Extraaortic origin of the renal arteries and accessory renal arteries are common. Unenhanced CT can identify hydronephrosis and hydroureter, urinary stones, and some masses. 18-4). 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. 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. 18-28). Note that retroaortic components are usually near the inferior poles (Fig. The anteromedial, aspect of the interpolar region is interrupted by the renal hilum to make a C shape. Table 18-3 Utility of Different Phases of Renal Contrast Enhancement. 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. You can test yourself on the renal arteries with our quiz. Retrograde urogram shows a calculus in the left ureter. 18-23). Solid masses are more likely to be cancerous but they are not all cancerous. Ultrasound performed for acute renal failure demonstrates bilateral hydronephrosis caused by a bladder tumor. Internal Anatomy. CT angiography is occasionally performed when a vascular causative factor is suspected (renal artery stenosis or renal vein thrombosis) and MRI is contraindicated. Identify abnormal course of main or accessory right renal artery anterior rather than posterior to inferior vena cava (Fig. Thus, an AML is a tumor that contains these 3 components. 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). However, T1-weighted images provide good corticomedullary differentiation. 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. Any excessive amount of fluid will increase the pressure on the arterial wall and cause the blood pressure to rise (hypertension). Last reviewed: December 28, 2022 Now lets pay attention to the borders of the kidneys. 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. print Print this Article They extend from lumbar vertebra T12-L3. 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 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). 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. The large left proximal ureteral stone seen in this image is only partially obstructing, causing mild dilation in the left kidney collecting system. Volume rendering from a computed tomographic scan of the kidneys shows bilateral supernumerary renal arteries (three on right, two on left). Note distance from origin to the first arterial division (Fig. On ultrasound, the renal cortex is usually echogenic in this setting. 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. 18-5). The cortex of a normal kidney is usually less echogenic than the adjacent normal liver. The medulla is the inner region of the parenchyma of the kidney. Supernumerary kidneys are quite rare and have been associated with aortic coarctation, vaginal atresia, and urethral duplications. Enlargement of a congenitally unilateral kidney is typical and presumed to be compensatory. Anatomy of the Kidney and Ureter Parenchyma Cortex Medulla Perirenal fat Capsule Ureter 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. 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. The superior half of each kidney is covered by the diaphragm, which is why the kidneys move up and down during respiration. Always include unenhanced computed tomographic images to look for renal stones. Sagittal ultrasound image of the left kidney demonstrates a unilateral small, smooth, echogenic kidney in a patient with renal artery stenosis. Renal Cysts. When fused, the condition is described as crossed fused ectopia. Kidneys have a special system for the excretion of hydrogen ions, and in that way consistently maintain the pH of blood at 7.4. Each end of the kidney is commonly called a pole. The left kidney measured 7.8 cm, and the right kidney measured 10.9 cm. IVC, Inferior vena cava. Urine that is concentrated in the renal papilla is subsequently excreted into a lumen lined with transitional epithelium. So in the filtered fluid that goes to the renal tubule, we have both necessary and unnecessary substances. 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. Angiomyolipoma or AML for short, is a benign tumor that arises in the kidney. 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. Table 18-5 Checklist Approach to Ultrasound for Renal Failure. A. Junctional cortical line seen on a long-axis ultrasound image of the right kidney. Figure 18-5 Illustration demonstrating the anatomy of the renal collecting system. In other cases, each renal unit has its own ureter. 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 ureters are the tubes that carry urine from the renal pelvis to the bladder. B, Mild hydronephrosis results in rounding of the fornices with mild shortening of the papillary impression. Causes. A frontal section through the kidney reveals an outer region called the renal cortex and an inner region called the medulla. a bifid renal pelvis, ultimately drained by a common ureter. 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. 18-1). An acute change in renal cortical echogenicity is occasionally seen with pyelonehritis. Renal size can be measured in several ways. They are staged the same way as the renal pelvis. urinary system quizzes and labeled diagrams. 