Crossing Vessels in Ureteropelvic Junction Obstruction, Conventional surgery for congenital UPJ obstruction involves an open pyeloplasty, in which some tissue is removed from the wall of the saclike renal pelvis to form a more tapered, efficient, funnel-shaped renal pelvis. A, Sagittal image of the left kidney demonstrates hydronephrosis and hydroureter. When both kidneys are on the same side crossed ectopia is present, because the ureter from one kidney must cross the midline to insert into the bladder (Fig. Kidneys have a special system for the excretion of hydrogen ions, and in that way consistently maintain the pH of blood at 7.4. The ureter and calyces were not dilated (not shown), helping to differentiate this anatomic variant from obstruction. Arterial stenosis was confirmed by magnetic resonance angiography. There are 8-18 renal pyramids in each kidney, that on the coronal section look like triangles lined next to each other with their bases directed toward the cortex and apex to the hilum. Static-fluid (T2-weighted) MR urography and phase-contrast MR angiography are useful techniques that do not require intravenous contrast material. In this region, the anterior and posterior hilar lip is identified (Fig. Renal cysts become fairly common as people age and usually do not cause symptoms or harm. 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. You can test yourself on the renal arteries with our quiz. 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. Coronal maximum intensity projection image from a contrast-enhanced computed tomographic scan demonstrates a dilated and tortuous lumbar veins joining the left renal vein. chronic obstruction, or severe or repeated urinary infections. When echogenicity of the renal cortex equals that of the liver, renal function is abnormal in approximately 38% of cases. The presence or absence of intravenous contrast media, as well as the phase of contrast enhancement, are key factors that determine the appearance of the renal parenchyma on CT (Table 18-3). However, you may have symptoms related to the condition that's causing it. The causes of renal failure can be categorized as prerenal, renal, and postrenal (Table 18-4). The patient had right flank pain but had a solitary calcification in the left pelvis on plain radiograph (not shown). When simple kidney cysts do cause symptoms, they might include: Pain in the side between the ribs and hip, stomach or back. Pain that radiates to the lower abdomen and groin. Coronal computed tomographic image in the corticomedullary phase shows normal corticomedullary differentiation along the lobulated contour, consistent with fetal lobulation. The cortex of a normal kidney is usually less echogenic than the adjacent normal liver. The most common cause is renal artery stenosis (see Fig. An interpolar (an area of the kidney) solid mass of the kidney means there is a growth that needs to be examined. Simple kidney cysts aren't cancer and rarely cause problems. For most people, obstruction of a single ureter does not induce renal failure. The urinary system comprises the upper urinary tracts (kidneys and ureters), the urinary bladder, and the urethra. 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. Each pyramid creates urine and terminates into a renal papilla. Radiologists divide the kidney into three parts: the upper pole, lower pole, and the interpole (which is in between them). Lets start with the right kidney anterior surface. normal kidney size in adults normal kidney size in children Structure Renal function is better evaluated by measured creatinine clearance, which takes into account not only the amount of creatinine in the blood but also the amount of creatinine within a specified volume of urine over a given period. 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. Anatomy of the Kidney and Ureter Parenchyma Cortex Medulla Perirenal fat Capsule Ureter Figure 18-27 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). Last reviewed: December 28, 2022 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. In addition to the renal artery, accessory renal arteries are present too. Other malfunctions of the kidney are presented through acute kidney failure, a serious and urgent medical condition. The kidneys are innervated by the renal plexus. Illustration demonstrating the anatomy of the renal collecting system. Crossed ectopia on intravenous pyelogram. urinary system quizzes and labeled diagrams. 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. A, Soft-tissue windows demonstrate no filling defect. After looking at the overview of the kidneys in situ, it may seemas they are cluttered with all abdominal organs. Figure 18-9 Coronal computed tomographic image in the corticomedullary phase shows normal corticomedullary differentiation along the lobulated contour, consistent with fetal lobulation. 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. 