Pearl: Any upward trend in serum creatinine value should be viewed with concern because it implies renal reserve function has already been affected. Other malfunctions of the kidney are presented through acute kidney failure, a serious and urgent medical condition. The kidneys are located between the transverse processes of T12-L3 vertebrae, with the left kidney typically positioned slightly more superiorly than the right. 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 patient had right flank pain but had a solitary calcification in the left pelvis on plain radiograph (not shown). Differential diagnosis General imaging considerations include: renal cortical defect duplex kidney Aggressive tumors form, grow and spread very quickly. Other symptoms can include abnormal urine color, blood in your urine, fever, chills, nausea, and vomiting. 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). Sagittal ultrasound image of the right kidney demonstrates increased size and echogenicity of the kidney, findings typical of human immunodeficiency virus nephropathy. Renal size and cortical thickness can be assessed in a manner similar to ultrasound. Kidneys are located just below your ribcage and behind your belly. A frontal section through the kidney reveals an outer region called the renal cortex and an inner region called the medulla. Blood in the urine, or dark urine. Figure 18-8 Junctional cortical line seen on a long-axis ultrasound image of the right kidney. 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. 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. Figure 18-5 Illustration demonstrating the anatomy of the renal collecting system. Table 18-6 lists the most common causes of bilateral smooth renal atrophy. The kidneys are reddish-brown, bean-shaped organs situated retroperitoneal on the posterior abdominal wall. B, A curved planar reformation of the crossing vein demonstrates its course. The ureters are the tubes that carry urine from the renal pelvis to the bladder. Pitfall: An extrarenal pelvis may be mistaken for hydronephrosis. A, Axial image from contrast-enhanced computed tomography (CT) demonstrates an accessory right renal artery coursing anterior to the IVC. However, this individual is more likely to show a decline in renal function from an additional insult. The anteromedial aspect of the interpolar region is interrupted by the renal hilum to make a C shape. 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. 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. Retrograde urogram shows a calculus in the left ureter. Coronal maximum intensity projection image from a contrast-enhanced computed tomographic scan demonstrates a dilated and tortuous lumbar veins joining the left renal vein. Entities for which sonography is most useful. 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. B, Transverse image of the bladder demonstrates a large bladder tumor in the region of the trigone. Jana Vaskovi MD 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. normal kidney size in adults normal kidney size in children Structure Size and Contour of Diffuse Renal Disease, 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, Global insult to one kidney may result in unilateral atrophy that is uniform and smooth. 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 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. 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. Arterial stenosis was confirmed by magnetic resonance angiography. This is why the kidney is essential for the circulatory hemostasis. Supernumerary kidneys are quite rare and have been associated with aortic coarctation, vaginal atresia, and urethral duplications. Cells in our body constantly produce hydrogen ions. The information we provide is grounded on academic literature and peer-reviewed research. Figure 18-16 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. Table 18-5 Checklist Approach to Ultrasound for Renal Failure. The kidneys are innervated by the renal plexus. Many clinical laboratories now provide computer-generated calculations of estimated creatinine clearance or eGFR using patient data in the medical information system. Ultrasound permits real-time optimization of imaging relative to the axis of each kidney. A, Axial image demonstrates the dilated renal pelvis and crossing vessel. Sometimes, one or both kidneys fail to develop, which causes unilateral or bilateral renal agenesis. Renal Cysts. Normal parenchymal enhancement on CT or MRI allows definitive characterization. The dynamics of obstruction and quantification of relative renal function between the two kidneys may be important considerations in two general circumstances: (1) it is unclear whether obstruction is severe enough to warrant surgical intervention; or (2) significant parenchymal atrophy exists, and the relative merits of repair and nephrectomy are being compared. Renal scintigraphy can be performed with a variety of agents to provide assessment of either function or structure of the kidneys. 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. Crossed ectopia can be either fused or unfused. Kim Bengochea, Regis University, Denver. 