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. 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). 18-23). Imaging must provide detailed images of the renal parenchyma and a survey of arterial, venous, and ureteral anatomy. In some cases, two separate kidneys drain into a bifid renal pelvis, ultimately drained by a common ureter. 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. 18-2). Renal scintigraphy can be performed with a variety of agents to provide assessment of either function or structure of the kidneys. The patient had right flank pain but had a solitary calcification in the left pelvis on plain radiograph (not shown). Anterior components of circumaortic vein can be small. Occasionally, a papilla will communicate directly with an infundibulum or the renal pelvis and is considered to be an aberrant papilla. Learn how we can help 1.2k views Reviewed Dec 09, 2022 Thank Dr. Frank Kuitems and 4 doctors agree 3 thanks The anteromedial aspect of the interpolar region is interrupted by the renal hilum to make a C shape. 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 phenomenon is due to T2-shortening and susceptibility (T2*) effects caused by concentrated gadolinium, and can potentially obscure filling defects and urothelial lesions. 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. Figure 18-15 Relation between the right renal artery and the inferior vena cava (IVC). Some of them are congenital, such as a third kidney, which is usually atrophic. The presence of significant renal parenchyma may justify surgical repair to maximize the functional contribution of that kidney. This can cause varicocele of the left testicle because gravity works against the column of the blood in the left testicular vein. Because the interlobular arteries form an arch overlying the pyramid, they are called the. Global insult to one kidney may result in unilateral atrophy that is uniform and smooth. Several calyces drain into each infundibulum, an elongated transition from the polygonal calyces to the saclike renal pelvis. These are chronic processes that lead to a loss of renal cortex gradually and uniformly. 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 ureter and calyces were not dilated (not shown), helping to differentiate this anatomic variant from obstruction. The initiation is caused by the increase in volume that stretches the walls of the calyces. Coronal computed tomographic image in the corticomedullary phase shows normal corticomedullary differentiation along the lobulated contour, consistent with fetal lobulation. Chronic obstruction, however, results in damage to the papilla, evident in the clubbed calyx of papillary necrosis (Fig. When abnormal echogenicity is detected, it is important to note whether it is unilateral or bilateral. The small portion of the lumen surrounding the papilla is called the. 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. Differential diagnosis General imaging considerations include: renal cortical defect duplex kidney Thus, an AML is a tumor that contains these 3 components. Because they rarely cause symptoms, renal cysts are most often found during . 18-18). The adrenal cortex directly influences renal function through the production of the hormone aldosterone to stimulate sodium reabsorption. The goal of imaging patients with renal failure is to identify a correctable cause in an effort to recover or preserve renal function. Axial image of the left kidney from a contrast-enhanced computed tomographic scan demonstrates an extrarenal pelvis. 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 calcium or uric acid will precipitate and form stones. The causes of renal failure can be categorized as prerenal, renal, and postrenal (Table 18-4). 18-12). The kidneys are located between the transverse processes of T12-L3 vertebrae, with the left kidney typically positioned slightly more superiorly than the right. normal kidney size in adults normal kidney size in children Structure Box 18-2 provides some tips regarding crossing vessels in UPJ obstruction. Figure 18-9 Coronal computed tomographic image in the corticomedullary phase shows normal corticomedullary differentiation along the lobulated contour, consistent with fetal lobulation. Illustration demonstrating the anatomy of the renal collecting system. Sagittal ultrasound image of the left kidney demonstrates a unilateral small, smooth, echogenic kidney in a patient with renal artery stenosis. Look for duplication, large extrarenal pelvis. This is why the kidney is essential for the circulatory hemostasis. Table 18-2 Association between Renal Cortical Echogenicity and Renal Parenchymal Disease. Ultrasound can often identify the cause in cases of bilateral obstruction (Fig. When simple kidney cysts do cause symptoms, they might include: Pain in the side between the ribs and hip, stomach or back. 18-22). Differential diagnosis General imaging considerations include: renal cortical defect duplex kidney 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. While migrating superiorly, the kidneys rotate medially along their long axes and the inferior supplying mesonephric arteries degenerate. The small portion of the lumen surrounding the papilla is called the calyx. 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. Each kidney should always be evaluated in long axis (coronal, sagittal, or both, depending on sonographic window) and axial to the kidney. The early excretory phase begins as early as 120 seconds after injection. 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. Note diameter of arteries because small accessory arteries may be sacrificed in many cases. Figure 18-8 Junctional cortical line seen on a long-axis ultrasound image of the right kidney. A, Enhancement of the mass is conspicuous in the corticomedullary phase. 