1. Cross Sectional Anatomy The kidneys hhholdorf

2. This is an image of what?

3. This is an image of what?

4. This is an image of what?

5. Renal Parenchyma

7. General Stuff Retroperitoneal
Left higher than the right (Liver on the rt)
Ascends during embryology from the lower abdomen.
Pelvic kidney?
Back pain? Could be your kidney!

8. Kidney Size ADULT CHILD INFANT 9.0 to 12.0 cm in length.
4.0 to 5.0 cm in width.
2.5 to 3.0 cm in height.
Minimum of 1 cm in cortical thickness.
CHILD
7.0 to 8.0 cm in length.
INFANT
5.0 to 6.0 cm in length.

9. Indications for Exam Increase in creatinine or BUN levels.
Urinary tract infection.
Flank pain.
Hematuria.
Hypertension.
Decrease in urine output.
Trauma.
Evaluate mass from previous medical imaging study (i.e., CT, MRI, IVP)

10. LABORATORY VALUES CREATININE BLOOD UREA NITROGEN
Normal 0.6 to 1.2 mg/dL.
A waste product produced from meat protein and normal wear and tear on the muscles in the body.
More specific in determining renal dysfunction than BUN levels.
Elevated in renal failure, chronic nephritis or urinary obstruction.
BLOOD UREA NITROGEN
Normal 11 to 23 mg/dL.
Produced from the breakdown of food proteins.
Elevated in urinary obstruction, renal dysfunction, or dehydration.
Decreased levels associated with over hydration, pregnancy, liver failure, decrease in protein intake, and smoking.

11. Laboratory Values: Continued
HEMATURIA
Visible or microscopic red blood cells in the urine.
Associated with early renal disease.
PROTEINURIA
Abnormal amount of proteins in the urine.
Associated with nephritis, nephrolithiasis, carcinoma, polycystic disease, hypertension, and diabetes mellitus.
Increases risk of developing progressive renal dysfunction.

12. Key terms
Dromedary hump cortical bulge on the lateral aspect of the kidney.
fascia fibrous connective membrane of the body that may be separate from other structures.
Fetal lobulation immaturity of renal development resulting in a lobulated renal contour.
Gerota’s fascia protective covering of tissue surrounding each kidney.

13. Dromedary Hump Kidney

14. Fetal lobulation variant

15. Renal parenchyma the functional tissue of the kidney consisting of the nephrons.
Renin renal enzyme that affects blood pressure.

16. Renal Parenchyma and relative echogenicity

17. Produces urine and erythroprotein.
FUNCTIONS OF THE URINARY SYSTEM
Produces urine and erythroprotein.
Influences blood pressure, blood volume, and intake or excretion of salt and water through the renin–angiotensin system.
Regulates serum electrolytes.
Regulates acid–base balance.

18. TECHNIQUE PREPARATION Kidneys—patient should be hydrated.
Renal vessels—nothing by mouth for 6 to hours before the examination.
Bladder—drink 8 to 16 ounces of water 1 hour before the examination.

19. EXAMINATION TECHNIQUE and imaging optimization
Use the highest-frequency abdominal transducer possible to obtain optimal resolution for penetration depth.
Place gain settings to display the normal adult renal cortex as moderate or low-level echogenicity and the renal sinus as the most echogenic with adjustments to reduce echoes within the vessels.

20. Position the focal zone(s) at or below the region of interest.
Sufficient imaging depth to visualize structures posterior to the region of interest.
Harmonic imaging and decreasing the compression (dynamic range) can be used to reduce artifactual echoes within anechoic structures and improve prominence of posterior acoustic shadowing.

21. Evaluation and documentation of the superior, inferior, medial, and lateral aspects of each kidney in the coronal or sagittal plane.

22. Evaluation and documentation of the superior pole, renal hilum, and inferior pole of each kidney in the transverse plane.
Measurements of maximum length, thickness, and width of each kidney.
Measurement of the cortical thickness of each kidney.

24. Evaluation and documentation of the bladder wall.
Prevoid and postvoid bladder volumes may be included.
Kidneys are best evaluated with an empty urinary bladder.
Documentation and measurement of any abnormality in two scanning planes should be included.

25. Right superior pole with intercostal approach
PATIENT POSITION
Supine
Right superior pole with intercostal approach
Right inferior pole with subcostal approach

26. What patient position is this?

27. Left posterior oblique (LPO)
Allows bowel to move away from right kidney
Subcostal or intercostal approach

28. Left Posterior Oblique incorrect

29. What patient position is this?

30. Left lateral decubitus
Liver and kidney “fall” from the rib cage
Aids in obese or gassy patients

31. What patient position is this?

32. Right posterior oblique (RPO)
Left superior pole with intercostal approach
Posterior subcostal approach for left inferior pole

33. What patient position is this?

34. Right lateral decubitus
Left posterior approach with deep inspiration
Prone
Demonstrates mid and inferior poles of both kidneys

35. What patient position is this?

36. Prone

37. RAO-Right Anterior Oblique

38. PHYSIOLOGY The nephron is the basic functional unit of the kidney.
Each kidney contains over one million nephrons.

39. The renal Nephron

40. ANATOMY
Renal capsule
Fibrous capsule (true capsule) surrounding the cortex
Renal cortex
Outer portion of the kidney

42. Medulla
Inner portion of the renal parenchyma
Within the medulla lie the renal pyramids
Renal pyramids contain tubules and the loops of Henle