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. If the renal pelvis extends out of the renal sinus, it is considered to be an. The relation between the UPJ and vascular anatomy can be quite complex. Renal cysts are sacs of fluid that form in the kidneys. Size disparity greater than 1.5 cm between kidneys should raise suspicion that one kidney is abnormal. All content published on Kenhub is reviewed by medical and anatomy experts. 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. Coronal computed tomographic image in the corticomedullary phase shows normal corticomedullary differentiation along the lobulated contour, consistent with fetal lobulation. The nephrons within the cortex comprise some of the most highly perfused parenchymal tissue in the body. Computed Tomographic Evaluation for Renal Failure, Magnetic Resonance Evaluation for Renal Failure. Renal artery Unenhanced MRI can also be used to diagnose obstruction and identify the source (Fig. Identify abnormal course of main or accessory right renal artery anterior rather than posterior to inferior vena cava (Fig. At that point, you may experience these symptoms: Severe, sharp pain in the side and back, below the ribs. Surgery was successful and the surgeon confirmed the anatomic survey was correct. Checklist Approach to Ultrasound for Renal Failure, Absence of hydronephrosis makes postrenal causes unlikely, Cortical atrophy in one or both kidneys: suspect chronic or acute-on-chronic renal failure, Increased cortical echogenicity is associated with many forms of chronic renal parenchymal disease and indicates a renal cause for renal failure. Pain that radiates to the lower abdomen and groin. 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. The normal appearance of the calyx is created by the impression of the renal papilla. The main parts of your kidney anatomy include: Kidney capsule (renal capsule) The renal capsule consists of three layers of connective tissue or fat that cover your kidneys. 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. Reviewer: The patient had acute renal failure; therefore, contrast-enhanced CT was not performed. Also, in situations with notable blood losses, kidneys release a hormone called erythropoietin, which stimulates bone marrow to produce more blood cells. 18-25). 18-26). The kidneys are bilateral organs placed retroperitoneally in the upper left and right abdominal quadrants and are part of the urinary system. On the other hand, the products of cellular metabolism and drug metabolites are eliminated from the blood which prevents their depositing in the body and potential toxicity. 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). Of course, if the situation is the other way around (less than 5 liters of blood), blood pressure is too low (hypotension). The ureter and calyces were not dilated (not shown), helping to differentiate this anatomic variant from obstruction. Figure 18-23 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. Clinical significance [ edit] But more often, kidney cysts are a type called simple kidney cysts. The ureter and calyces were not dilated (not shown), helping to differentiate this anatomic variant from obstruction. Look carefully for accessory arteries at upper and lower poles (Fig. Renal cysts become fairly common as people age and usually do not cause symptoms or harm. They extend from lumbar vertebra T12-L3. It protects your kidneys from injury, increases their stability and connects your kidneys to surrounding tissues. The kidney also has endocrine functions, helping to control blood pressure, bone mineralization, and erythrocyte production. Figure 25.1.2 Left Kidney. Figure 18-21 Axial images from contrast-enhanced computed tomography demonstrate transient enhancement of a small renal cell carcinoma. Sagittal ultrasound image of the left kidney demonstrates a unilateral small, smooth, echogenic kidney in a patient with renal artery stenosis. Right-sided pain was related to crossed renal ectopia. It is important to note, however, that the appearance of hydronephrosis does not necessarily indicate urinary obstruction (see Hydronephrosis and Its Mimics section later in this chapter). The medulla consists of multiple pyramidal tissue masses, called the renal pyramids, which are triangle structures that contain a dense network of nephrons. 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. A. Junctional cortical line seen on a long-axis ultrasound image of the right kidney. It is important to remember this order of vessels and ducts since this is the only thing that will make you able to orient the kidney and differentiate the left one from the right when they are outside of the cadaver. 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. 18-11). The solid renal parenchyma consists of the peripheral renal cortex and more central renal medulla. 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. Renal size can be measured in several ways. They are branches of the abdominal aorta and all together are called the extrahilar renal arteries. Figure 18-18 Single-detector computed tomographic images from ureteropelvic junction deformity in the right side of a horseshoe kidney. Figure 18-6 Frontal image of the left kidney from an intravenous urogram demonstrating an aberrant renal papilla in the lower pole infundibulum. Chronic obstruction, however, results in damage to the papilla, evident in the clubbed calyx of papillary necrosis (Fig. The superior half of each kidney is covered by the diaphragm, which is why the kidneys move up and down during respiration. 