KIDNEYS AND ADRENAL GLANDS

I. Introduction/General Information

A. Kidneys
1. Paired

2. Located between T-12 & L-3/L-4

3. Between iliac crests & lower ribs

4. Right normally more inferior than left

Relationship of the Kidneys to Vertebra and Ribs

Coronal Section, Right Kidney

4. Normal adult kidney measures:
superior inferior: 10 12 cm

medial
anterior

lateral: 5 6 cm
posterior: 3 4 cm

Introduction/General Information, cont

6. Portions of kidneys lie in six regions of the abdomen 1. right & left hypochondriac
2. epigastric 3. right & left lumbar 4. umbilical

Organs of the Urinary System

Kidneys Ureters Urinary bladder Urethra

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

Introduction, cont

3. In Epigastric region 4. ~ T-12 to L-1/L-2 5. Right usually more superior than left
Why?

Left Adrenal gland

Introduction/General Information, cont

C. Sonographic applications
1. Poorly functioning kidney 2. Cystic vs solid or complex mass 3. Post Renal Transplant Evaluation a. Cystic mass: may indicate fluid is not being absorbed b. Signs of rejection

Sonographic applications, continued

4. 5. 6. 7. 8.

Congenital anomalies Perirenal abscesses, adenopathy Presence/absence of kidney Ectopic kidney Adrenal mass or cyst:
a. Difficult to visualize b. Unless neonate or in utero

II. Detailed Anatomy

A. Kidneys
1. Paired, retroperitoneal structures 2. Immediately adjacent to vertebral bodies 3. Left: more superior
~ T-12 to upper L-4

4. Right: more inferior

~ L-1 to lower L-4
Kidneys, in situ

Position of the Kidneys

P Transverse Section through R/L Kidneys A

Detailed Anatomy of Kidneys, cont

5. Not held by ligaments

-May be displaced 2.5 cm by respiration

6. Upper pole lies more posterior than lower pole (on L.S.)
-due to lumbar curve
S

Detailed Anatomy of Kidneys, cont

7. Adjacent structures, Right kidney:

a. liver, GB b. descending of duodenum, hepatic flexure c. right adrenal, IVC d. right crus of diaphragm, psoas, quadratus lumborum muscles

Right Kidney: Relationships

Note:

Liver Gallbladder Duodenal bulb IVC

A

Right Kidney: Relationships

Note:

Liver Descending duodenum Psoas muscle Quadratus lumborum muscle IVC

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

Left Kidney: Relationships

Note:

Tail of pancreas Splenic flexure of colon Aorta Psoas and quadratus lumborum muscles

Detailed Anatomy, cont

9. Diaphragm lies superior & posterior

10.Transversus abdominis lies inferior 11. Separated from abdomen proper by parietal peritoneum 12. Surrounded by fatty capsule

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)

Coronal Section, Right Kidney

Detailed Anatomy of Kidneys, cont

14. Pancreas & duodenum are in direct contact

a. pancreatic cancers & duodenal ulcers can affect the kidney

b. all other organs in indirect contact, intraperitoneal

Detailed Anatomy of Kidneys, cont

15. Posteriorly, right kidney separated from pleura only by diaphragm

a. Why?? b. Kidney cancer can spread to lung, vice versa

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)

Position of the Kidneys on the Posterior Abdominal Wall

Note:
Fascia transversalis
Prerenal fascia Retrorenal fascia Perirenal (Gerotas) fascia

Detailed Anatomy of Kidneys, cont

c. Retrorenal layer 1. blends with fascia of psoas major & quadratus lumborum muscles 2. also with C. T. that binds vertebral column

Fascial Coverings: Retrorenal Layer

Retrorenal layer

Figure 23.2a

Detailed Anatomy of Kidneys, cont

d. Prerenal layer
1. extends medially 2. anterior to renal vessels, aorta & IVC 3. blends with layer from other side

Fascial coverings: Prerenal Layer

Prerenal layer

Figure 23.2a

Detailed Anatomy of Kidneys, cont

e. Fatty capsule lies between the layers f. Infections may spread via fascial sheath -- especially bacterial infections i.e., perinephritis

Fatty Capsule
Fatty Capsule (Perirenal fat)

Figure 23.2a

Detailed Anatomy of Kidneys, cont

17. Kidney maintains position by intraabdominal pressure & fasciae

a. Allows mobility during respiration b. Allows abdominal palpation of lower pole in some patients

Detailed Anatomy of Kidneys, cont

18. Two layers of renal fascia

a. fuse at upper pole b. separate at lower pole c. if fat decreases, mobility increases:
1. kidney may move between fascial planes 2. pelvic kidney

Detailed Anatomy of Kidneys, cont

d. Adrenals have own fasciae, will not move e. Kidney may be removed without disturbing adrenal gland f. Pathological result:
1. kidney may descend 2. cause kink in ureter

Detailed Anatomy of Adrenals

B. Adrenal Glands
1. ~ T-12 to L-1 or L-2 2. Located in epigastric region 3. Right adrenal lies more superior
a. Related to visceral surface of liver b. IVC & right crus lie medial

L. Adrenal Gland, in situ

Detailed Anatomy of Adrenals, cont

c. Right kidney lies posterior, inferior & slightly lateral

1. Has linear, pyramidal, or elongated shape 2. One limb extends along medial aspect

Detailed Anatomy of Adrenals, cont

4. Left adrenal
a. Lies posterior & medial to cardiac sphincter, spleen, medial to tail of pancreas b. aorta & left crus lie medial c. left kidney lies posterior, inferior, & lateral

