Kidneys are located just below your ribcage and behind your belly. In this way, the consistency of blood is preserved and no important substances are lost. B, Transverse image of the bladder demonstrates a large bladder tumor in the region of the trigone. CT is occasionally used to evaluate patients with renal failure. 18-25). Renal size can be measured in several ways. The large left proximal ureteral stone seen in this image is only partially obstructing, causing mild dilation in the left kidney collecting system. Sagittal ultrasound image of the right kidney demonstrates increased size and echogenicity of the kidney, findings typical of human immunodeficiency virus nephropathy. This apical projection is called the renal papilla and it opens to the minor calyx. A. Junctional cortical line seen on a long-axis ultrasound image of the right kidney. The patient had right flank pain but had a solitary calcification in the left pelvis on plain radiograph (not shown). 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. Urine from the calyces flows to the renal sinus via tributaries called infundibula. Small renal shadows may be seen on radiographs, and reniform shape is preserved on cross-sectional imaging. The uniform high attenuation of the nephrographic phase provides an optimal background for detecting small, low-attenuation lesions in the renal parenchyma (Fig. The kidneys can be divided into three main regions from cranial to caudal. BOX 18-3 Causes of Bilateral Hydronephrosis. 18-3). However, T1-weighted images provide good corticomedullary differentiation. 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). There are many clinical states related to kidney malfunction. A simple calyx receives urine from a single papilla; a compound calyx receives urine from multiple papillae (Fig. The nephrons within the cortex comprise some of the most highly perfused parenchymal tissue in the body. Because they rarely cause symptoms, renal cysts are most often found during . A, Soft-tissue windows demonstrate no filling defect. The portion of the kidney between the poles is called the interpolar region and contains the renal hilum (Fig. Caliectasis doesn't cause any symptoms on its own. Most diagnosed kidney growths are small and localized masses. Look carefully for accessory arteries at upper and lower poles (Fig. The renal fascia which besides the kidneys also encloses the suprarenal gland and its surrounding fat. 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. When this happens, the stones can block the flow of urine out of your kidneys. Right-sided pain was related to crossed renal ectopia. The normal appearance of the calyx is created by the impression of the renal papilla. 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. For most people, obstruction of a single ureter does not induce renal failure. 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. Ultrasound is usually used in the initial evaluation of the patient with newly diagnosed renal failure. Renal cysts become fairly common as people age and usually do not cause symptoms or harm. Several small stones are visible in the left kidney, and the left kidney is somewhat atrophied from chronic obstruction. The adrenal cortex directly influences renal function through the production of the hormone aldosterone to stimulate sodium reabsorption. 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. 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 calcium or uric acid will precipitate and form stones. 18-22). Maintaining kidney health. Accurate preoperative imaging protects the healthy donor from complications related to unanticipated variant anatomy. The anteromedial, aspect of the interpolar region is interrupted by the renal hilum to make a C shape. 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. It's not clear what causes simple kidney cysts. Crossed ectopia can be either fused or unfused. Volume rendering from a computed tomographic scan of the kidneys shows bilateral supernumerary renal arteries (three on right, two on left). The portion of the kidney between the poles is called the interpolar region and contains the renal hilum (Fig. When. 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. So in the filtered fluid that goes to the renal tubule, we have both necessary and unnecessary substances. 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). 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). 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. The visible contrast seen in the excretory phase has been concentrated many-fold. Urine that is concentrated in the renal papilla is subsequently excreted into a lumen lined with transitional epithelium. An increased amount of hydrogen ions can acidify the blood and cause a state called acidosis. But more often, kidney cysts are a type called simple kidney cysts. Each end of the kidney is commonly called a pole. print Print this Article D, If pressure on the papilla persists, the ischemic papilla undergoes necrosis, allowing the calyx to protrude outward toward the cortex. This refers to the forming of the stones within the system of calyces because of too much calcium or uric acid into the filtrate. Anatomical Position of the Kidneys Kidney Structure Ultrasound can often identify the cause in cases of bilateral obstruction (Fig. If this appearance were present bilaterally, chronic renal disease such as chronic glomerulonephritis would be a more likely explanation. Alternatively, the anterior to posterior orientation follows the same pattern: renal vein, renal artery and ureter. Perhaps of even greater importance, serum creatinine is not a sensitive test for minor insults to the kidney in otherwise healthy individuals. 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. 