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KIDNEYS AND ADRENAL
GLANDS
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I. Introduction/General Information
A. Kidneys
1. Paired2. Located between T-12 & L-3/L-4
3. Between iliac crests & lower ribs
4. Right normally more inferior than left
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Relationship of the Kidneys to
Vertebra and Ribs
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Coronal Section, Right Kidney4. Normal adult kidney
measures:
superior inferior: 10 12 cm
medial lateral: 5 6 cm
anterior posterior: 3 4 cm
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Introduction/General Information, cont
6. Portions of kidneys lie in six regionsof the abdomen
1. right & left hypochondriac
2. epigastric
3. right & left lumbar
4. umbilical
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Organs of the Urinary System Kidneys
Ureters
Urinarybladder
Urethra
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Introduction/General Information, cont
B. Adrenal Glands
1. Small, difficult to see
2. Triangular glands
a. under ribs
b. not well capsulated
c. usually anterior & medial to kidney
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Introduction, cont
3. In Epigastric region
4. ~ T-12 to L-1/L-2
5. Right usually moresuperior than left
Why?
Left Adrenal gland
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Introduction/General Information, cont
C. Sonographic applications
1. Poorly functioning kidney
2. Cystic vs solid or complex mass3. Post Renal Transplant Evaluation
a. Cystic mass: may indicate fluid is
not being absorbedb. Signs of rejection
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Sonographic applications, continued
4. Congenital anomalies
5. Perirenal abscesses, adenopathy
6. Presence/absence of kidney
7. Ectopic kidney
8. Adrenal mass or cyst:
a. Difficult to visualize
b. Unless neonate or in utero
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II. Detailed Anatomy
A. Kidneys1. Paired, retroperitoneal
structures2. Immediately adjacent
to vertebral bodies3. Left: more superior
~ T-12 to upper L-4
4. Right: more inferior~ L-1 to lower L-4
Kidneys, in situ
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Position of the Kidneys
P
A
Transverse Sectionthrough R/L Kidneys
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Detailed Anatomy of Kidneys, cont
5. Not held by ligaments
-May be displaced 2.5 cm by
respiration6. Upper pole lies more
posterior thanlower pole (on L.S.)
-due to lumbar curve S
I
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Detailed Anatomy of Kidneys, cont
7. Adjacent structures, Right kidney:
a. liver, GB
b. descending of duodenum, hepaticflexure
c. right adrenal, IVCd. right crus of diaphragm, psoas,
quadratus lumborum muscles
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Right Kidney: Relationships
Note:
Liver
Gallbladder
Duodenal bulb
IVC
A
P
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Right Kidney: Relationships
Note:
Liver
Descendingduodenum
Psoas muscle
Quadratus lumborummuscle
IVC
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Detailed Anatomy of Kidneys, cont
8. Adjacent structures, Left kidney:
a. spleen, tail of pancreas, left adrenal
b. ascending duodenum,gastroesophageal junction,transverse colon, jejunum
c. psoas & quadratus lumborum m.
d. aorta, left crus of diaphragm
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Left Kidney: Relationships
Note:
Tail of pancreas
Splenic flexure ofcolon
Aorta
Psoas and quadratuslumborum muscles
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Detailed Anatomy, cont
9. Diaphragm lies superior &
posterior
10.Transversus abdominislies inferior
11. Separated from abdomen
proper byparietal peritoneum
12. Surrounded by fattycapsule
S
I
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Detailed Anatomy of Kidneys, cont
13. Internal anatomy seen on ultrasound
a. Renal cortex
b. Renal medulla (pyramids)
c. Renal columns (of Bertin)
d. Renal pelvis
e. Papillae (apices of pyramids)f. Calyces (if dilated)
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Coronal Section, Right Kidney
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Detailed Anatomy of Kidneys, cont
14. Pancreas & duodenum are indirect contact
a. pancreatic cancers & duodenal
ulcers can affect the kidney
b. all other organs in indirect
contact, intraperitoneal
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Detailed Anatomy of Kidneys, cont
15. Posteriorly, right kidney separatedfrom pleura only by diaphragm
a. Why??