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. Table 18-7 Causes of Unilateral Small Smooth Kidney, Only gold members can continue reading. The kidneys are reddish-brown, bean-shaped organs situated retroperitoneal on the posterior abdominal wall. 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. So in the filtered fluid that goes to the renal tubule, we have both necessary and unnecessary substances. Made aware of such a vessel, the urologist may choose to perform an alternate procedure to avoid hemorrhagic complications. The phases of nephrogram development and contrast excretion parallel those seen on contrast-enhanced CT with one notable exception (Fig. The main unit of the medulla is the renal pyramid. The fused kidneys can have a variety of orientations, including side by side, in-line, or perpendicular. When hydronephrosis is absent, the causative factor for acute renal failure is almost certainly prerenal or renal. Diagnostic ultrasound uses sound wave technology to look at parts of your body, including: Brain Heart and blood vessels Breast Abdominal Organs Eyes Thyroid Skin and muscles Types of Ultrasound. Causes. Identify abnormal course of main or accessory right renal artery anterior rather than posterior to inferior vena cava (Fig. Figure 18-3 Illustration demonstrating basic intrarenal arterial anatomy. 2023 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. Since the abdominal organs are not paired, the left kidney is not related to the same organs as the right kidney. C, More severe hydronephrosis results in more pronounced shortening of the papilla. Serum creatinine, however, is dependent not only on its disposal but also its production. Renal artery 18-28). 18-10). Figure 18-14 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. It is also permeable for the products of the metabolism, such are creatinine and drug metabolites. B, Transverse image of the bladder demonstrates a large bladder tumor in the region of the trigone. 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. Kim Bengochea, Regis University, Denver. Figure 18-21 Axial images from contrast-enhanced computed tomography demonstrate transient enhancement of a small renal cell carcinoma. In other cases, both kidneys can be fused, usually at the inferior poles, which is a congenital state called the horseshoe kidney. 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. The superior half of each kidney is covered by the diaphragm, which is why the kidneys move up and down during respiration. 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. 18-3). In cases of unilateral obstruction with acute renal failure, sonographic evaluation may show evidence of chronic renal parenchymal disease in the unobstructed kidney. In most kidneys, the renal hilum faces more anteromedial in the upper half of the kidney and more directly medial in the lower half. A. Junctional cortical line seen on a long-axis ultrasound image of the right kidney. 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). Size disparity greater than 1.5 cm between kidneys should raise suspicion that one kidney is abnormal. In this case, the right kidney had more favorable anatomy for laparoscopic donor nephrectomy. This method is the standard in evaluation of UPJ obstruction and often is used for other types of chronic obstruction. 18-8). Normal parenchymal enhancement on CT or MRI allows definitive characterization. Figure 18-24 Normal magnetic resonance imaging appearance of the kidneys. The kidneys help remove waste products from the . These kidney functions can sure seem overwhelming, especially if you have to memorise them! The cortex of a normal kidney is usually less echogenic than the adjacent normal liver. a bifid renal pelvis, ultimately drained by a common ureter. In most cases, the kidneys are situated with the inferior poles slightly. Kidneys have a special system for the excretion of hydrogen ions, and in that way consistently maintain the pH of blood at 7.4. 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. The renal corpuscle has two components: the glomerular (Bowmans) capsule in which sits the glomerulus. All rights reserved. If the renal pelvis extends out of the renal sinus, it is considered to be an. B, Mild hydronephrosis results in rounding of the fornices with mild shortening of the papillary impression. Each kidney should always be evaluated in long axis (coronal, sagittal, or both, depending on sonographic window) and axial to the kidney. In this way, the consistency of blood is preserved and no important substances are lost. Note that there is no contrast in the aorta. People with unilateral agenesis often are unaware that they lack one kidney until an accidental discovery, since the one kidney that they have is able to functionally compensate for the other. Several calyces drain into each infundibulum, an elongated transition from the polygonal calyces to the saclike renal pelvis. Cells in our body constantly produce hydrogen ions. 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. Dimitrios Mytilinaios MD, PhD Figure 18-4 Illustration demonstrating the relation between the renal papilla and calyx. The patient had right flank pain but had a solitary calcification in the left pelvis on plain radiograph (not shown). A simple calyx receives urine from a single papilla; a compound calyx receives urine from multiple papillae (Fig. B, A curved planar reformation of the crossing vein demonstrates its course. 18-1). 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. You can test yourself on the renal arteries with our quiz. A potential benefit of MRI is the lack of exposure to ionizing radiation, although unenhanced CT would still be required to detect stones (the presence of stones increases the donors risk for renal insufficiency later in life and could disqualify them as a donor candidate). When the renal arteries enter the kidney through the hilum, they split into anterior and posterior branches. Some centers use diuretics or fluid bolus, or both, during CT urography to dilute the excreted contrast to improve assessment of the urothelium. The kidneys can be divided into three main regions from cranial to caudal. 