ANAT - Renal + Posterior Abdominal Wall Flashcards
(84 cards)
1
Q
what are 1-5?
A
- 1 = medullary pyramid
- 2 = interlobular a.
- 3 = renal a.
- 4 = renal v.
- 5 = hilum
2
Q
what are 6-10?
A
- 6 = renal pelvis
- 7 = ureter
- 8 = minor calyx
- 9 = renal capsule
- 10 = inferior extremity
3
Q
what are 11, 12, 13, 15, 17?
A
- 11 = superior extremity
- 12 = interlobular v.
- 13 = nephron
- 15 = major calyx
- 17 = renal column
4
Q
what vertebral level are the kidney hila located at?
A
- L: L1/L2
- R: L2
5
Q
3 typical constrictions of ureters + clinical significance
A
- pelvi-ureteric junction (PUJ) (abdominal ureter)
- where it crosses the pelvic brim (pelvic ureter)
- where it enters the trigone of the bladder (intramural ureter) - VUJ
- clinical significance = kidney stones can lodge
6
Q
how can prostate cancer impact urine
A
- can move into internal iliac L/N which are right next to ureters
- causes retrograde peristalsis > ureters and renal pelvis enlarge = hydronephrosis
7
Q
vertebral levels of each kidney
A
- L) = T11-L2
- R) = T12-L3 (lower b/c liver)
8
Q
arrangement of kidney hilum
A
- anterior: renal v.
- middle: renal a.
- posterior: renal pelvis
9
Q
where do the kidneys migrate and how does their vasculature change during this process?
A
- migrate superiorly from pelvis to reach adrenal glands
- also rotate 90 degrees towards midline (hila were anterior and become medial)
- as they ascend, they are originally supplied by the common iliac aa. and then different renal aa. form before one becomes dominant (1 in 5 people have multiple/accessory renal aa.)
10
Q
abnormalities associated with kidney migration
A
- pelvic kidney: kidney stays in pelvis and doesn’t move up or rotate
- horsehoe kidney
- ventral renal pelvis: kidney doesn’t rotate = can obstruct renal pelvis
- lateral renal pelvis = rotates laterally instead of medially
11
Q
horseshoe kidney + complications
A
- anatomical variation = fusion of kidneys at their inferior pole > difficult to ascend and rotate
- not normally pathological but can impair urine drainage, risk of kidney stones + UTI or compress renal a.
12
Q
kidney arteries
A
- renal > segmental > interlobar > arcuate > cortical/radiate/interlobULar > afferent arteriole
13
Q
segments of the kidney + relevance
A
- apical and lower (anterior and posterior)
- upper and middle (anterior)
- posterior
- all supplied by a segmental a. with no anastomosis = functionally independent segments
- if one of the arteries is occluded it will only affect one segment
14
Q
where does pain refer from the kidneys and ureters?
A
- kidneys: flanks (anterior and posterior)
- ureters: loin to groin pain (flank to suprapubic - follows course of ureter)
15
Q
describe course of ureters
A
- descend anterior to tips of lumbar transverse processes
- descend anterior to psoas major, along medial border
- cross anteriorly over bifurcation of COMMON iliac a.
- descends anterolaterally to sacrum
- goes under vas deferens (if present -‘water under the bridge’)
- enters obliquely thru trigone at posterior bladder wall
16
Q
lymph drainage of each 1/3 of the ureter
A
- upper: lumbar (para-aortic)
- middle: common iliac
- lower: external iliac
17
Q
psoas sign
A
- pain during passive extension or active contraction of psoas major
- can be due to chemical irritation from nearby inflammation e.g. appendix, crohn’s, diverticulitis, ureteric calculi or infection
18
Q
drainage of gonadal v.
A
- L) = drains into renal a.
- R) = drains into IVC
19
Q
blood supply of the adrenal glands
A
- superior suprarenal a. = comes off inferior phrenic a. (from aorta)
- middle suprarenal a. = comes directly off abdominal aorta
- inferior suprarenal a. = comes off renal a. (from aorta)
20
Q
venous drainage of adrenal glands
A
- L suprarenal v. > L renal v. (SOMETIMES joined by L inferior phrenic v.) -> IVC
- R suprarenal -> directly into IVC
21
Q
describe the muscles of the posterior abdominal wall
A
- psoas major + iliacus: tendons join to form iliopsoas tendon = attaches to lesser trochanter
- psoas minor: anterior to psoas major
- quadratus lumborum = superior to iliacus
- more laterally, anterolateral abdominal muscles (ext oblique, int oblique, transversus abdominis)
22
Q
arcuate ligaments
A
- thickenings in the posterior abdominal wall
- median: formed by joining of diaphragmatic crura to T12 vertebra
- medial: runs from vertebral body to transverse process of L1/L2
- lateral: runs from transverse process of L2 to 12th rib
23
Q
median arcuate ligament syndrome
A
- normally, median arcuate ligament arches anterior to the aorta at T12, where the coeliac trunk is also located
- if the median arcuate ligament is lower, or coeliac trunk is higher, CT can get compressed = reduced blood flow and sympathetic nerve supply to foregut
24
Q
structures associated with each arcuate ligament
A
- median: forms anterior boundary of aortic hiatus (therefore transmits aorta, azygos v., thoracic duct)
- medial: psoas major, sympathetic trunk
- lateral: quadratus lumborum, subcostal vessels and nerve
25
differences in the structure of the three diaphragmatic hiatuses
- caval (T8): directly pierces central tendon
- oesophageal (T10): right crus splits into two muscular bundles which wrap around the oesophagus
- aortic (T12): bounded anteriorly by the median arcuate ligament, laterally by the crura and posteriorly by the T12 vertebra
26
diaphragmatic crura and what structures are associated with them?
