Kidneys

Objectives
1. Renal system Organs
2. General features & location
3. Borders, surfaces & poles etc
4. Hilum & structures passing through it
5. Anterior relations & Posterior relations
6. Capsule & coverings of Kidneys
7. Internal structure & Functional units of kidney
8. Blood supply & Segments of kidney
9. Surgical exposure of kidney from behind
10.Clinicals = pelvic cavity, Horse shoe shaped & renal agenesis
Kidneys
Synonyms: Ren: kidney (in Latin); Nephros: kidney (in
Greek).
1. The kidneys are two bean-shaped, reddish-brown organs
within the abdomen situated on the posterior abdominal
wall.
2. They are the major excretory organs and remove the
waste products of protein metabolism and excess of
water and salts from the blood and are thus essential for
maintaining the electrolyte and water balance in the
tissue fluids of the body, necessary for survival.
Kidneys
The kidneys lie on the posterior abdominal wall, one on each side
of the vertebral column, behind the peritoneum, opposite 12th
thoracic and upper three lumbar (T12–L3) vertebrae. They occupy
epigastric, hypochondriac, lumbar and umbilical regions.
1. The right kidney lies at a slightly lower level than the left one
due to the presence of liver on the right side.
2. The left kidney is little nearer to the median plane than the right.
3. Their long axes are slightly oblique (being directed downward
and laterally) so that their upper ends or poles are nearer to each
other than the lower poles. The upper poles are 2.5 cm away from
the midline, the hilum are 5 cm away from the midline, and the
lower poles are 7.5 cm away from the midline.
Kidneys
4. Both kidneys move downward in vertical direction for 2.5 cm
during respiration.
5. Transpyloric plane passes through the upper part of the hilum of
the right kidney and through the lower part of the hilum of the left
kidney.
Shape and Measurements
Shape: Bean shaped.
Measurements:
Length: 11 cm. (left kidney is slightly longer and narrower).
Width: 6 cm.
Thickness: (anteroposterior) 3 cm.
Weight: 150 g in males; 135 g in females.
Kidneys
Each kidney presents the following external features:
1. Two poles (superior and inferior).
2. Two surfaces (anterior and posterior).
3. Two borders (medial and lateral).
4. A hilum.
POLES
1. The superior (upper) pole is thick and round and lies nearer to the
median plane than the inferior pole. It is related to the suprarenal
gland.
2. The inferior (lower) pole is thin and pointed and lies 2.5 cm above
the iliac crest.
Kidneys
SURFACES
1. The anterior surface is convex and faces anterolaterally.
2. The posterior surface is flat and faces posteromedially.
However, in practice it is difficult to recognize anterior
and posterior surfaces. This however is done easily by seeing the
relationship of structures present at the hilum
BORDERS
1. The medial border of each kidney is convex above and
below near the poles and concave in the middle. It slopes downward
and laterally, and presents a vertical fissure in its middle part called
hilum/hilus which has anterior and posterior lips.
2. The lateral border of each kidney is convex.
Kidneys
HILUM
The medial border (central part) of the kidney presents a deep
vertical slit called hilum. It transmits, from before backward, the
following structures
1. Renal vein.
2. Renal artery.
3. Renal pelvis.
4. Subsidiary branch of renal artery.
In addition to the above structures the hilum also transmits
lymphatics and nerves, the latter being sympathetic and mainly
vasomotor in nature.
Kidneys = Anterior relations
The anterior relations of two kidneys are different.
Anterior surface of the right kidney:
1. Right suprarenal gland.
2. Right lobe of the liver.
3. Second part of the duodenum.
4. Hepatic (right colic) flexure.
5. Jejunum.
Out of these, liver and jejunum are separated from the
kidney by peritoneum.
Kidneys = Anterior relations
Anterior surface of the left kidney:
1. Left suprarenal gland.
2. Spleen.
3. Stomach.
4. Pancreas and splenic vessels.
5. Left colic flexure.
6. Jejunum.
Out of these, stomach, spleen, and jejunum are separated
from the kidney by peritoneum.
Kidneys = Posterior relations
The posterior relations of two kidneys are the same
exceptthat right kidney is related to one rib while left kidney
is related to two ribs:
1. Four muscles: Diaphragm, quadratus lumborum, psoas
major, and transversus abdominis.
2. Three nerves: Subcostal (T12), iliohypogastric (L1), and
ilioinguinal (L1). The subcostal nerve is accompanied by the
subcostal vessels.
3. One or two ribs: The right kidney is related to the 12th rib
whereas the left kidney is related to the 11th and 12th ribs.
Kidneys
CAPSULES (COVERINGS) OF KIDNEY
From within outwards, the kidney is surrounded by four
capsules/coverings as follows
1. Fibrous capsule (true capsule).
2. Perirenal (perinephric) fat.
3. Renal fascia (false capsule).
4. Pararenal (paranephric) fat.
1. Fibrous capsule (true capsule) = It is a thin membrane which closely
invests the kidney. It is formed by the condensation of fibrous
connective tissue in the peripheral part of the organ.