Human Adrenal Gland

Adrenal Gland In Situ

Coronal Section / Adrenal Gland

Detailed Anatomy of Adrenals, cont

d. More triangular in shape e. One limb may extend along medial aspect of left kidney

f. Fourth part of duodenum is caudad

Detailed Anatomy, cont

C. Blood supply 1. Renal arteries: a. arise from abdominal aorta b. Divide into 2 or 3 branches before entering kidney c. If 3 branches, may form:
1. vascular fork 2. may constrict ureter

Renal Arteries with Vascular Fork

Note the numerous branches of the renal artery prior to entering the kidney hilus

Detailed Anatomy, cont

d. R. renal artery courses from aorta posterior to IVC into hilus e. Left renal artery course is from aorta directly to hilus f. May see 2 or 3 pairs of renal arteries g. Gonadal arteries:
1. may arise from renal artery 2. usually arise from aorta

Origin of Renal, Gonadal Arteries

Note the right gonadal artery arising from the aorta, then branching to form the inferior capsular artery.

R and L Renal Arteries Gonadal Arteries

Variations in Renal Arteries

The presence of multiple renal arteries represents persistence of fetal vessels

Detailed Anatomy, cont

2. Renal Veins
a. Right renal vein enters IVC directly b. Left renal vein passes anterior to aorta, posterior to SMA, then into IVC c. Venous pattern complex

Variations in Renal Veins

Note the duplication in the Left Renal Vein Branches surround aorta

Pathway of Renal Vessels

Detailed Anatomy, cont

d. On the left side:

1. anastomosis of veins 2. from left adrenal, pampiniform plexus of testis, perirenal fat, ureter

e. Surgery may permit spread of infection f. Malignancies frequently spread via renal vein

Detailed Anatomy, cont

3. Adrenal glands a. Blood supply intensive

b. Superior adrenal artery arises from inferior phrenic artery c. Middle suprarenal artery arises from aorta

Detailed Anatomy, cont

d. Inferior suprarenal artery arises from renal artery e. Only one vein drains each gland
1. right drains directly into IVC

2. left drains into left renal vein

Origin of Adrenal Arteries

Note the
superior artery arising from the phrenic a., the middle artery from the aorta, and the inferior artery from the superior capsular artery via the R. renal artery
Superior Adrenal Artery

Inferior Adrenal Artery

Middle Adrenal Artery

Detailed Anatomy, cont

D. Lymphatics
1. Renal lymphatic channels follow veins
2. Most drain into paraaortic nodes a. Lie inferior at ~ L-3 or L-4 b. Near bifurcation of aorta

Detailed Anatomy, continued

E. In neonate kidney, note:

a. Large size of adrenal vs kidney b. Lobulation of kidney (plastinated
specimen)

c. Increased amount of perirenal fat d. Paraganglia along aorta

1. precursor to aortic nodes 2. degenerate in childhood
Lobulated Fetal Kidneys

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 regions supplied by T-11 to L-2 nerves b. Pain may refer to testis or anterior thigh

III. Gray-scale anatomy

A. U/S can differentiate renal pyramids, cortex, columns, calyces, pelvis

1. Pyramids appear echodense regions within parenchyma

a. Apex of pyramid = papilla b. Apex points toward pelvis

2. Cortex, columns less dense than liver

IV. Renal Pathology A. Malpositioned (ectopic) kidney

1. Kidneys migrate cephalad during development 2. Ptosis (Gr. falling): kidney has sunk from its usual site in fossa 3. Pelvic Kidney:
a. lies in floor of pelvic cavity b. may be hypoplastic, distorted

Pelvic Kidney

Note the paths of the renal artery and renal vein in pelvic kidneys
Ectopic Kidneys

Malpositioned Kidney, continued

2. If kidney not identified in renal fossa, scan lower abdomen & pelvis 3. If reniform mass is observed in abdomen or pelvis, check renal fossa 4. If pelvic or ectopic kidney seen in pregnancy, C-section advised 5. Crossed kidneys usually seen in pediatric age group

Renal Pathology, continued

B. Hypoplasia
1. Kidney small, with poor function 2. Appears distorted with increased lobulation 3. Differentiation from diseased kidney may be difficult
Renal Hypoplasia

Renal Pathology, continued

4. Differentiation from true renal agenesis may be difficult

a. In agenesis, fossa may contain bowel (simulates hypoplasia) b. Both may result in hypertrophy of contralateral kidney

Renal Pathology, continued

C. Duplication/Fusion:
1. May be a duplex collecting system or two separate components 2. If complete separation occurs, upper pole ureter may form ureterocele:
Duplex/Fused Collection Systems

Renal Pathology, continued

a. Leads to obstruction & hydronephrosis b. May have septations c. Appears as triangular, sonolucent sac in upper aspect of kidney

Hydronephrosis

Renal Pathology, continued

3. Horseshoe Kidney
a. Most common fusion anomaly b. Usually fused at inferior pole c. The isthmus may simulate a retroperitoneal mass d. May be confused with para-aortic lymph nodes e. Look for malrotated pelvis

Abnormal Kidney Structures

Note the fused lower pole and rotated pelves

Pancake Kidney

Horseshoe Kidney

Malrotated Kidneys

Renal Pathology, continued

Renal and Adrenal Diseases: In Patho