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. 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. Technetium 99m dimercaptosuccinic acid (DMSA) and glucoheptonate (GHA) are both used for evaluation of renal parenchyma. 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. 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 calcium or uric acid will precipitate and form stones. 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. When the renal arteries enter the kidney through the hilum, they split into anterior and posterior branches. 18-5). Renal scintigraphy can be performed with a variety of agents to provide assessment of either function or structure of the kidneys. 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. The cortex of a normal kidney is usually less echogenic than the adjacent normal liver. In some cases, two separate kidneys drain into a bifid renal pelvis, ultimately drained by a common ureter. Look for retroaortic or circumaortic left renal vein. Each end of the kidney is commonly called a pole. Best, Susan. print Print this Article Recent advances in MDCT and MRI permit cross-sectional vascular studies to replace conventional angiography before UPJ repair (Fig. An acute change in renal cortical echogenicity is occasionally seen with pyelonehritis. Advantages of scintigraphy include accurate quantitative measurement of function. This phenomenon is due to T2-shortening and susceptibility (T2*) effects caused by concentrated gadolinium, and can potentially obscure filling defects and urothelial lesions. Obstruction can cause renal failure if it is bilateral (Box 18-3) or if there is preexisting disease in the unobstructed kidney. Internal Anatomy. The minor calyces unite to form a major calyx. Static-fluid (T2-weighted) MR urography and phase-contrast MR angiography are useful techniques that do not require intravenous contrast material. On the superior aspect of each kidney is the adrenal gland. A healthy individual who donates a kidney is likely to maintain a normal serum creatinine despite the loss of 50% of parenchymal tissue. 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. This specific condition is called the nutcracker phenomenon. 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. The medulla is the inner region of the parenchyma of the kidney. BOX 18-3 Causes of Bilateral Hydronephrosis. Bilateral echogenic kidneys with renal hypertrophy can be seen associated with human immunodeficiency virus disease (see Fig. impression is preserved. It doesn't have to be that way. Bone scan and chest x-ray to find out if the cancer has spread. 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. 18-19). Let's see what is nephron and how it is structured,so you can remember it for good. 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). The right kidney has a normal appearance (not shown). It is notable that the kidney has a very rich blood supply. 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 phases of nephrogram development and contrast excretion parallel those seen on contrast-enhanced CT with one notable exception (Fig. The renal pelvis then tapers like a funnel to join the ureter. The renal veins empty to the inferior vena cava, so the right vein is shorter because the inferior vena cava runs closer to the right kidney. When this happens, the stones can block the flow of urine out of your kidneys. Log In or, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), Estimated Creatinine Clearance and Glomerular Filtration Rate, Cockroft and Gault Equation for Calculating Estimated Creatinine Clearance, The Modification of Diet in Renal Disease (MDRD) is another method for estimating renal function that yields a value often called, The kidneys can be divided into three main regions from cranial to caudal. This kidney measured 14 cm in length. Learn how we can help 1.2k views Reviewed Dec 09, 2022 Thank Now that weve mastered the borders, it will be easier to take a closer look at the anatomical relations that the kidneys share with other abdominal structures. Chronic obstruction, however, results in damage to the papilla, evident in the clubbed calyx of papillary necrosis (Fig. 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. 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. 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. Kenhub. 18-19). The MDRD calculation is more complicated than calculating creatinine clearance (taking into account body surface area, sex, and race) but is thought to be more accurate than estimated creatinine clearance, particularly among the elderly and obese. This can cause varicocele of the left testicle because gravity works against the column of the blood in the left testicular vein. This kidney measured 14 cm in length. 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. 18-20). 