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. Living renal donor allografts account for more than half of the transplanted kidneys in the United States. Each kidney should always be evaluated in long axis (coronal, sagittal, or both, depending on sonographic window) and axial to the kidney. Frequent urination (having to go the bathroom often). 18-19). 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. The calcium or uric acid will precipitate and form stones. Jana Vaskovi MD B, Axial CT image from a different patient demonstrates the more common location of the right renal artery posterior to the IVC. Dimitrios Mytilinaios MD, PhD A, A low-attenuation lesion is difficult to identify during the corticomedullary phase. If the renal pelvis is entirely within the confines of the renal sinus, it is considered intrarenal. The main unit of the medulla is the renal pyramid. The kidneys are bilateral organs placed retroperitoneally in the upper left and right abdominal quadrants and are part of the urinary system. 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. The kidneys have two functional areas that are managed and staged independently, the kidney parenchyma and the renal pelvis. A bean-like structure like the kidney has two borders: medial and lateral. BOX 18-3 Causes of Bilateral Hydronephrosis. Because the interlobular arteries form an arch overlying the pyramid, they are called the. Read more. Made. 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. Yet, the relations of the kidneys with other organs are often found in Anatomy tests. In other cases, both kidneys can be fused, usually at the inferior poles, which is a congenital state called the horseshoe kidney. I would honestly say that Kenhub cut my study time in half. Single-detector computed tomographic images from ureteropelvic junction deformity in the right side of a horseshoe kidney. Causes. Bone scan and chest x-ray to find out if the cancer has spread. Table 18-6 lists the most common causes of bilateral smooth renal atrophy. The superior half of each kidney is covered by the diaphragm, which is why the kidneys move up and down during respiration. 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. Note that retroaortic components are usually near the inferior poles (Fig. The renal corpuscle has two components: the glomerular (Bowmans) capsule in which sits the glomerulus. Learn more about the anatomy of the kidneys and the urinary system with our urinary system quizzes and labeled diagrams. Duplication of the urinary tract is discussed in detail in Chapter 19. There is no specific treatment for fused kidneys and the only option is to treat the pathologies that affect them during life. Each end of the kidney is commonly called a pole. Both renal arteries, left and right, arise just below the superior mesenteric artery, with the left renal artery positioned slightly superiorly to the right one. The shape of the calyx is formed by the impression of the renal papilla. * Entities for which sonography is most useful. Kidneys are located just below your ribcage and behind your belly. Table 18-3 Utility of Different Phases of Renal Contrast Enhancement. The solid renal parenchyma consists of the peripheral renal cortex and more central renal medulla. print Print this Article Table 18-7 Causes of Unilateral Small Smooth Kidney, Only gold members can continue reading. Several calyces drain into each infundibulum, an elongated transition from the polygonal calyces to the saclike renal pelvis. Reading time: 23 minutes. Because an extrarenal pelvis is not confined by the renal parenchyma, there is a tendency for it to expand. 18-26). Horseshoe kidneys result from midline fusion of the kidneys, typically at the level of the origin of the inferior mesenteric artery. A healthy individual who donates a kidney is likely to maintain a normal serum creatinine despite the loss of 50% of parenchymal tissue. The kidneys serve important . 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. 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. Publication types Review MeSH terms Humans 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. Note origin of inferior accessories near inferior poles on each side. Ultrasound It can be seen as a triangular echogenic cortical defect, frequently seen in upper lobe parenchyma. 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. Created for people with ongoing healthcare needs but benefits everyone. When fused, the condition is described as crossed fused ectopia. 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. Thus, any upward trend in the serum creatinine value should be viewed with concern when considering the administration of potentially nephrotoxic or renally excreted intravenous contrast media. Learn how we can help 1.2k views Reviewed Dec 09, 2022 Thank Dr. Frank Kuitems and 4 doctors agree 3 thanks Look for retroaortic or circumaortic left renal vein. Learning a quickmnemonic'VAD' can help you remember these structures (renal Vein, renal Artery, Duct a.k.a ureter). 