2. It is readily stripped off from the surface of the normal kidney. The
capsule passes through the hilum to line the renal sinus and becomes
continuous with the walls of calyces where they are attached with the
kidney. If the kidney is inflamed, this capsule becomes firmly adherent
to the organ and cannot be stripped off.
Kidneys
Perirenal (perinephric) fat
1. It is a layer of adipose tissue, surrounding the fibrous
capsule of the kidney.
2. It fills the space inside the loosely fitting sheath of the
renal fascia enclosing the kidney and suprarenal gland.
3. This fatty capsule is thickest at the borders of kidney and
is prolonged through hilum into the renal sinus.
4. In chronic debilitating diseases, the depletion of
perinephric fat can cause downward displacement of the
kidney, which may lead to the kinking of the ureter.
Kidneys
Kidneys = Renal fascia (false capsule/ fascia of gerota)
It is a fibroareolar sheath, which surrounds the kidney and perirenal fat.
It consists of the following two layers:
1. An ill-defined anterior layer (fascia of Toldt).
2. A well-defined posterior layer (fascia of Zuckerkandl).
Extensions
1. Superiorly, the two layers first enclose the suprarenal gland in a separate
compartment and then fuse with each other and become continuous with the
diaphragmatic fascia.
2. Inferiorly, the two layers remain separate and enclose the ureter. The anterior layer is
gradually lost in the extraperitoneal tissue of iliac fossa while the posterior layer blends
with the fascia iliaca.
3. Laterally, the two layers unite firmly and become continuous with the fascia
transversalis.
4. Medially, the anterior layer passes in front of the kidney and renal vessels and merges
with the connective tissue surrounding the aorta and inferior vena cava (IVC). The
posterior layer passes behind the kidney and is attached to fascia covering the
quadratus lumborum and psoas major.
Kidneys = coverings
At the medial border of the kidney, the two layers are
attached by a connective tissue septum being pierced by
the renal vessels. Because of this attachment (septum),
perirenal effusion of the fluid does not usually extend
across into the opposite perirenal space.
Pararenal (paranephric) fat
It is a layer of fat lying outside the renal fascia. It consists of
considerable quantity of fat being more abundant
posteriorly and toward the lower pole of the kidney. It fills
the paravertebral gutter and forms a cushion for the kidney.
When the kidney is split longitudinally, it
presents the kidney proper and the renal
sinus.
Kidney Proper
The naked eye examination of the
kidney proper presents an outer cortex
and an inner medulla.
The cortex is located just below the
renal capsule and extends between the
renal pyramids (vide infra) as renal
columns (columns of Bertini). The
cortex appears pale yellow with granular
texture.
The medulla is composed of 5–11 dark
conical masses called renal pyramids
(pyramids of Malpighi). The apices of
renal pyramids form nipple-like
projections—the renal papillae which
invaginate the minor calyces.
A renal pyramid along with its covering
cortical tissue forms a lobe of the
kidney.
Renal Sinus
It is a cavity of considerable size present
within the kidney. It takes up a large part
of the interior of the kidney and opens
at the medial border of the kidney as hilus.
It contains:
1. Greater part of the renal pelvis, major
and minor calyces.
2. Renal vessels, lymphatics, and nerves.
3. Fat.
The sinus is lined by the continuation of
the true capsule of the kidney. Numerous
nipple-like elevations (renal papillae)
indent the wall of the sinus. The renal
pelvis within the sinus is divided into two
or three large branches, called
major calyces, which further divides to
form 5–11 short branches called minor
calyces.
Kidneys
The kidneys are supplied by the renal arteries. Usually there is one
renal artery for each kidney, but in about 30% individuals accessory
renal arteries are also found. They commonly arise from the aorta
and enter the kidney at the hilus or at one of its poles, usually the
lower pole. The renal arteries have a blood flow in excess of 1
L/minute.
Renal arteries
The renal arteries arise directly from the abdominal aorta just below
the origin of the superior mesenteric artery (i.e., at the level of
intervertebral disc between L1 and L2).
1. The right renal artery passes to the right behind the inferior vena
cava and right renal vein, while the left renal artery passes to the left
behind the left renal vein.
Kidneys = Blood supply
2. At or near the hilum of the kidney, each renal artery divides
into anterior and posterior divisions.
The anterior division supplies apical, upper, middle, and lower
segments, while posterior division supplies only posterior
segment. The branches supplying the sgements are called
segmental arteries. The anterior segmental arteries are usually
larger than the posterior.
3. Each of these segmental arteries after supplying renal sinus
divides into lobar branches.
4. The lobar arteries break up into two or three interlobar arteries
which pass through renal columns between the pyramids.
