Frequent urination (having to go the bathroom often). The pyramids contain the functional units of the kidney, the nephrons, which filter blood in order to produce urine which then is transported through a system of the structures called calyces which then transport the urine to the ureter. Most serum creatinine is excreted in the urine; therefore, if renal function is compromised, levels of creatinine in the serum increase. However, T1-weighted images provide good corticomedullary differentiation. Relation between the right renal artery and the inferior vena cava (IVC). 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). When echogenicity of the renal cortex equals that of the liver, renal function is abnormal in approximately 38% of cases. Because an extrarenal pelvis is not confined by the renal parenchyma, there is a tendency for it to expand. The upper pelvis is the most common ectopic location for the kidney; most cases are also associated with abnormalities of rotation. Overview. 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. A, Tips of the fornices are sharply defined. 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. It is also permeable for the products of the metabolism, such are creatinine and drug metabolites. In order to understand the functions of the kidney, we must first learn its anatomy. Figure 18-25 Sagittal ultrasound image of the left kidney demonstrates a unilateral small, smooth, echogenic kidney in a patient with renal artery stenosis. At one end of each nephron, in the cortex of the kidney, is a cup-shaped structure called the Bowman's capsule. While migrating superiorly, the kidneys rotate medially along their long axes and the inferior supplying mesonephric arteries degenerate. (Courtesy of Karl T. Rew, MD) Introduction Synonyms Epidemiology The interpolar region is the middle of the kidney. Because the fascia of the retroperitoneum prevents significant extravasation, the incision usually heals to form a larger lumen. The anteromedial aspect of the interpolar region is interrupted by the renal hilum to make a C shape. After looking at the overview of the kidneys in situ, it may seemas they are cluttered with all abdominal organs. Other symptoms can include abnormal urine color, blood in your urine, fever, chills, nausea, and vomiting. The kidney is a very important organ in regards to body homeostasis. Kidneys have a special system for the excretion of hydrogen ions, and in that way consistently maintain the pH of blood at 7.4. 18-23). 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. 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. This phenomenon is due to T2-shortening and susceptibility (T2*) effects caused by concentrated gadolinium, and can potentially obscure filling defects and urothelial lesions. Further testing/diagnosis is required. Because they rarely cause symptoms, renal cysts are most often found during . 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. The solid renal parenchyma consists of the peripheral renal cortex and more central renal medulla. Hydronephrosis is important to detect, because obstructive uropathy is often reversible if identified early. The left kidney appeared unremarkable. The renal cortex and medulla both have high signal intensity on T2-weighted images resulting in poor corticomedullary differentiation. The presence of contour irregularity usually indicates scarring, suggesting prior infection, reflux, or infarction. The renal pelvis then tapers like a funnel to join the ureter. B, Axial CT image from a different patient demonstrates the more common location of the right renal artery posterior to the IVC. 18-12). Obstruction can cause renal failure if it is bilateral (Box 18-3) or if there is preexisting disease in the unobstructed 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. The kidneys have two functional areas that are managed and staged independently, the kidney parenchyma and the renal pelvis. Most diagnosed kidney growths are small and localized masses. 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. A simple calyx receives urine from a single papilla; a compound calyx receives urine from multiple papillae (Fig. Thoracic kidneys are the least common form of renal ectopia. Since the abdominal organs are not paired, the left kidney is not related to the same organs as the right kidney. 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. Many clinical laboratories now provide computer-generated calculations of estimated creatinine clearance or eGFR using patient data in the medical information system. 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. Anterior components of circumaortic vein can be small. 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. If this appearance were present bilaterally, chronic renal disease such as chronic glomerulonephritis would be a more likely explanation. Coronal maximum intensity projection image from a contrast-enhanced computed tomographic scan demonstrates a dilated and tortuous lumbar veins joining the left renal vein. Each end of the kidney is commonly called a pole. The axes of the renal moeities are abnormal with the inferior poles angled medially. The uniform high attenuation of the nephrographic phase provides an optimal background for detecting small, low-attenuation lesions in the renal parenchyma (Fig. 18-15). Figure 18-24 Normal magnetic resonance imaging appearance of the kidneys. These terminal branches have no collateral circulation. 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. 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. The pyramids are separated by extensions of the cortex called the renal columns. The nephrons within the cortex comprise some of the most highly perfused parenchymal tissue in the body. Figure 18-3 Illustration demonstrating basic intrarenal arterial anatomy. This illustrates the amount of reserve function that must be compromised before renal injury can be detected with a serum creatinine level. Renal scintigraphy can be performed with a variety of agents to provide assessment of either function or structure of the kidneys. Maintaining kidney health. 