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. In other cases, both kidneys can be fused, usually at the inferior poles, which is a congenital state called the horseshoe kidney. The small portion of the lumen surrounding the papilla is called the. Ultrasound can often identify the cause in cases of bilateral obstruction (, Pelvic mass (cervical, rectal, uterine, prostate cancer). 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. In most cases, unenhanced CT is performed when the duration and cause of renal failure are unknown because exposure to iodinated contrast media could impair recovery of renal function. It can be caused by a variety of factors, but most often arises because of the ischemia of the kidney and the toxic effect of some medications, resulting in the failure of all kidney functions. 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. Computed Tomographic Evaluation for Renal Failure, Magnetic Resonance Evaluation for Renal Failure. Recent advances in MDCT and MRI permit cross-sectional vascular studies to replace conventional angiography before UPJ repair (Fig. 18-16). A, A low-attenuation lesion is difficult to identify during the corticomedullary phase. Global insult to one kidney may result in unilateral atrophy that is uniform and smooth. A, Sagittal image of the left kidney demonstrates hydronephrosis and hydroureter. 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. Because the interlobular arteries form an arch overlying the pyramid, they are called the arcuate arteries. In most kidneys, the renal hilum faces more anteromedial in the upper half of the kidney and more directly medial in the lower half. 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. 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. Author: Many clinical laboratories now provide computer-generated calculations of estimated creatinine clearance or eGFR using patient data in the medical information system. Internal Anatomy. Sometimes, one or both kidneys fail to develop, which causes unilateral or bilateral renal agenesis. Association between Renal Cortical Echogenicity and Renal Parenchymal Disease. Annotated axial image of the right kidney from a contrast-enhanced computed tomographic scan demonstrates hilar anatomy of the kidney. 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. 18-26). Yet, the relations of the kidneys with other organs are often found in Anatomy tests. 18-23). A, Axial image demonstrates the dilated renal pelvis and crossing vessel. Note origin of inferior accessories near inferior poles on each side. The phases of nephrogram development and contrast excretion parallel those seen on contrast-enhanced CT with one notable exception (Fig. They are staged the same way as the renal pelvis. For that reason, we got you covered with this topic nicely and concisely. 18-3). The kidneys are bilateral organs placed retroperitoneally in the upper left and right abdominal quadrants and are part of the urinary system. The isthmus connecting the kidneys is variable, ranging from normal renal cortex to a thin fibrous band. On axial sections, the polar regions of the kidney typically form a closed circle or donut shape, with the hole formed by renal sinus fat. The kidneys are bilateral organs placed retroperitoneally in the upper left and right abdominal quadrants and are part of the urinary system. IVC, Inferior vena cava. Kidney cysts are round pouches of fluid that form on or in the kidneys. A healthy individual who donates a kidney is likely to maintain a normal serum creatinine despite the loss of 50% of parenchymal tissue. 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. Ultrasound It can be seen as a triangular echogenic cortical defect, frequently seen in upper lobe parenchyma. Advantages of scintigraphy include accurate quantitative measurement of function. As the lobules of metanephric blastema coalesce to form each kidney, they do not always result in a smooth, uniform band of cortex. 18-24). Figure 18-13 Volume rendering from a computed tomographic scan of the kidneys shows bilateral supernumerary renal arteries (three on right, two on left). The kidneys are a pair of bean-shaped organs located below the rib cage, one on each side of the spine. Each kidney has a single renal vein which conducts the blood out of the kidney and is positioned anterior to the artery. IVC, Inferior vena cava. This method is the standard in evaluation of UPJ obstruction and often is used for other types of chronic obstruction. In the medulla, 5-8 renal pyramids are separated by connective tissue renal columns. 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. Ultrasound permits real-time optimization of imaging relative to the axis of each kidney. Size disparity greater than 1.5 cm between kidneys should raise suspicion that one kidney is abnormal. Last reviewed: December 28, 2022 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. When multiple clefts in the renal cortex are present throughout the kidney, it is described as fetal lobulation. This kidney measured 14 cm in length. Table 18-1 Imaging the Living Renal Donor. Three-dimensional volume rendering from contrast-enhanced multidetector computed tomography examination of the kidneys demonstrates typical orientation of a horseshoe kidney. Note diameter of arteries because small accessory arteries may be sacrificed in many cases. 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. Our engaging videos, interactive quizzes, in-depth articles and HD atlas are here to get you top results faster. urinary system quizzes and labeled diagrams. Obstruction can cause renal failure if it is bilateral (Box 18-3) or if there is preexisting disease in the unobstructed kidney. 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. If the renal pelvis is entirely within the confines of the renal sinus, it is considered intrarenal. 