18-19). Renal scintigraphy can be performed with a variety of agents to provide assessment of either function or structure of the kidneys. 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. B, Low-attenuation lesion in the late nephrographic/early excretory phase is less suspicious in appearance. 18-18). Renal artery Figure 18-15 Relation between the right renal artery and the inferior vena cava (IVC). This illustrates the amount of reserve function that must be compromised before renal injury can be detected with a serum creatinine level. Radiologists divide the kidney into three parts: the upper pole, lower pole, and the interpole (which is in between them). The kidneys are reddish-brown, bean-shaped organs situated retroperitoneal on the posterior abdominal wall. 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. A healthy individual who donates a kidney is likely to maintain a normal serum creatinine despite the loss of 50% of parenchymal tissue. Calcifications and renal calculi are notoriously poorly demonstrated with MRI. Best, Susan. and parenchymal mass without the risks for nephrotoxicity associated with iodinated contrast media or nephrogenic systemic fibrosis associated with gadolinium contrast agents. Fever. For most of the students, the nephron is a mystical complexed structure that may be hard to understand. 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. Accurate preoperative imaging protects the healthy donor from complications related to unanticipated variant anatomy. When hydronephrosis is absent, the causative factor for acute renal failure is almost certainly prerenal or renal. (Courtesy of Karl T. Rew, MD) Introduction Synonyms Epidemiology 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. and grab your free ultimate anatomy study guide! 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. The solid renal parenchyma consists of the peripheral renal cortex and more central renal medulla. As the lobules of metanephric blastema coalesce to form each kidney, they do not always result in a smooth, uniform band of cortex. These surfaces are separated by the edges of the kidney, which are the major convexity laterally, and minor concavity medially. Coronal maximum intensity projection image from a contrast-enhanced computed tomographic scan demonstrates a dilated and tortuous lumbar veins joining the left renal vein. 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. In other cases, each renal unit has its own ureter. A. Junctional cortical line seen on a long-axis ultrasound image of the right kidney. Figure 18-13 Volume rendering from a computed tomographic scan of the kidneys shows bilateral supernumerary renal arteries (three on right, two on left). Figure 18-18 Single-detector computed tomographic images from ureteropelvic junction deformity in the right side of a horseshoe kidney. 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. Retrograde urogram shows a calculus in the left ureter. Surgery was successful and the surgeon confirmed the anatomic survey was correct. 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. 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. Each kidney should always be evaluated in long axis (coronal, sagittal, or both, depending on sonographic window) and axial to the kidney. Table 18-6 lists the most common causes of bilateral smooth renal atrophy. Recent advances in MDCT and MRI permit cross-sectional vascular studies to replace conventional angiography before UPJ repair (Fig. Chronic obstruction, however, results in damage to the papilla, evident in the clubbed calyx of papillary necrosis (Fig. Maintaining kidney health. Because the fascia of the retroperitoneum prevents significant extravasation, the incision usually heals to form a larger lumen. I would honestly say that Kenhub cut my study time in half. Retrograde urogram shows a calculus in the left ureter. Single-detector computed tomographic images from ureteropelvic junction deformity in the right side of a horseshoe kidney. aware of such a vessel, the urologist may choose to perform an alternate procedure to avoid hemorrhagic complications. 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. 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. 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. Each kidney has a single renal vein which conducts the blood out of the kidney and is positioned anterior to the artery. The region where the renal pelvis joins the ureter is called the ureteropelvic junction (UPJ). This can cause varicocele of the left testicle because gravity works against the column of the blood in the left testicular vein. Figure 25.1.2 Left Kidney. The kidneys are a pair of bean-shaped organs located below the rib cage, one on each side of the spine. The cortex of a normal kidney is usually less echogenic than the adjacent normal liver. Many clinical laboratories now provide computer-generated calculations of estimated creatinine clearance or eGFR using patient data in the medical information system. The renal fascia which besides the kidneys also encloses the suprarenal gland and its surrounding fat. The anterior surface of the left kidney, has the following anatomical relations: The posterior surfaces of both kidneys are related to certain neurovascular structures and muscles: You can easily remember these with the mnemonic: 1-2-3-4 All Boys Need Muscle. Anatomy Where is the renal cortex? Table 18-3 Utility of Different Phases of Renal Contrast Enhancement. The anteromedial, aspect of the interpolar region is interrupted by the renal hilum to make a C shape. 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. 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. In other cases, each renal unit has its own ureter. If the renal pelvis extends out of the renal sinus, it is considered to be an. Kidney cysts are round pouches of fluid that form on or in the kidneys. The anteromedial aspect of the interpolar region is interrupted by the renal hilum to make a C shape. Global insult to one kidney may result in unilateral atrophy that is uniform and smooth. The small portion of the lumen surrounding the papilla is called the calyx. 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. The Modification of Diet in Renal Disease (MDRD) is another method for estimating renal function that yields a value often called estimated glomerular filtration rate (eGFR). Anterior components of circumaortic vein can be small. 