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. 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. The information we provide is grounded on academic literature and peer-reviewed research. 18-5). The cortex of a normal kidney is usually less echogenic than the adjacent normal liver. 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). 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 kidneys have two functional areas that are managed and staged independently, the kidney parenchyma and the renal pelvis. They are usually characterized as "simple" cysts, meaning they have a thin wall and contain water-like fluid. 18-26). Supernumerary kidneys are quite rare and have been associated with aortic coarctation, vaginal atresia, and urethral duplications. Ultrasound permits real-time optimization of imaging relative to the axis of each kidney. The kidney is a very important organ in regards to body homeostasis. 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). Solid masses are more likely to be cancerous but they are not all cancerous. Aggressive tumors form, grow and spread very quickly. When echogenicity of the renal cortex equals that of the liver, renal function is abnormal in approximately 38% of cases. B, The lesion becomes more conspicuous during the nephrographic phase. Because the fascia of the retroperitoneum prevents significant extravasation, the incision usually heals to form a larger lumen. Always include unenhanced computed tomographic images to look for renal stones. Best, Susan. Note that retroaortic components are usually near the inferior poles (Fig. In this region, the anterior and posterior hilar lip is identified (Fig. The renal cortex is part of your kidney, which itself is part of the urinary tract. 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. Pearl: Any upward trend in serum creatinine value should be viewed with concern because it implies renal reserve function has already been affected. Creatinine is a breakdown product of creatine, found within muscle. 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. Literature supports the use of either multidetector computed tomography (MDCT) or MRI in donor evaluation. This illustrates the amount of reserve function that must be compromised before renal injury can be detected with a serum creatinine level. 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. Sometimes, one or both kidneys fail to develop, which causes unilateral or bilateral renal agenesis. and parenchymal mass without the risks for nephrotoxicity associated with iodinated contrast media or nephrogenic systemic fibrosis associated with gadolinium contrast agents. 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. 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. Figure 18-10 Crossed ectopia on intravenous pyelogram. Crossed ectopia can be either fused or unfused. If this appearance were present bilaterally, chronic renal disease such as chronic glomerulonephritis would be a more likely explanation. Kenhub. For most people, obstruction of a single ureter does not induce renal failure. The posterior branch supplies the posterior part of the kidney, whereas the anterior branch arborizes into five segmental arteries, each supplying a different renal segment. 18-7). Renal scintigraphy can be performed with a variety of agents to provide assessment of either function or structure of the kidneys. Just remember ' A WET BED', which stands for: The kidneys have their anterior and posterior surfaces. 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. In general, the amount of blood in the body is 5 liters. 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 portion of the kidney between the poles is called the interpolar region and contains the renal hilum (Fig. 18-4). Other symptoms can include abnormal urine color, blood in your urine, fever, chills, nausea, and vomiting. The left kidney measured 7.8 cm, and the right kidney measured 10.9 cm. Advantages of scintigraphy include accurate quantitative measurement of function. The kidneys are innervated by the renal plexus. Because the fascia of the retroperitoneum prevents significant extravasation, the incision usually heals to form a larger lumen. 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. Orientations, including side by side, in-line, or perpendicular dilated ( not shown ), helping to this... Uric acid will precipitate and form stones with one notable exception ( Fig renal,! Renal injury can be performed with a serum creatinine, however, is dependent not on. To one kidney is essential for the excretion of hydrogen ions, and vomiting kidney may in! Long axes and the inferior poles slightly with concern because it implies reserve! Imaging appearance of the lumen surrounding the papilla this anatomic variant from obstruction resonance imaging appearance of renal. When echogenicity of the calyces just remember ' a WET BED ' which. Excretory phase begins as early as 120 seconds after injection inferior vena cava ( Fig and... Any upward trend in serum creatinine, however, results in rounding of calyces. The kidney between the poles is called the paired, the amount blood. Computed tomographic image in the region of the fornices with Mild shortening of the is! Members can continue reading renal sinus, it is considered to be an aberrant papilla are... Measured 10.9 cm ( MDCT ) or MRI allows definitive characterization they have a special system the., a papilla will communicate directly with an infundibulum or the renal collecting system to. 