Calcifications and renal calculi are notoriously poorly demonstrated with MRI. Anterior components of circumaortic vein can be small. The phases of nephrogram. The interpolar region is the middle of the kidney. The presence of significant renal parenchyma may justify surgical repair to maximize the functional contribution of that kidney. Annotated axial image of the right kidney from a contrast-enhanced computed tomographic scan demonstrates hilar anatomy of the kidney. Note that the left renal vein receives blood from the left suprarenal and left testicular veins. 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. The kidneys are paired retroperitoneal structures that are normally located between the transverse processes of T12-L3 vertebrae, with the left kidney typically somewhat more superior in position than the right. Because an extrarenal pelvis is not confined by the renal parenchyma, there is a tendency for it to expand. 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. 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. 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. The small portion of the lumen surrounding the papilla is called the. 18-3). Renal cysts become fairly common as people age and usually do not cause symptoms or harm. B, Low-attenuation lesion in the late nephrographic/early excretory phase is less suspicious in appearance. Sometimes, one or both kidneys fail to develop, which causes unilateral or bilateral renal agenesis. Radiologists divide the kidney into three parts: the upper pole, lower pole, and the interpole (whi. Bilateral echogenic kidneys with renal hypertrophy can be seen associated with human immunodeficiency virus disease (see Fig. 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. Cells in our body constantly produce hydrogen ions. Because the interlobular arteries form an arch overlying the pyramid, they are called the arcuate arteries. A prominent bar of renal cortex situated between the superior and interpolar regions of the kidney is called a column of Bertin and is occasionally mistaken on ultrasound for a renal mass. However, T1-weighted images provide good corticomedullary differentiation. "Angio" indicates blood vessels, "myo" indicates muscle, and "lipoma" indicates fat. 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). C, More severe hydronephrosis results in more pronounced shortening of the papilla. Anatomical Position of the Kidneys Kidney Structure All rights reserved. Figure 18-3 Illustration demonstrating basic intrarenal arterial anatomy. Figure 18-20 Axial image from unenhanced computed tomography of the kidneys performed 2 days after an angiographic procedure demonstrates stasis of contrast in the renal cortex, resulting in a persistent corticomedullary phase of enhancement. 18-4). Ultrasound It can be seen as a triangular echogenic cortical defect, frequently seen in upper lobe parenchyma. 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. Serum creatinine levels or other kidney function tests to check if the kidneys are getting rid of waste. BOX 18-2 Crossing Vessels in Ureteropelvic Junction Obstruction. Blood in the urine, or dark urine. Radiologists divide the kidney into three parts: the upper pole, lower pole, and the interpole (which is in between them). 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. Global insult to one kidney may result in unilateral atrophy that is uniform and smooth. Figure 18-24 Normal magnetic resonance imaging appearance of the kidneys. If the renal pelvis extends out of the renal sinus, it is considered to be an. Depending on where the cyst is located, it can affect how the kidney works. 18-12). Read More Created for people with ongoing healthcare needs but benefits everyone. Renal size can be measured in several ways. 18-25). Some of them are congenital, such as a third kidney, which is usually atrophic. Best, Susan. Anatomy of the Kidney and Ureter Parenchyma Cortex Medulla Perirenal fat Capsule Ureter 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. 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). Ultrasound to get images of your kidneys. 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. Table 18-5 summarizes a checklist approach to the ultrasound examination. In most cases, the kidneys are situated with the inferior poles slightly more lateral and anterior than the superior poles. The kidneys are bilateral organs placed retroperitoneally in the upper left and right abdominal quadrants and are part of the urinary system. 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. 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. 18-4). 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. During the 6th to 9th weeks of life, the kidneys begin to ascend from their position in the pelvis to the level of T12-L1, inferior to the adrenal glands. 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. Some divide the excretory phase into the early excretory phase (contrast mainly confined to the kidney) and late excretory phase (contrast in the ureters). The kidneys are innervated by the renal plexus. Ultrasound can often identify the cause in cases of bilateral obstruction (, Pelvic mass (cervical, rectal, uterine, prostate cancer). There are many clinical states related to kidney malfunction. 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. Urine from the calyces flows to the renal sinus via tributaries called infundibula. 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 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. Besides blood volume and pressure regulation, kidneys also participate in the production of calcitriol (the active form of vitamin D). A, Tips of the fornices are sharply defined. Renal size and cortical thickness can be assessed in a manner similar to ultrasound. Table 18-7 lists causes of unilateral smooth renal atrophy. The ureter and calyces were not dilated (not shown), helping to differentiate this anatomic variant from obstruction. Crossed ectopia can be either fused or unfused. Accurate preoperative imaging protects the healthy donor from complications related to unanticipated variant anatomy. The visible contrast seen in the excretory phase has been concentrated many-fold. These kidney functions can sure seem overwhelming, especially if you have to memorise them! 18-26). Concerning lymphatic drainage, each kidney drains into the lateral aortic (lumbar) lymph nodes, which are placed around the origin of the renal artery. 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. Note number of veins by inspecting inferior vena cava along entire length of kidney. They are usually characterized as "simple" cysts, meaning they have a thin wall and contain water-like fluid. 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 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. Figure 18-2 Annotated axial image of the right kidney from a contrast-enhanced computed tomographic scan demonstrates hilar anatomy of the kidney. Note that there is no contrast in the aorta. Table 18-2 Association between Renal Cortical Echogenicity and Renal Parenchymal Disease. Three-dimensional volume rendering from contrast-enhanced multidetector computed tomography examination of the kidneys demonstrates typical orientation of a horseshoe kidney. This method is the standard in evaluation of UPJ obstruction and often is used for other types of chronic obstruction. The right kidney has a normal appearance (not shown). In most cases, the kidneys are situated with the inferior poles slightly. When abnormal echogenicity is detected, it is important to note whether it is unilateral or bilateral. 18-25). Unenhanced CT can identify hydronephrosis and hydroureter, urinary stones, and some masses. 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