Kidney Diseases

Published on 16/04/2015 by admin

Filed under Surgery

Last modified 22/04/2025

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12 Kidney Diseases

Anatomy of the Kidneys

image

Kidney in Situ

Position of the Kidneys

• Retroperitoneal, posterior to upper GI organs
• Lying on lateral borders of upper psoas muscles
• Kidneys and adrenals lie within perirenal (perinephric) fat that is enclosed by fibrous renal fascia (Gerota’s).
• Retroperitoneal pararenal fat surrounds renal fascia.
• Parts of right kidney lie posterior to liver, duodenum, and right colic (hepatic) flexure.
• Right-dominant liver forces right kidney to lie lower than the left.
• Parts of left kidney lie posterior to stomach, tail of pancreas, spleen, and left colic (splenic) flexure.
• Upper parts of both kidneys overlie posterior inferior diaphragm.
• Right kidney also typically overlies quadratus lumborum, 12th rib, and transversus abdominis.
• Left kidney overlies quadratus lumborum, 11th and 12th ribs, and transversus abdominis.
image

Gross Structure of Kidney

Internal Renal Structure

• Renal capsule: fibrous, invests cortex, terminates around the rim of minor calyces in renal sinus
• Cortex: contains Bowman’s capsules and glomeruli (renal corpuscles), proximal and distal convoluted tubules, proximal collecting ducts, arcuate arteries and veins, cortical capillary plexus
• Medulla, pyramids: contain loops of Henle, distal collecting ducts, vasa rectae, medullary capillary plexus
• Renal (cortical) columns (Bertini): lie between pyramids, like cortex, contain renal corpuscles, tubules, and vessels
• Renal papilla: apex of pyramid, contains collecting tubule openings, drains into minor calyx

Collecting System

• Minor calyces: collect urine from papillary tubules
• Major calyces: formed by union of 8-10 minor calyces
• Renal pelvis: formed by union of 2-4 major calyces, connects in turn to ureter

Ureter

• Fibromuscular tube with mucosa
• Upper: renal pelvis to upper border of sacrum
• Middle: overlies sacrum
• Lower: border of sacrum to bladder
• Blood supply: upper from renal arteries, middle from ovarian or testicular arteries, lower from vesical arteries
image

Nerves of Kidneys, Ureters, and Urinary Bladder

Innervation of Kidneys and Ureters

• Parasympathetic

image Preganglionic: vagal fibers run through celiac and superior mesenteric plexuses, joining renal nerve plexus for distribution to ganglion cells in renal parenchyma, pelvis, and ureter

• Sympathetic

image Preganglionic: fibers run through splanchnic nerves (especially least), celiac, and superior mesenteric plexuses to synapse in aorticorenal ganglia.
image Postganglionic: fibers distributed to smooth muscle of renal vessels and gomeruli

• Sensory

image Segmental visceral afferent fibers run parallel to sympathetic fibers to dorsal root ganglia and spinal segments T11-L2.

Vessels and lymphatics

• Renal hilus: vessel entry and exit region
image

Intrarenal Arteries and Renal Segments

image

Renal Artery and Vein in Situ

Arterial Supply

• Renal arteries are usually paired main branches on the right and left sides of abdominal aorta.
• Often variable, in up to 40% of cases
• Variations include accessory renal arteries (in addition to main) and pelvic branches with pelvic or horseshoe kidneys
• Renal artery branches at hilum typically lie posterior to renal veins and anterior to renal pelvis.

Venous Drainage

• Renal veins: usually single main branches, left and right, draining directly into the right-sided abdominal vena cava
• Long course of left renal vein passes anterior to aorta and under superior mesenteric artery (nutcracker configuration).
image

Lymph Vessels and Nodes of Kidneys

Lymphatic Drainage

• Parenchymal, subcapsular, and perirenal plexuses drain into caval and aortic (lumbar) nodes.
• Lumbar nodes drain through lumbar lymphatic trunks into cisterna chyli.

Clinical Correlates

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Renal Stones

image

Obstructive Uropathy

Stones

• Symptoms: severe colicky pain and restlessness
• Urinalysis might demonstrate blood and stones.
• CT can demonstrate stones and hydronephrosis.
• Calcium oxalate (phosphate)

image Most common (~75%) and radiopaque
image Increased occurrence due to increased colonic uptake of oxalate in terminal ileum resection

• Magnesium ammonium phosphate (struvite) stones (~15%) are radiopaque and can occur with infections producing urease (e.g., Proteus mirabilis).
• Struvite stones can develop into staghorn calculi that fill renal pelvis.
• Uric acid stones (~7%)

image Radiolucent
image Increased incidence in patients with ileostomies, gout, and myeloproliferative diseases

• Cysteine stones (~2%)

image Radiolucent to radiopaque
image Associated with congenital disorders of cysteine reabsorption

• Surgical indications: intractable infection or pain, progressive obstruction, progressive kidney damage, solitary kidney

Renal Cancer

• Renal cell carcinoma (hypernephroma): most common primary tumor
• Symptoms: abdominal pain, mass, hematuria
• About 15% calcified
• About 33% metastasized by time of diagnosis, to lung (most common) or colon
• Greatest risk factor: smoking
• Treatment

image Radical nephrectomy
image Selective radiation, chemotherapy, immunotherapy
image Appropriate resection of metastases

• von Hippel–Lindau syndrome: recurrent renal cell cancer, cysts, pheochromocytomas, CNS tumors
• Nephroblastoma (Wilms’ tumor)

image Rare renal malignant tumor of early childhood: 8/million incidence
image Manifests commonly as asymptomatic abdominal mass
image Tumor cells produce renin, leading to hypertension.
image Associated with hypospadias, cryptorchidism, ocular malformations

• Most common secondary renal tumor: breast metastasis
• Other neoplasms

image Transitional cell cancer of renal pelvis
image Angiomyolipomas
image Oncocytomas

image

Surgical Approaches to the Kidney

Surgical Approaches to the Kidneys

• Multiple different surgical approaches to kidneys: anterior, lateral or flank, lumbar or posterior, laparoscopic
• Lateral and posterior approaches are extraperitoneal.
• Preferred approach depends on disease, size and extent of lesion, obstruction, trauma, cancer or resection, and failure or transplant.
• Radical nephrectomy (typical treatment for renal cell carcinoma): resection of kidney, perinephric fat, Gerota’s fascia
• Partial resection for solitary or for multiple or recurring tumors (e.g., von Hippel–Lindau syndrome)

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