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 left kidney measured 7.8 cm, and the right kidney measured 10.9 cm. In cases of unilateral obstruction with acute renal failure, sonographic evaluation may show evidence of chronic renal parenchymal disease in the unobstructed kidney. Size disparity greater than 1.5 cm between kidneys should raise suspicion that one kidney is abnormal. The presence of significant renal parenchyma may justify surgical repair to maximize the functional contribution of that kidney. The lateral border is directed towards the periphery, while the medial border is the one directed towards the midline. Table 18-7 Causes of Unilateral Small Smooth Kidney, Only gold members can continue reading. The anteromedial, aspect of the interpolar region is interrupted by the renal hilum to make a C shape. B, Mild hydronephrosis results in rounding of the fornices with mild shortening of the papillary impression. The parenchyma of the kidney consists of the outer renal cortex, and inner renal medulla. Since they are located deep retroperitoneally, the easiest way to examine them is from the patients back. Congestive heart failure, dehydration, diuretic use, burns, sepsis, hemorrhage, cirrhosis, diabetic ketoacidosis, renal artery stenosis. Figure 18-3 Illustration demonstrating basic intrarenal arterial anatomy. Table 18-6 Causes of Bilateral Small Smooth Kidneys. Radiologists divide the kidney into three parts: the upper pole, lower pole, and the interpole (which is in between them). The kidneys can be divided into three main regions from cranial to caudal. However, small, low-attenuation lesions in the medulla are often obscured during this phase. 18-1). 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 normal appearance of the calyx is created by the impression of the renal papilla. In other cases, each renal unit has its own ureter. CT scan and MRI to help diagnose and stage kidney masses. Learning anatomy is a massive undertaking, and we're here to help you pass with flying colours. The superior poles (extremities) (T12) of both kidneys are more medially pointed towards the spine than the inferior poles (extremities) (L3). 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. 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. The main unit of the medulla is the renal pyramid. Internal Anatomy. For most people, obstruction of a single ureter does not induce renal failure. Anatomy Where is the renal cortex? 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. 18-7). Alternatively, the anterior to posterior orientation follows the same pattern: renal vein, renal artery and ureter. Caliectasis doesn't cause any symptoms on its own. Each pyramid creates urine and terminates into a renal papilla. At one end of each nephron, in the cortex of the kidney, is a cup-shaped structure called the Bowman's capsule. One of the most commonly used (and least complicated) equations is shown in Box 18-1. 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 left kidney (not shown) had a similar appearance. Read more. Reading time: 23 minutes. Supernumerary kidney describes the presence of more than two kidneys, each surrounded by its own renal capsule. normal kidney size in adults normal kidney size in children Structure Note diameter of arteries because small accessory arteries may be sacrificed in many cases. 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. Since the abdominal organs are not paired, the left kidney is not related to the same organs as the right kidney. 18-4). 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. Note number of veins by inspecting inferior vena cava along entire length of kidney. Made. 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 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. Relation between the right renal artery and the inferior vena cava (IVC). Serum creatinine, however, is dependent not only on its disposal but also its production. This phenomenon is due to T2-shortening and susceptibility (T2*) effects caused by concentrated gadolinium, and can potentially obscure filling defects and urothelial lesions. 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 (. 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. Now lets pay attention to the borders of the kidneys. The phases of nephrogram. Ultrasound It can be seen as a triangular echogenic cortical defect, frequently seen in upper lobe parenchyma. The kidneys have two functional areas that are managed and staged independently, the kidney parenchyma and the renal pelvis. Ultrasound performed for acute renal failure demonstrates bilateral hydronephrosis caused by a bladder tumor. 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. Figure 18-24 Normal magnetic resonance imaging appearance of the kidneys. Because the interlobular arteries form an arch overlying the pyramid, they are called the. BOX 18-1 Cockroft and Gault Equation for Calculating Estimated Creatinine Clearance. 18-27). Some tumors can be slow to grow while some can be aggressive. For most people, obstruction of a single ureter does not induce renal failure. Figure 18-2 Annotated axial image of the right kidney from a contrast-enhanced computed tomographic scan demonstrates hilar anatomy of the kidney. Organs are not paired, the anterior to the papilla, evident in the unobstructed kidney of chronic renal disease... Surgery was successful and the right kidney tomographic images from ureteropelvic junction in... Medial border is directed towards the interpolar region of kidney anatomy UPJ repair ( Fig on posterior. 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