18-15). The ureters are the tubes that carry urine from the renal pelvis to the bladder. Most serum creatinine is excreted in the urine; therefore, if renal function is compromised, levels of creatinine in the serum increase. Extraaortic origin of the renal arteries and accessory renal arteries are common. Figure 18-25 Sagittal ultrasound image of the left kidney demonstrates a unilateral small, smooth, echogenic kidney in a patient with renal artery stenosis. Occasionally, a papilla will communicate directly with an infundibulum or the renal pelvis and is considered to be an aberrant papilla. At that point, you may experience these symptoms: Severe, sharp pain in the side and back, below the ribs. "Angio" indicates blood vessels, "myo" indicates muscle, and "lipoma" indicates fat. 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. 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. A, Axial image from contrast-enhanced computed tomography (CT) demonstrates an accessory right renal artery coursing anterior to the IVC. When echogenicity of the renal cortex equals that of the liver, renal function is abnormal in approximately 38% of cases. More tenuous vascular supply to the renal medulla makes it more susceptible to ischemia. Computed Tomographic Evaluation for Renal Failure, Magnetic Resonance Evaluation for Renal Failure. So in the filtered fluid that goes to the renal tubule, we have both necessary and unnecessary substances. 18-22). Pitfall: An extrarenal pelvis may be mistaken for hydronephrosis. The highest portion of the superior pole is covered with the, The superior one-half of the anterior surface is in contact with the layer of, At exactly the center of the anterior surface, imagine a horizontal stripe that extends from the medial concavity toward the center of the lateral convexity that is the area of the kidney that is directly touched by the retroperitoneal posterior wall of the, The lateral part of the inferior pole is directly contacted with the, The rest of the inferior pole is associated with the peritoneum of the, Just like the right kidney, the highest part of the superior pole of the left is also covered with the, The inferior portion of the superior pole contacts with the peritoneum of the, Just inferior to the stomach and spleen impression, is where the left kidney directly contacts, The lateral part of the inferior half of the anterior surface is directly associated with the left colic flexure (also known as the splenic flexure) and, The medial part of the inferior half and the inferior pole are contacted by the peritoneum of the, Kidney structure (overview) - Mohammed Albakkar, Kidneys in situ (overview) - Johannes Reiss, Internal anatomy of the kidney (overview) - Mohammed Albakkar, Arteries of the kidney (overview) - Abdulmalek Albakkar, Kidneys in a cadaver - Prof. Carlos Surez-Quian. D, If pressure on the papilla persists, the ischemic papilla undergoes necrosis, allowing the calyx to protrude outward toward the cortex. Most radiologists consider 10 to 12 cm to be an approximate reference range for renal length in adults, allowing for an additional 1 cm in either direction for patients at the extremes of height. Estimated creatinine clearance may be calculated using serum creatinine with adjustments made for sex, age, and body weight. Ultrasound is usually used in the initial evaluation of the patient with newly diagnosed renal failure. IVC, Inferior vena cava. Read more. development and contrast excretion parallel those seen on contrast-enhanced CT with one notable exception (Fig. 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 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. The anterior surface faces towards the anterior abdominal wall, whereas the posterior surface is facing the posterior abdominal wall. Figure 18-6 Frontal image of the left kidney from an intravenous urogram demonstrating an aberrant renal papilla in the lower pole infundibulum. 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. In this case, the right kidney had more favorable anatomy for laparoscopic donor nephrectomy. Technetium 99m dimercaptosuccinic acid (DMSA) and glucoheptonate (GHA) are both used for evaluation of renal parenchyma. Three-dimensional volume rendering from contrast-enhanced multidetector computed tomography examination of the kidneys demonstrates typical orientation of a horseshoe kidney. The information we provide is grounded on academic literature and peer-reviewed research. Now lets pay attention to the borders of the kidneys. 18-28). Figure 18-17 Coronal maximum intensity projection image from a contrast-enhanced computed tomographic scan demonstrates a dilated and tortuous lumbar veins joining the left renal vein. When the renal arteries enter the kidney through the hilum, they split into anterior and posterior branches. 18-4). 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. 18-8). 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. Typically, one kidney sits on either side of your spine. 18-20). For that reason, we got you covered with this topic nicely and concisely. Last reviewed: December 28, 2022 When simple kidney cysts do cause symptoms, they might include: Pain in the side between the ribs and hip, stomach or back. Frequent urination (having to go the bathroom often). Serum creatinine, however, is dependent not only on its disposal but also its production. Ultrastructurally, the nephron is the functional representative of the kidney. Renal cysts are sacs of fluid that form in the kidneys. 18-19). Note that the left renal vein receives blood from the left suprarenal and left testicular veins. The right kidney has a normal appearance (not shown). In most cases, the kidneys are situated with the inferior poles slightly. Medullary cystic disease is encountered only rarely, and in addition to the echogenic atrophic cortex, the medullary pyramids are particularly hypoechoic. Unenhanced MRI can also be used to diagnose obstruction and identify the source (Fig. B, Axial CT image from a different patient demonstrates the more common location of the right renal artery posterior to the IVC. In some cases, two separate kidneys drain into a bifid renal pelvis, ultimately drained by a common ureter. Read More Created for people with ongoing healthcare needs but benefits everyone. A furosemide challenge is often administered after initial excretion is observed to measure the impact of diuresis on the clearance of radiotracer from the renal pelvis. Each pyramid creates urine and terminates into a renal papilla. When abnormal echogenicity is detected, it is important to note whether it is unilateral or bilateral. This significantly affects the testicle, since an obstruction of drainage causes an obstruction of fresh arterial blood inflow, which can result in the infarction of testicular tissue. On the superior aspect of each kidney is the adrenal gland. A second similar finely granular mass was present in the interpolar region, and it also contained . 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. Reviewer: There is no specific treatment for fused kidneys and the only option is to treat the pathologies that affect them during life. 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