43. Column of Bertin
Inward extension of the renal cortex between the renal pyramids
Renal sinus
Central portion of the kidney
Contains the major and minor calyces, peripelvic fat, fibrous tissues, arteries, veins, lymphatics, and part of the renal pelvis
Renal hilum
Contains the renal artery, renal vein, and ureter

44. Column of Bertin between the renal Pyramids

46. Gerota’s Fascia “C”

47. Location
Paired bean-shaped structures lying in a sagittal oblique plane in the retroperitoneal cavity.
Located between the first and third lumbar vertebrae.
Superior poles lie more posterior and medial.
Inferior poles lie more anterior and lateral.
Left kidney lies superior to the right kidney.

48. Each Kidney Is Located
Anterior to the psoas and quadratus lumborum muscles.
Medial to the transverse abdominus muscle and liver or spleen.
Lateral to the quadratus lumborum muscle.

49. Renal Anatomical Variants
Dromedary hump
Cortical bulge on the lateral aspect of the kidney
Demonstrated most often on the left
Asymptomatic Lateral outward cortical bulge
Echogenicity equal to the cortex Carcinoma?
Hematoma?

50. What is this an image of?

51. What is this an image of?

52. Congenital Anomalies
Agenesis
Absence of the kidney(s)

53. Renal Agenesis Unilateral or bilateral Asymptomatic when unilateral
Fatal when bilateral
Associated with genital anomalies Empty renal fossa(e)
Large, contralateral kidney Pelvic kidney?
Surgical removal?

54. Diagnosis, please.

55. Horseshoe kidney

56. What is this?

57. Horseshoe kidney

58. Renal Vasculature

59. MAIN RENAL ARTERY
The right renal artery arises from the anterolateral aspect of the aorta. The left renal artery arises from the posterolateral aspect of the aorta.
May have multiple ipsilateral arteries

60. A single ipsilateral artery may divide into multiple renal arteries at the hilum
Courses posterior to the renal vein
Main renal artery arises  cm inferior to the origin of the superior mesenteric artery
Right renal artery is longer than the left renal artery

61. Demonstrates low-resistance blood flow
Supplies the kidney, ureter, and adrenal gland
Segmental artery
After entering the renal hilum the artery divides into 4-5 segmental arteries

62. Interlobar artery
Branch of the segmental artery
Course alongside the renal pyramids
Demonstrates low-resistance blood flow

63. Renal Vasculature—
Arcuate artery
Boundary between the cortex and medulla
Branch of the interlobar artery located at the base of the medulla
Arcuate arteries give rise to the interlobular arteries
Demonstrates low-resistance blood flow
Interlobular artery
Branch of the arcuate arteries entering the renal glomeruli

64. MAIN RENAL VEIN
Formed from the junction of tributaries in the renal hilum
Courses anterior to the renal artery
Left renal vein receives the left suprarenal and left gonadal vein
Left renal vein is longer than the right renal vein
Dilatation of the left renal vein due to mesenteric compression may be demonstrated

65. Ureter Anatomy
25 – 34 cm long tubular structure connecting the renal pelvis to the urinary bladder.
Coarse vertically with retroperitoneum along the psoas muscles.
Insert posterior and inferiorly at the Trigone of the bladder.
Distal ureter at the trigone considered extraperitoneal.

67. Support Structure of the Kidneys
Psoas muscle
Major groin muscle
Primary flexor of the hip joint
Lies posterior to the inferior pole of each kidney
Quadratus lumborum muscle
Muscle of the posterior abdominal wall
Lies posterior and medial to each kidney
Transversus abdominus muscle
Deepest layer of flat muscles of the anterolateral wall
Lies lateral to each kidney
Gerota’s fascia
Fibrous covering of tissue surrounding each kidney
Also known as Gerota’s capsule; renal fascia
Perinephric fat
Fatty tissue surrounding each kidney
Renal capsule
Protective connective tissue capsule surrounding each kidney

68. Gerota’s Fascia “C”

69. Protocol Right Kidney Sagittal Mid-Med and Lateral Borders
Measure upper pole to lower pole
Doppler Right Renal artery-Nml is low resistant
Transverse
Mid pole-Measure side to side
Upper pole to lower pole
Doppler IVC to check for thrombus

70. Protocol Left Kidney Sagittal Mid-Med Lateral
Measure Upper pole to lower pole
Transverse
Measure mid pole (Lateral side to Medial Side)
Upper pole to lower pole
OTHER
Check bladder

71. Homework Locate the following on a cartoon and an ultrasound image:
Renal Sinus
Column of Bertin
Psoas muscle
Renal Hilum
Perinephric fat
Segmental artery
Interlobar artery
Main Renal Artery
Main Renal Vein

72. List the protocol for a renal exam.

73. Answer the following either True or False.
The kidneys are retroperitoneal.
Right higher than the left.
Descends during embryology from the upper abdomen.

74. Which is not an indication for a renal exam?
A. increase in creatinine
B. Decrease in BUN levels
C. Flank Pain.
D. Hematuria
The protective covering of tissue surrounding each kidney is called:
A. parenchyma
B. Renal cortex
C. Gerota’s fascia