18-2). Urine that is concentrated in the renal papilla is subsequently excreted into a lumen lined with transitional epithelium. normal kidney size in adults normal kidney size in children Structure The upper poles are normally oriented more medially and posteriorly than the lower poles. 18-19). Enlargement of a congenitally unilateral kidney is typical and presumed to be compensatory. These are chronic processes that lead to a loss of renal cortex gradually and uniformly. It is notable that the kidney has a very rich blood supply. 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. 18-4). The uniform high attenuation of the nephrographic phase provides an optimal background for detecting small, low-attenuation lesions in the renal parenchyma (Fig. In most kidneys, the renal hilum faces more anteromedial in the upper half of the kidney and more directly medial in the lower half. Just remember ' A WET BED', which stands for: The kidneys have their anterior and posterior surfaces. On the other hand, kidneys do have relations with peritoneum, or precisely with the specific organs that are covered with peritoneum which are placed directly adjacent to the kidneys. 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. The ureter and calyces were not dilated (not shown), helping to differentiate this anatomic variant from obstruction. 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. In some cases, two separate kidneys drain into a bifid renal pelvis, ultimately drained by a common ureter. 18-20). The cortex of a normal kidney is usually less echogenic than the adjacent normal liver. The visible contrast seen in the excretory phase has been concentrated many-fold. Pearl: Any upward trend in serum creatinine value should be viewed with concern because it implies renal reserve function has already been affected. 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 (. 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. (Courtesy of Karl T. Rew, MD) Introduction Synonyms Epidemiology Hypotension is a stimulus for the kidneys to increase the retention of fluid and thus increase blood pressure. 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. Most serum creatinine is excreted in the urine; therefore, if renal function is compromised, levels of creatinine in the serum increase. Retrograde urogram shows a calculus in the left ureter. Despite the complexity of renal physiology, many attempt to assess renal function with a simple quantitative measure, the serum creatinine. Note that the left renal vein receives blood from the left suprarenal and left testicular veins. When this happens, the stones can block the flow of urine out of your kidneys. Some centers use diuretics or fluid bolus, or both, during CT urography to dilute the excreted contrast to improve assessment of the urothelium. BOX 18-2 Crossing Vessels in Ureteropelvic Junction Obstruction. 18-3). For most people, obstruction of a single ureter does not induce renal failure. Association between Renal Cortical Echogenicity and Renal Parenchymal Disease. Figure 18-6 Frontal image of the left kidney from an intravenous urogram demonstrating an aberrant renal papilla in the lower pole infundibulum. Extraaortic origin of the renal arteries and accessory renal arteries are common. Axial image of the left kidney from a contrast-enhanced computed tomographic scan demonstrates an extrarenal pelvis. These surfaces are separated by the edges of the kidney, which are the major convexity laterally, and minor concavity medially. Always include unenhanced computed tomographic images to look for renal stones. Renal cysts are sacs of fluid that form in the kidneys. Crossed ectopia can be either fused or unfused. Other methods include classical surgical removal of the stone, either through the ureter or by open surgery. The kidney tissue is protected by three layers that entirely surround the kidney: Outside the fascia is the most superficial layer a layer of fat tissue called the paranephric fat. Increased cortical echogenicity is associated with many forms of chronic renal parenchymal disease and indicates a renal cause for renal failure. Register now Several calyces drain into each infundibulum, an elongated transition from the polygonal calyces to the saclike renal pelvis. 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. 18-23). 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 renal pelvis then tapers like a funnel to join the ureter. 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). Several small stones are visible in the left kidney, and the left kidney is somewhat atrophied from chronic obstruction. The glomerulus is actually a web of arterioles and capillaries, with a special filter which filters the blood that runs through the capillaries, the glomerular membrane. 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. 