5. When an interlobar artery reaches the base of the associated
pyramids, it divides dichotomously into the arcuate arteries.
Kidneys
6. The arcuate arteries run parallel to the surface of the kidney between the
pyramids and the overlying cortex.
7. The renal arteries do not anastomose with adjacent arcuate arteries but give
branches which pass radially toward the surface of the kidney which are called
interlobular arteries.
8. The afferent arterioles from interlobular arteries pass to the capillaries of
glomeruli, which then reunite to form efferent arterioles.
9. The efferent arterioles divide to form peritubular capillary plexus around the
convoluted tubules.
10. The capillaries drain into the interlobular veins and then into interlobar
veins, which run along the corresponding arteries.
11. The interlobular veins drain into the arcuate veins which in turn drain into
interlobar veins which pass through the kidney tissue to the sinus where they
join to form the renal vein.
The junction between the areas
supplied by the anterior and
posterior divisions of the renal
artery is called Brödel’s line (an
important anatomical landmark).
It is on the posterior aspect of the
kidney at the junction of medial
two third and lateral one-third. It is
a functional avascular plane
between the posterior segment
medially and the upper and middle
segments, hence suitable site for
surgical incision to remove the
renal stones
(nephrolithotomy).
• Congenital anomalies:
(a) Lobulated kidney: The persistence
of fetal lobulation in the adult kidney:
It is of no clinical significance.
(b) Aberrant artery: The persistence of
one of the fetal arteries is common
(30% individuals), especially an artery
from the aorta to the lower pole of the
kidney.
(c) Congenital polycystic kidney: It is
is formed if the luminal continuity
between the nephrons and collecting
tubules fail to establish. The
glomeruli continue to excrete urine
which accumulates in the
tubules due to lack of outlet. As a
result tubules undergo cystic
enlargements (retention cysts
(d) Horseshoe kidney (1 in 800; It
occurs due to fusion of the lower
poles of the kidneys. The ureters
pass anterior to the isthmus. The
inferior mesenteric artery also
passes anterior to the isthmus
which limits the ascent of the
horseshoe kidney.
(e) Renal agenesis (1 in 500): It
occurs when ureteric bud fails to
develop. Unilateral renal agenesis is
relatively common. A physician
should never assume that a patient
has two kidneys. A surgeon must
confirm this fact before considering
nephrectomy.
Kidneys
Renal pain:
1. The renal pain is felt in the loin and often radiates downward
and forward into the groin. The nature of pain varies from
dull ache to severe spasmodic pain.
2. The renal pain occur either due to stretching of the renal
capsule or due to spasm of the smooth muscle in the renal
pelvis. The afferent fibres pass successively through the
renal plexus, lowest splanchnic nerve, sympathetic trunk,
and enter the T12 spinal segment.
3. The pain is commonly referred along the subcostal nerve to
the flank and anterior abdominal wall and along the
ilioinguinal nerve (L1) into the groin.
Kidneys
EXPOSURE OF THE KIDNEY FROM BEHIND
For posterior surgical approaches to the contents of the
abdominal cavity, viz., kidney and ureter or the sympathetic
trunk, one should know the composition of the posterior
abdominal wall in the lumbar region. This is well
appreciated by the anatomical exposure of the kidney from
behind.
Loin: It is the region on the back of the trunk, bounded
above by the 12th rib, below by the iliac crest, medially by
the posterior median line, and laterally by flank.
Kidneys
Surface Marking of Kidney on the Back
It is done within parallelogram of Morris which is drawn in
the following way:
1. First two horizontal lines are drawn one at the level of spine of T11 and
other at the level of spine of L3.
2. Then two vertical lines are drawn, one 2.5 cm away and other 9 cm
away from the posteromedian plane.
3. The centre of hilum of the each kidney lies approximately at the lower
border of L1.
Incisions
1. Give median vertical incision extending from the spine
of T11 to the spine of L2.
2. Then make horizontal incisions extending from the upper and lower
ends of the vertical incision.
Kidneys = Layers to be Reflected to Reach the Kidney
The following layers can be reflected one by one in order to expose the kidney (Fig.
11.20):
1. Skin. 2. Superficial fascia.
3. Posterior layer of the thoraco-lumbar fascia with attached latissimus dorsi and
serratus posterior inferior muscles.
4. Erector spinae (sacrospinalis) muscles.
5. Middle layer of the thoraco-lumbar fascia.
6. Quadratus lumborum muscle.
7. Anterior layer of the Thoraco-lumbar fascia.
Renal angle:
It is an angle between the lower border of the 12th rib and the lateral border of
erector spinae muscle. This angle becomes full following kidney enlargements
and formation of perinephric abscess. It is the site of tenderness in case of
perinephric abscess. Renal pain is usually felt in this angle as a dull ache
Kidneys