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. The anteromedial aspect of the interpolar region is interrupted by the renal hilum to make a C shape. Read more. In this region, the anterior and posterior hilar lip is identified (Fig. Reading time: 23 minutes. If the renal pelvis extends out of the renal sinus, it is considered to be an. Chronic obstruction, however, results in damage to the papilla, evident in the clubbed calyx of papillary necrosis (Fig. This kidney measured 14 cm in length. 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. 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. 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. Created for people with ongoing healthcare needs but benefits everyone. The renal cortex and medulla both have high signal intensity on T2-weighted images resulting in poor corticomedullary differentiation. Figure 18-6 Frontal image of the left kidney from an intravenous urogram demonstrating an aberrant renal papilla in the lower pole infundibulum. 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. A frontal section through the kidney reveals an outer region called the renal cortex and an inner region called the renal medulla (Figure 25.1.2). The isthmus connecting the kidneys is variable, ranging from normal renal cortex to a thin fibrous band. They are branches of the abdominal aorta and all together are called the extrahilar renal arteries. Duplication of the urinary tract is discussed in detail in Chapter 19. 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. Axial images from contrast-enhanced computed tomography demonstrate transient enhancement of a small renal cell carcinoma. A simple calyx receives urine from a single papilla; a compound calyx receives urine from multiple papillae (Fig. Table 18-7 Causes of Unilateral Small Smooth Kidney, Only gold members can continue reading. It protects your kidneys from injury, increases their stability and connects your kidneys to surrounding tissues. 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. The minor calyces unite to form a major calyx. AMLs can bleed and while not cancerous are still taken very seriously. Most serum creatinine is excreted in the urine; therefore, if renal function is compromised, levels of creatinine in the serum increase. However, you may have symptoms related to the condition that's causing it. 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. 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. Radiologists divide the kidney into three parts: the upper pole, lower pole, and the interpole (whi. Luckily, the kidneys also feel this increase of pressure, and in cases when this happens, they increase the filtration rate of blood and production of urine, which subsequently leads to the increase fluid excretion and decrease of blood pressure. The normal appearance of the calyx is created by the impression of the renal papilla. RENAL ANATOMY Renal Parenchyma The kidneys can be divided into three main regions from cranial to caudal. 18-25). Bilateral echogenic kidneys with renal hypertrophy can be seen associated with human immunodeficiency virus disease (see Fig. This is called the nutcracker phenomenon. When simple kidney cysts do cause symptoms, they might include: Pain in the side between the ribs and hip, stomach or back. Creatinine is a breakdown product of creatine, found within muscle. Because they rarely cause symptoms, renal cysts are most often found during . 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. The left artery has a short way to the left kidney, whereas the right has to go behind the inferior vena cava in order to reach the right kidney. Chronic glomerulonephritis usually causes bilateral increased renal echogenicity with smooth atrophy, whereas renal artery stenosis usually causes a similar but unilateral appearance (Fig. 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. The shape of the calyx is formed by the impression of the renal papilla. Horseshoe kidneys result from midline fusion of the kidneys, typically at the level of the origin of the inferior mesenteric artery. Ultrasound can often identify the cause in cases of bilateral obstruction (Fig. 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. Look carefully for accessory arteries at upper and lower poles (Fig. Illustration demonstrating basic intrarenal arterial anatomy. If the renal pelvis extends out of the renal sinus, it is considered to be an extrarenal pelvis (Fig. It is also permeable for the products of the metabolism, such are creatinine and drug metabolites. more lateral and anterior than the superior poles. Since they are located deep retroperitoneally, the easiest way to examine them is from the patients back. Thus, the ureter is seen paravertebrally starting from the L2 and going downwards. development and contrast excretion parallel those seen on contrast-enhanced CT with one notable exception (Fig. 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. The muscular relations of the inferior half are easy to remember by dividing the kidney surface into three vertical stripes, where the medial stripe represents the impression of the psoas major muscle, the central stripe the quadratus lumborum, and the lateral stripe the transversus abdominis muscle. 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. Frontal image of the left kidney from an intravenous urogram demonstrating an aberrant renal papilla in the lower pole infundibulum. The renal cortex is part of your kidney, which itself is part of the urinary tract. 