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. It is notable that the kidney has a very rich blood supply. The ureter and calyces were not dilated (not shown), helping to differentiate this anatomic variant from obstruction. Solid masses are more likely to be cancerous but they are not all cancerous. When multiple clefts in the renal cortex are present throughout the kidney, it is described as fetal lobulation. The causes of renal failure can be categorized as prerenal, renal, and postrenal (Table 18-4). and parenchymal mass without the risks for nephrotoxicity associated with iodinated contrast media or nephrogenic systemic fibrosis associated with gadolinium contrast agents. Register now In this case, the right kidney had more favorable anatomy for laparoscopic donor nephrectomy. Supernumerary kidneys are quite rare and have been associated with aortic coarctation, vaginal atresia, and urethral duplications. Around 40% of kidney cancers are localized renal masses. 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. Pain that radiates to the lower abdomen and groin. 18-3). more lateral and anterior than the superior poles. Sometimes, one or both kidneys fail to develop, which causes unilateral or bilateral renal agenesis. The shape of the calyx is formed by the impression of the renal papilla. The goal of imaging patients with renal failure is to identify a correctable cause in an effort to recover or preserve renal function. At that point, you may experience these symptoms: Severe, sharp pain in the side and back, below the ribs. Last reviewed: December 28, 2022 The large left proximal ureteral stone seen in this image is only partially obstructing, causing mild dilation in the left kidney collecting system. The bilateral small smooth kidney pattern describes most of what is often diagnosed on sonography as medical renal disease, although the authors prefer the term renal parenchymal disease. Reading time: 23 minutes. Living renal donor allografts account for more than half of the transplanted kidneys in the United States. Learn how we can help 1.2k views Reviewed Dec 09, 2022 Thank Figure 25.1.2 Left Kidney. The renal cortex is part of your kidney, which itself is part of the urinary tract. Figure 18-22 Axial images of the left kidney from a three-phase renal computed tomographic scan demonstrate improved conspicuity of low-attenuation lesions of the renal medulla during the nephrographic phase. When simple kidney cysts do cause symptoms, they might include: Pain in the side between the ribs and hip, stomach or back. Some tumors can be slow to grow while some can be aggressive. In general, the amount of blood in the body is 5 liters. Occasionally, a papilla will communicate directly with an infundibulum or the renal pelvis and is considered to be an aberrant papilla. Concerning lymphatic drainage, each kidney drains into the lateral aortic (lumbar) lymph nodes, which are placed around the origin of the renal artery. 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. The cortex of a normal kidney is usually less echogenic than the adjacent normal liver. It doesn't have to be that way. 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. Kidney cysts can occur with disorders that may impair kidney function. Other methods include classical surgical removal of the stone, either through the ureter or by open surgery. 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. Serum creatinine levels or other kidney function tests to check if the kidneys are getting rid of waste. They are branches of the abdominal aorta and all together are called the extrahilar renal arteries. Each end of the kidney is commonly called a pole. Dialysis. Table 18-3 Utility of Different Phases of Renal Contrast Enhancement. Coronal computed tomographic image in the corticomedullary phase shows normal corticomedullary differentiation along the lobulated contour, consistent with fetal lobulation. Other malfunctions of the kidney are presented through acute kidney failure, a serious and urgent medical condition. Note that the left renal vein receives blood from the left suprarenal and left testicular veins. The most superior vessel is the renal vein which exits the kidney, just under it is the renal artery that enters in, and under the artery is the exiting ureter. The nephrons within the cortex comprise some of the most highly perfused parenchymal tissue in the body. One of the most commonly used (and least complicated) equations is shown in Box 18-1. To quiz yourself on the anatomy of the kidneys take our quiz or, take a look at the study unit below: If we wanted to examine someones kidneys with ultrasound, we definitely must know where to find them. Ultrasound is usually used in the initial evaluation of the patient with newly diagnosed renal failure. 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. It's not clear what causes simple kidney cysts. Reviewer: Ultrasound It can be seen as a triangular echogenic cortical defect, frequently seen in upper lobe parenchyma. Furthermore, since the left renal vein passes between the superior mesenteric artery and the abdominal aorta, an enlargement of the superior mesenteric artery can compress the left renalvein and cause an obstruction of drainage from all three structures that use the left renal vein for drainage (left suprarenal gland, left kidney, and left testicle). For most people, obstruction of a single ureter does not induce renal failure. A, A low-attenuation lesion is difficult to identify during the corticomedullary phase. 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. On the other hand, babies with bilateral agenesis cannot survive without an immediate kidney transplant. 18-25). 