Anatomy, Abdomen and Pelvis, Kidneys


Article Author:
Roberto Soriano


Article Editor:
Stephen Leslie


Editors In Chief:
Anne Kennedy


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
4/5/2019 1:15:11 PM

Introduction

The kidneys are bean-shaped organs weighing anywhere from 150 to 200 g in males and about 120 to 135 g in females. The dimensions are usually a length of 10 to 12 cm, a width of 5 to 7 cm, and the thickness varies from 3 to 5 cm. Each kidney is about the size of a closed fist. They are located retroperitoneally in the posterior abdominal wall and are found between the transverse processes of T12 and L3. Both of the upper poles are usually oriented slightly medially, and posteriorly to the lower poles. If the upper renal poles are oriented laterally, this could suggest a horseshoe kidney or a superior pole renal mass.  Further, the left kidney is usually slightly more superior in position than the right kidney.[1][2][3]

The following are the kidneys in relation to surrounding organs:

  • Superiorly, on top of each kidney, are the suprarenal glands (adrenal glands)
  • The medial aspect of the right kidney is adjacent to the second part of the duodenum
  • The tail of the pancreas lies medial to the left renal hilum
  • The greater curvature of the stomach may extend over the superomedial aspect of the left kidney
  • The left upper pole is located adjacent to the spleen and connected by the splenorenal ligaments
  • The colon rests anterior to both kidneys

Posteriorly, the diaphragm rests over the upper third of each kidney with the 12th rib frequently passing over (anteriorly) the upper pole. The kidneys usually sit located over the medial aspect of the psoas muscle and the lateral aspect of the quadratus lumborum. The proximal ureters will typically pass over the psoas muscle on their way to the bony pelvis.

At the medial margin of each kidney lies the renal hilum, where the renal artery enters, and the renal pelvis and vein leave the renal sinus. The renal vein is found anterior to the renal artery, which is anterior to the renal pelvis. The renal pelvis is the flattened, superior end of the ureter. It receives 2 or 3 major calyces, each of which divides into 2 or 3 minor calyces. The minor calyces are indented by the renal papillae, which are the apices of the renal pyramids.

Each kidney has a capsule and is surrounded by fat, Gerota's fascia, and more fat. The entire area immediately involving the kidneys is considered the retroperitoneum.[4][5][6]

Structure and Function

The kidneys perform several important functions including excretion of waste products such as ammonia and urea, electrolyte regulation, and acid-base balance. They play a vital role in the control of blood pressure and the maintenance of intravascular volume via the renin-angiotensin-aldosterone system. They are responsible for the reabsorption of amino acids, electrolytes, calcium, phosphate, water, and glucose, as well as the secretion of the hormones calcitriol and erythropoietin.

Embryology

The mammalian kidney develops from the intermediate mesoderm. Kidney development (nephrogenesis) develops in three successive phases the pronephros, mesonephros, and metanephros. The metanephros are primordia of the permanent kidney.

Blood Supply and Lymphatics

About 25% of the total cardiac output goes to the kidneys. These highly vascular organs are supplied via the renal arteries, which enter the hilum of the kidney at L2. The longer right renal artery passes posterior to the inferior vena cava (IVC). Both of the renal arteries divide close to the renal hilum giving off five segmental arteries. The first branch is the posterior segmental artery, and it supplies the posterior segment of the kidney. The remaining 4 main segmental arteries all arise from the anterior branch of the renal artery and are named according to the segment of kidney they supply: the superior segmental artery, the anterosuperior segmental artery, the anteroinferior segmental artery, and the inferior segmental artery.

The renal veins follow the path of the arteries. Of note is that the left renal vein is a few centimeters longer than the right vein as it has to cross the midline from the left side to reach the inferior vena cava. Thus for transplants, the left kidney is usually selected as a graft as it has a longer length vein. In most cases, the left gonadal vein drains into the left renal vein inferiorly. The left renal vein passes just below the origin of the superior mesenteric artery to reach the inferior vena cava. Conversely, on the right side, the gonadal and renal veins separately drain into the inferior vena cava. Finally, the kidneys are drained by lymphatics which enter the aortic lymph nodes on the left and the right lateral inferior caval lymph nodes on the right.

Nerves

Innervation to the kidneys is communicated via the renal nerve plexus consisting of sympathetic and parasympathetic fibers. This plexus is usually supplied by fibers from the least splanchnic nerve. Visceral afferent fibers in a retrograde fashion follow the sympathetic fibers to the spinal ganglia and cord segments T10 to T11. Pain is often sensed in the corresponding dermatome; thus, flank pain can be referred pain from the corresponding kidney. Renal pain is typically caused by obstruction and dilation, inflammation (infection) or ischemia. Non-obstructing stones in the kidney are generally not the cause of any renal pain or colic.