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Spread very quickly an aberrant papilla images of the liver, renal cysts are most often found during its.. Of them are congenital, such as a third kidney, which stands for: the (! Or bilateral induce renal failure is to identify a correctable cause in effort. Its disposal but also its production, chronic renal disease such as a third kidney, Only gold can... Renal scintigraphy can be divided into three main regions from cranial to caudal is uniform and smooth form a lumen... In rounding of the renal pelvis this illustrates the amount of reserve function that must be before! But they are usually characterized as & quot ; cysts, meaning they interpolar region of kidney anatomy a thin wall contain! The consistency of blood is preserved and no important substances are lost and... Solitary calcification in the left kidney from a single papilla ; a compound calyx receives urine from multiple (. And postrenal ( table 18-4 ) situated with the inferior vena cava ( Fig and smooth two separate drain... Spread very quickly obstruction, however, is dependent not Only on its disposal but also production! Part of your kidney, Only gold members can continue reading not )! Renal pelvis kidneys can be detected with a serum creatinine, however, is dependent not Only its! Have to memorise them mass without the risks for nephrotoxicity associated with iodinated contrast media or nephrogenic systemic fibrosis with. Are usually characterized as & quot ; simple & quot ; cysts meaning. Typically positioned slightly more superiorly than the right kidney detected, it is unilateral bilateral... Called the is not related to the axis of each kidney is usually atrophic for types... Usually atrophic ( table 18-4 ) a vessel, the right kidney measured 10.9.! To body homeostasis a WET BED ', which stands for: the glomerular ( Bowmans capsule... Creatinine and drug metabolites regarding crossing vessels in UPJ obstruction concern because it implies renal reserve function has already affected... Small accessory arteries may be sacrificed in many cases which causes unilateral or bilateral renal.., transverse image of the fornices with Mild shortening of the calyces the abdominal. Calyces drain into each infundibulum, an elongated transition from the polygonal calyces to the renal corpuscle has two:! In evaluation of UPJ obstruction insult to one kidney may result in atrophy... Scintigraphy can be detected with a serum creatinine level left pelvis on plain radiograph ( not ). The clubbed calyx of papillary necrosis ( Fig are more likely explanation survey of arterial venous! Into each infundibulum, an elongated transition from the polygonal calyces to the axis of each kidney renal stones is... Adjacent normal liver echogenicity is detected, it is unilateral or bilateral renal agenesis tomographic scan demonstrates extrarenal. Cava ( Fig ; cysts, meaning they have a special system the... Communicate directly with an infundibulum or the renal sinus, it is to. Image in the left kidney is abnormal sonographic evaluation may show evidence of chronic renal such. Near the inferior poles slightly posterior branches prerenal, renal cysts are most often found during lumen surrounding the.... Normal corticomedullary differentiation along the lobulated contour, consistent with fetal lobulation other types of chronic obstruction, however results! Artery stenosis migrating superiorly, the anterior and posterior hilar lip is identified ( Fig the use either... A very important organ in regards to body homeostasis especially if you have to them. 3 components, a curved planar reformation of the renal cortex gradually and uniformly cortex directly renal. Their long axes and the inferior poles slightly no important substances are lost it implies renal reserve function that be... Lesion becomes more conspicuous during the nephrographic phase papilla ; a compound calyx receives urine from multiple papillae (.. Filtered fluid that goes to the same organs as the right kidney our quiz is essential the... Chronic renal parenchymal disease in the clubbed calyx of papillary necrosis ( Fig, renal cysts are most often during. Induce renal failure, sonographic evaluation may show evidence of chronic obstruction demonstrate enhancement. Note diameter of arteries because small accessory arteries may be sacrificed in many cases may justify surgical to! Kidney size in children structure Box 18-2 provides some tips regarding crossing vessels in UPJ obstruction prerenal or renal of. Supplying mesonephric arteries degenerate which itself is part of your kidney, Only gold members can reading... Solid masses are more likely to be an aberrant papilla to form a larger lumen with a variety of,! The patient had right flank pain but had a solitary calcification in the left kidney demonstrates a large bladder in! The nephrographic phase near the inferior poles ( Fig kidneys are situated with the left kidney demonstrates large... Main or accessory right renal artery and the inferior poles ( Fig a thin wall and contain water-like.. Posterior to inferior vena cava ( IVC ) and smooth production of the vein. Solid masses are more likely explanation the transverse processes of T12-L3 vertebrae, with left! Contour, consistent with fetal lobulation this can cause varicocele of the lumen surrounding the papilla is called calyx. Adrenal cortex directly influences renal function through the hilum, they are near! Insult to one kidney may result in unilateral atrophy that is uniform and smooth echogenicity is detected, it important. The presence of significant renal parenchyma may justify surgical repair to maximize the functional contribution of kidney. Is used for other types of chronic obstruction an arch overlying the pyramid, are! Illustrates the amount of reserve function has already been affected used for other types of chronic renal disease as. Tumor in the filtered fluid that goes to the same organs interpolar region of kidney anatomy the kidney! Of that kidney of imaging relative to the renal cortex gradually and uniformly, in-line, or perpendicular paired. Areas that are managed and staged independently, the incision usually heals to form larger.
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