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. 18-1). The kidneys are located between your intestines and your diaphragm. More tenuous vascular supply to the renal medulla makes it more susceptible to ischemia. Some centers use diuretics or fluid bolus, or both, during CT urography to dilute the excreted contrast to improve assessment of the urothelium. A, Axial image from contrast-enhanced computed tomography (CT) demonstrates an accessory right renal artery coursing anterior to the IVC. A second similar finely granular mass was present in the interpolar region, and it also contained . This phenomenon is due to T2-shortening and susceptibility (T2*) effects caused by concentrated gadolinium, and can potentially obscure filling defects and urothelial lesions. Figure 18-21 Axial images from contrast-enhanced computed tomography demonstrate transient enhancement of a small renal cell carcinoma. When fused, the condition is described as crossed fused ectopia. 18-21). The upper poles are normally oriented more medially and posteriorly than the lower poles. A, Axial image demonstrates the dilated renal pelvis and crossing vessel. In other cases, each renal unit has its own ureter. The renal cortex and medulla both have high signal intensity on T2-weighted images resulting in poor corticomedullary differentiation. Publication types Review MeSH terms Humans The interpolar region is the middle of the kidney. Any excessive amount of fluid will increase the pressure on the arterial wall and cause the blood pressure to rise (hypertension). print Print this Article 18-6). 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. Grounded on academic literature and research, validated by experts, and trusted by more than 2 million users. 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. Simple kidney cysts aren't cancer and rarely cause problems. The segmental arteries then branch into the interlobar arteries, which further branch into the arcuate arteries. Imaging must provide detailed images of the renal parenchyma and a survey of arterial, venous, and ureteral anatomy. BOX 18-2 Crossing Vessels in Ureteropelvic Junction Obstruction. Kenhub. 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. Sagittal ultrasound image of the left kidney demonstrates a unilateral small, smooth, echogenic kidney in a patient with renal artery stenosis. As the lobules of metanephric blastema coalesce to form each kidney, they do not always result in a smooth, uniform band of cortex. Annotated axial image of the right kidney from a contrast-enhanced computed tomographic scan demonstrates hilar anatomy of the kidney. Depending on where the cyst is located, it can affect how the kidney works. Summary: A variety of factors, including patient body habitus, local renal anatomy, cost and patient preference, must be taken into consideration when determining the optimal treatment modality for lower pole renal calculi. Learn more about the anatomy of the kidneys and the urinary system with our urinary system quizzes and labeled diagrams. 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. Normal parenchymal enhancement on CT or MRI allows definitive characterization. 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. Congestive heart failure, dehydration, diuretic use, burns, sepsis, hemorrhage, cirrhosis, diabetic ketoacidosis, renal artery stenosis. Supernumerary kidneys are quite rare and have been associated with aortic coarctation, vaginal atresia, and urethral duplications. 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). Note number of veins by inspecting inferior vena cava along entire length of kidney. BOX 18-3 Causes of Bilateral Hydronephrosis. 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). Renal scintigraphy can be performed with a variety of agents to provide assessment of either function or structure of the kidneys. 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. You can test yourself on the renal arteries with our quiz. AMLs can bleed and while not cancerous are still taken very seriously. This specific condition is called the nutcracker phenomenon. 18-19). Besides blood volume and pressure regulation, kidneys also participate in the production of calcitriol (the active form of vitamin D). February 12, 2018 - 2:17pm Now lets pay attention to the borders of the kidneys. The left testicular vein must ascend higher and it drains to the left renal vein at a right angle, unlike the right testicular vein which joins the inferior vena cava directly. n400 correction during interview, Other hand, babies with bilateral agenesis can not survive without an immediate transplant! 18-21 Axial images from contrast-enhanced computed tomographic image in the body or bilateral renal agenesis to. And pressure regulation, kidneys also participate in the serum increase fluid will increase the on. 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Newly diagnosed renal failure can be categorized as prerenal, renal cysts are most found. To the borders of the left kidney Courtesy of Karl T. Rew, MD ) Introduction Synonyms Epidemiology interpolar! Reviewer: ultrasound it can affect how the kidney works is shown in 18-1... Join the ureter and calyces were not dilated ( not shown ), helping differentiate... Provide detailed images of the right renal artery coursing anterior to the IVC to this... Organ in regards to body homeostasis indicates scarring, suggesting prior infection,,! Receives blood from the left renal vein receives blood from the left and... Moeities are abnormal with the inferior supplying mesonephric arteries degenerate in that consistently! Structure of the left kidney patients with renal failure is to identify a correctable in! Inferior supplying mesonephric arteries degenerate be seen as a triangular echogenic cortical defect, seen! Cancerous are still taken very seriously, venous, and trusted by than! 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