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 left kidney measured 7.8 cm, and the right kidney measured 10.9 cm. They are usually characterized as "simple" cysts, meaning they have a thin wall and contain water-like fluid. Renal artery The parenchyma of the kidney consists of the outer renal cortex, and inner renal medulla. When the renal arteries enter the kidney through the hilum, they split into anterior and posterior branches. When simple kidney cysts do cause symptoms, they might include: Pain in the side between the ribs and hip, stomach or back. Dimitrios Mytilinaios MD, PhD The kidneys are paired retroperitoneal structures that are normally located between the transverse processes of T12-L3 vertebrae, with the left kidney typically somewhat more superior in position than the right. a bifid renal pelvis, ultimately drained by a common ureter. It protects your kidneys from injury, increases their stability and connects your kidneys to surrounding tissues. Note that the left renal vein receives blood from the left suprarenal and left testicular veins. Diabetes, hypertension, acute tubular necrosis, Increased echogenicity has high association with parenchymal disease, Acute tubular necrosis usually results in an increased RI, whereas prerenal causes usually do not have an increased RI; postrenal causes often increase the RI, but hydronephrosis should be present in those cases, If present, suspect neurogenic bladder or outlet obstruction, Often severe aortic disease or fibromuscular dysplasia. Solid masses are more likely to be cancerous but they are not all cancerous. The solid renal parenchyma consists of the peripheral renal cortex and more central renal medulla. 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. Coronal maximum intensity projection image from a contrast-enhanced computed tomographic scan demonstrates a dilated and tortuous lumbar veins joining the left renal vein. This is called the nutcracker phenomenon. However, sometimes ureteroscopy is required to confirm the diagnosis in patients with hematuria. The left kidney measured 7.8 cm, and the right kidney measured 10.9 cm. 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. February 12, 2018 - 2:17pm Differential diagnosis General imaging considerations include: renal cortical defect duplex kidney Figure 18-3 Illustration demonstrating basic intrarenal arterial anatomy. Renal cysts are sacs of fluid that form in the kidneys. It is also permeable for the products of the metabolism, such are creatinine and drug metabolites. Figure 18-7 Axial image of the left kidney from a contrast-enhanced computed tomographic scan demonstrates an extrarenal pelvis. 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. 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. This specific condition is called the nutcracker phenomenon. Unenhanced MRI can also be used to diagnose obstruction and identify the source (Fig. 18-19). 18-20). 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. Some centers use diuretics or fluid bolus, or both, during CT urography to dilute the excreted contrast to improve assessment of the urothelium. Renal scintigraphy can be performed with a variety of agents to provide assessment of either function or structure of the kidneys. Kenhub. 18-25). 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. It participates in vital processes such as regulation of blood osmolarity and pH, regulation of blood volume and blood pressure, production of hormones, and filtration of foreign substances. This can cause varicocele of the left testicle because gravity works against the column of the blood in the left testicular vein. In this region, the anterior and posterior hilar lip is identified (Fig. Supernumerary kidneys are quite rare and have been associated with aortic coarctation, vaginal atresia, and urethral duplications. Always include unenhanced computed tomographic images to look for renal stones. Pearl: Any upward trend in serum creatinine value should be viewed with concern because it implies renal reserve function has already been affected. Size disparity greater than 1.5 cm between kidneys should raise suspicion that one kidney is abnormal. The kidneys are located between your intestines and your diaphragm. 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. The superior poles (extremities) (T12) of both kidneys are more medially pointed towards the spine than the inferior poles (extremities) (L3). Arterial stenosis was confirmed by magnetic resonance angiography. 18-15). 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). Kidney cysts can occur with disorders that may impair kidney function. This is just a peek into the kidney physiology. The fused kidneys can have a variety of orientations, including side by side, in-line, or perpendicular. Thus, the ureter is seen paravertebrally starting from the L2 and going downwards. chronic obstruction, or severe or repeated urinary infections. Horseshoe kidneys result from midline fusion of the kidneys, typically at the level of the origin of the inferior mesenteric artery. 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. Chronic obstruction, however, results in damage to the papilla, evident in the clubbed calyx of papillary necrosis (Fig. Since they are located deep retroperitoneally, the easiest way to examine them is from the patients back. B, Mild hydronephrosis results in rounding of the fornices with mild shortening of the papillary impression. Sagittal ultrasound image of the left kidney demonstrates a unilateral small, smooth, echogenic kidney in a patient with renal artery stenosis. 18-2). The anteromedial aspect of the interpolar region is interrupted by the renal hilum to make a C shape. 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. 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