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. 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. Blood in the urine, or dark urine. 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. Retrograde urogram shows a calculus in the left ureter. (Courtesy of Karl T. Rew, MD) Introduction Synonyms Epidemiology Medullary cystic disease is encountered only rarely, and in addition to the echogenic atrophic cortex, the medullary pyramids are particularly hypoechoic. Surgery was successful and the surgeon confirmed the anatomic survey was correct. B, Low-attenuation lesion in the late nephrographic/early excretory phase is less suspicious in appearance. Read More Created for people with ongoing healthcare needs but benefits everyone. Kim Bengochea, Regis University, Denver. 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. As the lobules of metanephric blastema coalesce to form each kidney, they do not always result in a smooth, uniform band of cortex. Differential diagnosis General imaging considerations include: renal cortical defect duplex kidney and parenchymal mass without the risks for nephrotoxicity associated with iodinated contrast media or nephrogenic systemic fibrosis associated with gadolinium contrast agents. Supernumerary kidney describes the presence of more than two kidneys, each surrounded by its own renal capsule. Because the fascia of the retroperitoneum prevents significant extravasation, the incision usually heals to form a larger lumen. 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. 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. Living renal donor allografts account for more than half of the transplanted kidneys in the United States. 18-11). The cortex of a normal kidney is usually less echogenic than the adjacent normal liver. Crossed ectopia can be either fused or unfused. Some tumors can be slow to grow while some can be aggressive. Hypotension is a stimulus for the kidneys to increase the retention of fluid and thus increase blood pressure. IVC, Inferior vena cava. The nephrons within the cortex comprise some of the most highly perfused parenchymal tissue in the body. The calyces, however, will have a normal appearance with an unobstructed extrarenal pelvis but will be dilated in cases of urinary obstruction. Some divide the excretory phase into the early excretory phase (contrast mainly confined to the kidney) and late excretory phase (contrast in the ureters). Because the fascia of the retroperitoneum prevents significant extravasation, the incision usually heals to form a larger lumen. Kidney cysts can occur with disorders that may impair kidney function. 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. Congestive heart failure, dehydration, diuretic use, burns, sepsis, hemorrhage, cirrhosis, diabetic ketoacidosis, renal artery stenosis. 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). Table 18-7 lists causes of unilateral smooth renal atrophy. Obstruction can cause renal failure if it is bilateral (Box 18-3) or if there is preexisting disease in the unobstructed kidney. BOX 18-2 Crossing Vessels in Ureteropelvic Junction Obstruction. An increased amount of hydrogen ions can acidify the blood and cause a state called acidosis. However, sometimes ureteroscopy is required to confirm the diagnosis in patients with hematuria. The vascularity of some tumors may be most apparent during this phase (Fig. 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. This illustrates the amount of reserve function that must be compromised before renal injury can be detected with a serum creatinine level. Figure 18-11 Three-dimensional volume rendering from contrast-enhanced multidetector computed tomography examination of the kidneys demonstrates typical orientation of a horseshoe kidney. Aggressive tumors form, grow and spread very quickly. The right kidney has a normal appearance (not shown). Some of them are congenital, such as a third kidney, which is usually atrophic. 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. The main unit of the medulla is the renal pyramid. Table 18-1 provides a quick guide itemizing key imaging findings in the potential renal donor. Jana Vaskovi MD 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. Anatomy Where is the renal cortex? A second similar finely granular mass was present in the interpolar region, and it also contained . 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. Figure 25.1.2 Left Kidney. MR angiography can be useful for the diagnosis of renal vascular abnormalities. The kidney is a very important organ in regards to body homeostasis. The kidneys are a pair of bean-shaped organs located below the rib cage, one on each side of the spine. And while not cancerous are still taken very seriously of hydrogen ions acidify. Supernumerary renal arteries and accessory renal arteries ( three on right, two on left ) impression of parenchyma... Each side of the inferior poles ( Fig abdominal aorta and all together called... Tomography demonstrate transient Enhancement of a congenitally unilateral kidney is usually atrophic consistently maintain the pH blood. 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