b. Kidney cancer can spread tolung, vice versa
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Detailed Anatomy of Kidneys, cont
16. Fasciae:
a. Supportive C.T. layers
b. Fascia transversalis:
1. at lateral border of kidney
2. splits into prerenal &retrorenal layers
3. forms perirenal fascia (aka:Gerotas fascia)
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Position of the Kidneys on the Posterior
Abdominal Wall
Note:
FasciatransversalisPrerenal fasciaRetrorenal fascia
Perirenal(Gerotas)fascia
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Detailed Anatomy of Kidneys, cont
c. Retrorenal layer
1. blends with fascia of psoasmajor & quadratuslumborum muscles
2. also with C. T. thatbinds vertebral column
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Fascial Coverings: Retrorenal Layer
Figure 23.2a
Retrorenallayer
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Detailed Anatomy of Kidneys, cont
d. Prerenal layer
1. extends medially
2. anterior to renal vessels,aorta & IVC
3. blends with layer from otherside
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Fascial coverings: Prerenal Layer
Figure 23.2a
Prerenal layer
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Detailed Anatomy of Kidneys, cont
e. Fatty capsule lies between the
layersf. Infections may spread via fascial
sheath
-- especially bacterial infections i.e., perinephritis
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Fatty Capsule
Figure 23.2a
Fatty Capsule(Perirenal fat)
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Detailed Anatomy of Kidneys, cont
17. Kidney maintains position by intra-abdominal pressure & fasciae
a. Allows mobility during respiration
b. Allows abdominal palpation oflower pole in some patients
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Detailed Anatomy of Kidneys, cont
18. Two layers of renal fascia
a. fuse at upper pole
b. separate at lower polec. if fat decreases, mobility
increases:
1. kidney may move betweenfascial planes
2. pelvic kidney
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Detailed Anatomy of Kidneys, cont
d. Adrenals have own fasciae, will
not movee. Kidney may be removed without
disturbing adrenal gland
f. Pathological result:
1. kidney may descend
2. cause kink in ureter
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Detailed Anatomy of Adrenals
B. Adrenal Glands1. ~ T-12 to L-1 or L-2
2. Located in epigastricregion
3. Right adrenal liesmore superior
a. Related to visceralsurface of liver
b. IVC & right crus liemedial L. Adrenal Gland, in situ
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Detailed Anatomy of Adrenals, cont
c. Right kidney lies
posterior, inferior
& slightly lateral
1. Has linear,
pyramidal, orelongated shape
2. One limb extendsalong medialaspect
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Detailed Anatomy of Adrenals, cont
4. Left adrenal
a. Lies posterior & medial to
cardiac sphincter, spleen, medial to tailof pancreas
b. aorta & left crus lie medial
c. left kidney lies posterior, inferior, &lateral
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Adrenal Gland In Situ Coronal Section / Adrenal Gland
Human Adrenal Gland
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Detailed Anatomy of Adrenals, cont
d. More triangular in shape
e. One limb may extend alongmedial aspect of left kidney
f. Fourth part of duodenum is
caudad
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Detailed Anatomy, cont
C. Blood supply1. Renal arteries:
a. arise from abdominal aortab. Divide into 2 or 3 branches before
entering kidney
c. If 3 branches, may form:1. vascular fork
2. may constrict ureter
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Renal Arteries with Vascular Fork Note the
numerous
branches ofthe renalartery priorto entering
the kidneyhilus
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Detailed Anatomy, cont
d. R. renal artery courses from aorta
posteriorto IVC into hiluse. Left renal artery course is from
aorta directlyto hilusf. May see 2 or 3 pairs of renal
arteriesg. Gonadal arteries:
1. may arise from renal artery
2. usually arise from aorta
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Origin of Renal, Gonadal Arteries Note the
rightgonadal
arteryarising fromthe aorta,thenbranching
to form theinferiorcapsularartery.
