of blood is preserved and no important substances are lost. As the lobules of metanephric blastema coalesce to form each kidney, they do not always result in a smooth, uniform band of cortex. Frequent urination (having to go the bathroom often). When echogenicity of the renal cortex equals that of the liver, renal function is abnormal in approximately 38% of cases. Finally, the arcuate arteries branch into the interlobular arteries which branch off even further by giving afferent arterioles to run blood past the glomerulus for blood filtration. Global insult to one kidney may result in unilateral atrophy that is uniform and smooth. Reviewer: Pitfall: An extrarenal pelvis may be mistaken for hydronephrosis. As the lobules of metanephric blastema coalesce to form each kidney, they do not always result in a smooth, uniform band of cortex. Because production of creatinine is affected by sex, age, muscle mass, protein intake, and liver function, the serum creatinine can be an inaccurate predictor of renal function, particularly in those at the extremes of age and body weight. Learn how we can help 1.2k views Reviewed Dec 09, 2022 Thank Each nephron contains a renal corpuscle, which is the initial component that filters the blood, and a renal tubule that processes and carries the filtered fluid to the system of calyces. The left kidney measured 7.8 cm, and the right kidney measured 10.9 cm. Renal scintigraphy can be performed with a variety of agents to provide assessment of either function or structure of the kidneys. It doesn't have to be that way. Because the interlobular arteries form an arch overlying the pyramid, they are called the arcuate arteries. Figure 18-15 Relation between the right renal artery and the inferior vena cava (IVC). Figure 18-9 Coronal computed tomographic image in the corticomedullary phase shows normal corticomedullary differentiation along the lobulated contour, consistent with fetal lobulation. Some divide the excretory phase into the early excretory phase (contrast mainly confined to the kidney) and late excretory phase (contrast in the ureters). Table 18-1 provides a quick guide itemizing key imaging findings in the potential renal donor. Technetium 99m dimercaptosuccinic acid (DMSA) and glucoheptonate (GHA) are both used for evaluation of renal parenchyma. When multiple clefts in the renal cortex are present throughout the kidney, it is described as fetal lobulation. The renal pelvis then tapers like a funnel to join the ureter. Kim Bengochea, Regis University, Denver. Small renal shadows may be seen on radiographs, and reniform shape is preserved on cross-sectional imaging. The small portion of the lumen surrounding the papilla is called the calyx. The presence of significant renal parenchyma may justify surgical repair to maximize the functional contribution of that kidney. Retrograde urogram shows a calculus in the left ureter. 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