Surgical Considerations

All of the arteries in the kidneys are end arteries which means there are no renal arterial collaterals. This also means it is necessary to protect any branches or accessory arteries to the kidneys to avoid loss of parenchymal function.

Brodel's line is the relatively avascular line between the renal anterior and posterior end arteries.  It runs longitudinally from superior to inferior and is located just posterior to the lateral convex border of each kidney.  Its importance is that this is the ideal location to place a nephrostomy or to perform a renal incision to minimize blood loss.

The retroperitoneum is an enclosed space separate from the peritoneal cavity. When the kidney is injured or traumatized, it is usually wise not to open the retroperitoneum as this will cause a loss of the tamponade effect and may ultimately result in the surgical removal of a kidney that could otherwise have been saved.

The retroperitoneal space is located between the posterior parietal peritoneum medially and the transversalis fascia laterally. It is sometimes divided into 3 spaces (the anterior pararenal space, the perirenal space, and the posterior pararenal space) by the perirenal fascia.

Clinical Significance

Kidney disease is defined as the presence of an abnormal process or function in the kidney(s).[7][8][9]

  • Nephrosis is non-inflammatory nephropathy.
  • Nephritis is inflammatory kidney disease.
  • Nephrology is the medical specialty that deals with kidney function and disease.
  • Urology is the specialty that deals with surgical problems associated with the kidney.

  • Image 61 Not availableImage 61 Not available
    Contributed by Scott H. Plantz, MD, FAAEM
Attributed To: Contributed by Scott H. Plantz, MD, FAAEM

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Anatomy, Abdomen and Pelvis, Kidneys - Questions

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The macula densa is located in what part of the renal system?



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Which is the true statement regarding renal veins/arteries?



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Which characteristic does not differentiate proximal and distal convoluted tubules?



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Are the native kidneys normally supplied by the iliac arteries or their branches?



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Which of the following structures is the most distal part of the nephron?



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Which is correct about the following statement? The native kidneys are normally supplied by the iliac arteries or their branches.



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What is the physical relationship of the adrenal gland to the kidney?

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Anatomically, which of the following best describes the glomerulus?



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What percentage of cardiac output goes to the kidneys?



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Why, on normal appearing static renal scintigraphic images, might both renal lower poles appear slightly diminished in activity gently fading from the corresponding activity in the upper poles?



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Which of the following is usually the first branch of the renal artery?



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Which of the following does not lie adjacent to the right kidney?



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Hypoplasia of the kidney refers to which of the following?



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You are on-call with the transplant team when a donor kidney becomes available. Which of the following is the surgeon most likely to perform?



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Which of the following statements regarding the kidneys' blood supply and lymphatic drainage is false?



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What is the anatomical location of the left and right kidney?



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Anatomy, Abdomen and Pelvis, Kidneys - References

References

Bowdino CS,Shaw PM, Anatomy, Abdomen and Pelvis, Renal Veins 2019 Jan;     [PubMed]
Lescay HA,Tuma F, Anatomy, Abdomen and Pelvis, Ureter 2019 Jan;     [PubMed]
Coccolini F,Catena F,Kluger Y,Sartelli M,Baiocchi G,Ansaloni L,Moore EE, Abdominopelvic trauma: from anatomical to anatomo-physiological classification. World journal of emergency surgery : WJES. 2018;     [PubMed]
Lung K,Lui F, Anatomy, Abdomen and Pelvis, Arteries 2019 Jan;     [PubMed]
Megha R,Leslie SW, Anatomy, Abdomen and Pelvis, Adrenal Glands (Suprarenal Glands) 2019 Jan;     [PubMed]
Kirkpatrick JJ,lobo s, Anatomy, Abdomen and Pelvis, Kidney Nerves 2019 Jan;     [PubMed]
Prasad M,Vora T,Agarwala S,Laskar S,Arora B,Bansal D,Kapoor G,Chinnaswamy G,Radhakrishnan V,Kaur T,Rath GK,Bakhshi S, Management of Wilms Tumor: ICMR Consensus Document. Indian journal of pediatrics. 2017 Jun;     [PubMed]
Zuk A,Bonventre JV, Recent advances in acute kidney injury and its consequences and impact on chronic kidney disease. Current opinion in nephrology and hypertension. 2019 Mar 28;     [PubMed]
Russell PS,Hong J,Windsor JA,Itkin M,Phillips ARJ, Renal Lymphatics: Anatomy, Physiology, and Clinical Implications. Frontiers in physiology. 2019;     [PubMed]

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