R and LRenalArteries
GonadalArteries
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Variations in Renal Arteries The
presence of
multiplerenalarteriesrepresents
persistenceof fetalvessels
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Detailed Anatomy, cont
2. Renal Veinsa. Right renal vein enters IVC
directlyb. Left renal vein passes anterior
to aorta, posteriortoSMA, then into IVC
c. Venous pattern complex
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Variations in Renal Veins
Note theduplication in
the Left RenalVein
Branchessurround aorta
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Pathway of Renal Vessels
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Detailed Anatomy, cont
d. On the left side:
1. anastomosis of veins2. from left adrenal, pampiniformplexus of testis, perirenal fat,ureter
e. Surgery may permit spread ofinfection
f. Malignancies frequently spread viarenal vein
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Detailed Anatomy, cont
3. Adrenal glands
a. Blood supply intensiveb. Superior adrenal artery arises
from inferior phrenic artery
c. Middle suprarenal artery arisesfrom aorta
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Detailed Anatomy, cont
d. Inferior suprarenal artery arisesfrom renal artery
e. Only one vein drains each gland
1. right drains directly into IVC2. left drains into left renal vein
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Origin of Adrenal ArteriesNote the
superiorarteryarising from
the phrenic a.,the middleartery from theaorta, and theinferiorartery
from thesuperiorcapsular arteryviathe R. renalartery
SuperiorAdrenal
Artery MiddleAdrenalArteryInferior
AdrenalArtery
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Detailed Anatomy, cont
D. Lymphatics
1. Renal lymphatic channels
follow veins2. Most drain into para-
aortic nodes
a. Lie inferior at ~ L-3 or L-4
b. Near bifurcation of aorta
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Detailed Anatomy, continued
E. In neonate kidney, note:a. Large size of adrenal vs
kidney
b. Lobulation of kidney (plastinatedspecimen)
c. Increased amount of perirenalfat
d. Paraganglia along aorta1. precursor to aortic nodes
2. degenerate in childhood
Lobulated FetalKidneys
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Detailed Anatomy, cont
E. Innervation
1. Sensory nerve fibers of kidney &
ureter join spinal cord at T-11 to L-2
2. Passage of calculi causes peristaltic
action of ureter
a. Muscle spasms cause pain in regionssupplied by T-11 to L-2 nerves
b. Pain may refer to testis or anterior thigh
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III. Gray-scale anatomyA. U/S can differentiate renal pyramids,
cortex, columns, calyces, pelvis
1. Pyramids appear echodense regionswithin parenchyma
a. Apex of pyramid = papilla
b. Apex points toward pelvis
2. Cortex, columns less dense than liver
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IV. Renal PathologyA. Malpositioned (ectopic) kidney
1. Kidneys migrate cephalad during
development2. Ptosis (Gr. falling): kidney has
sunk from its usual site in fossa3. Pelvic Kidney:
a. lies in floor of pelvic cavityb. may be hypoplastic, distorted
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Pelvic Kidney
Note the
paths ofthe renalartery andrenal veinin pelvickidneys
Ectopic Kidneys
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Malpositioned Kidney, continued
2. If kidney not identified in renal fossa,scan lower abdomen & pelvis
3. If reniform mass is observed in abdomenor pelvis, check renal fossa
4. If pelvic or ectopic kidney seen in
pregnancy, C-section advised5. Crossed kidneys usually seen inpediatric age group
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Renal Pathology, continued
B. Hypoplasia
1. Kidney small, with poorfunction
2. Appears distorted withincreased lobulation
3. Differentiation fromdiseased kidneymay be difficult
Renal Hypoplasia
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Renal Pathology, continued
4. Differentiation from true renal agenesismay be difficult
a. In agenesis, fossa may contain
bowel (simulates hypoplasia)b. Both may result in hypertrophy of
contralateral kidney
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Renal Pathology, continued
C. Duplication/Fusion:
1. May be a duplex
collecting system or twoseparate components
2. If complete separationoccurs, upper pole ureter
may form ureterocele:
Duplex/FusedCollection Systems
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Renal Pathology, continued
a. Leads to obstruction &
hydronephrosis
b. May have septations
c. Appears as triangular,sonolucent sac inupper aspect of kidney
Hydronephrosis
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Renal Pathology, continued
3. Horseshoe Kidneya. Most common fusion anomaly
b. Usually fused at inferior polec. The isthmus may simulate aretroperitoneal mass
d. May be confused with para-aortic
lymph nodese. Look for malrotated pelvis
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Abnormal Kidney Structures
Note the
fusedlower poleandrotated
pelves
PancakeKidney
HorseshoeKidney
Malrotated
Kidneys
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Renal Pathology, continued
Renal and Adrenal Diseases: In Patho