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. Advantages of scintigraphy include accurate quantitative measurement of function and parenchymal mass without the risks for nephrotoxicity associated with iodinated contrast media or nephrogenic systemic fibrosis associated with gadolinium contrast agents. Renal Cysts. 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 renal fascia which besides the kidneys also encloses the suprarenal gland and its surrounding fat. In this way, the consistency of blood is preserved and no important substances are lost. impression is preserved. Differential diagnosis General imaging considerations include: renal cortical defect duplex kidney However, sometimes ureteroscopy is required to confirm the diagnosis in patients with hematuria. These terminal branches have no collateral circulation. Recent advances in MDCT and MRI permit cross-sectional vascular studies to replace conventional angiography before UPJ repair (Fig. B, Transverse image of the bladder demonstrates a large bladder tumor in the region of the trigone. 18-9). Axial images from contrast-enhanced computed tomography demonstrate transient enhancement of a small renal cell carcinoma. Each end of the kidney is commonly called a pole. The medulla consists of multiple pyramidal tissue masses, called the renal pyramids, which are triangle structures that contain a dense network of nephrons. In this case, the right kidney had more favorable anatomy for laparoscopic donor nephrectomy. 18-4). Increasing pressure within the lumen initially distends the fornices (acutely angled portions of the calyx along the sides of the papillae), whereas the central portion of the papillary impression is preserved. 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. Because the fascia of the retroperitoneum prevents significant extravasation, the incision usually heals to form a larger lumen. 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. Maintaining kidney health. 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. 18-15). Unenhanced MRI can also be used to diagnose obstruction and identify the source (Fig. Normal parenchymal enhancement on CT or MRI allows definitive characterization. The anteromedial aspect of the interpolar region is interrupted by the renal hilum to make a C shape. The early excretory phase begins as early as 120 seconds after injection. Thoracic kidneys are the least common form of renal ectopia. Further testing/diagnosis is required. The interpolar region is the middle of the kidney. 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). All content published on Kenhub is reviewed by medical and anatomy experts. Note that there is no contrast in the aorta. An increased amount of hydrogen ions can acidify the blood and cause a state called acidosis. Chronic glomerulonephritis usually causes bilateral increased renal echogenicity with smooth atrophy, whereas renal artery stenosis usually causes a similar but unilateral appearance (Fig. Note number of veins by inspecting inferior vena cava along entire length of kidney. Comparative views of the CT scan ( a axial, b coronal, and c sagittal planes) and corresponding views of the physical model ( d superior view, e median view, and f median view). However, T1-weighted images provide good corticomedullary differentiation. The left kidney (not shown) had a similar appearance. 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 renal cortex is part of your kidney, which itself is part of the urinary tract. 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. The isthmus connecting the kidneys is variable, ranging from normal renal cortex to a thin fibrous band. Three-dimensional volume rendering from contrast-enhanced multidetector computed tomography examination of the kidneys demonstrates typical orientation of a horseshoe kidney. Note origin of inferior accessories near inferior poles on each side. Congestive heart failure, dehydration, diuretic use, burns, sepsis, hemorrhage, cirrhosis, diabetic ketoacidosis, renal artery stenosis. AMLs can bleed and while not cancerous are still taken very seriously. 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. A. Junctional cortical line seen on a long-axis ultrasound image of the right kidney. The small portion of the lumen surrounding the papilla is called the. Literature supports the use of either multidetector computed tomography (MDCT) or MRI in donor evaluation. Supernumerary kidneys are quite rare and have been associated with aortic coarctation, vaginal atresia, and urethral duplications. 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). C, More severe hydronephrosis results in more pronounced shortening of the papilla. I hope this helps. Ultrasound It can be seen as a triangular echogenic cortical defect, frequently seen in upper lobe parenchyma. Attempt to assess renal function is compromised, levels of creatinine in the aorta, cirrhosis, ketoacidosis! Shows normal corticomedullary differentiation along the lobulated contour, consistent with fetal.! 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