- crura = two crus
- left (smaller and shorter): pierced by L/R splanchnic n..
- right (larger and longer): forms oesophageal hiatus (transmits oesophagus and vagus nn.)
27
nerves of the posterior abdominal wall (superior to inferior)
- subcostal n. (T12): runs inferolaterally from lateral arcuate ligament, between transversus abdominis and int oblique
- iliohypogastric and ilioinguinal n. (L1): run inferolaterally from psoas major
- genitofemoral n. (L1/2): runs inferiorly down the anterior surface of psoas major
- lateral femoral cutaneous n. (L2/3): run inferolaterally from psoas major
28
macula densa
- located in the DCT, near the afferent arteriole (part of juxtaglomerular apparatus)
- senses Na+ > regulates GFR and activates RAAS if BP is low
29
vasa recta (nephron) vs peritubular capillaries
- location
- function
- vasa recta: straight vessels which surround the loop of Henle (helps create counter current)
- peritubular capillaries: surround PCT and DCT (helps reabsorb or excrete solutes)
30
renal corpuscle
- consists of glomerulus + bowman's capsule
- space between glomerulus and bowman's capsule = 'urinary space'
31
which embryological layer gives rise to the kidneys and ureters? what else does it give rise to?
- intermediate mesoderm
- also gives rise to gonads, ducts and accessory glands
32
development of kidneys
- intermediate mesoderm gives rise to PROnephros > forms pronephric tubules then ducts > NON-FUNCTIONAL, NO ADULT EQUIVALENT
- pronephric duct forms MESOnephros > mesonephric tubules then ducts > temporarily functional (produces urine in embryo) > drains inferiorly into cloaca
- mesonephric duct forms METAnephric diverticulum (aka ureteric bud) > forms collecting ducts, calyces, renal pelvis and ureter
- ureteric bud interacts with metanephric blastema (mesenchyme) to give rise to the rest of the nephron
33
describe how the metanephric mesenchyme gives rise to the nephron
- mesenchyme + ureteric bud interact and form pre-tubular aggregate
- renal/epithelial vesicle
- comma-shaped body
- S-shaped body (glomerulus + Bowman's capsule proximally, PCT in the middle, DCT distally)
- capillary loop stage (glomerular capillaries form, surrounded by bowman's capsule)
- glomerulus and tubules mature
34
variation of nephron number and what can it mean?
- normal can be from 200k to 2.5 mil nephrons
- low nephron number = can be due to premature birth or genetics = increased risk of CKD and HTN
35
why is there significant variation in nephron numbers?
- genetic factors: different levels of GDNF (PROMOTES branching of ureteric bud and metanephric mesenchyme) and BMP4 which INHIBITS it
- environmental factors
36
renal agenesis
- lack of development of a kidney due to metanephric mesenchyme not interacting with ureteric bud
37
examples of congenital kidney abnormalities
- hypoplastic (less nephrons than normal)
- cystic dysplastic (some cysts and some nephrons > can still function a little)
- multicystic dysplastic (no function) - forms aplastic kidney = tiny dysplastic remnant - 40% chance of occurrence on other side too
- duplex = mesonephric duct forms two ureteric buds = two ureters
38
2 tests to evaluate kidney function in utero
- check if bladder is filling
- check for sufficient amniotic fluid
- check structure of kidney to see if there are any cysts
39
what can cause congenital abnormalities of the kidneys?
- ureter enters the bladder too proximally or distally to trigone = obstruction at entry into bladder = retrograde flow and hydronephrosis = dysplasia and cysts
40
trigone of the bladder
- triangle shape on internal posterior surface
- top two vertices = ureterovesical junction (UVJ)
- bottom vertex = urethral orifice
41
what is the functional sphincter of the bladder
- urethra has an internal and external sphincter like the rectum but ureters don't
- when detrusor muscle expands or contracts, ureters become blocked due to their oblique orientation = blocks backflow AND normal flow of urine
42
which ducts do the male/female gonads develop from?
- mesonephric (Wolffian) duct: testes, ductus deferens, seminal vesicles
- paramesonephric (mullerian) duct: fallopian tubes, uterus, proximal vagina
43
persistent mullerian duct/wolffian duct syndrome
- persistent mullerian: when males develop a uterus or fallopian tubes due to mullerian (paramesonephric) duct
- persistent wolffian: when females develop ductus deferens due to wolffian (mesonephric) duct
44
congenital defect associated with gonads and bladder
- mesonephric (male) duct insertion into developing bladder or verumontanum = stops urine from passing into bladder = BILATERAL retrograde flow and hydronephrosis = bad
- usually treated in utero with catheter or surgery
45
2 urethral sphincters + function
- internal: smooth (involuntary)
- external (intrinsic rhabdosphincter): skeletal (voluntary)
- contract to hold urine in, relax to void
46
role of pelvic floor muscles in urination
- maintain tone of urethra
- maintain bladder's position in pelvic cavity
47
when can vesicouteral reflux (VUR) occur
- when ureter penetrates bladder perpendicularly instead of obliquely = retrograde flow of urine = hydrometer and hydronephrosis
- risk of renal scarring and upper UTI
48
innervation of the bladder
- sympathetic: hypogastric nerves inhibit detrusor muscle (B3 receptor) and stimulates contraction of internal urethral sphincter (a1 receptor)
- parasympathetic: pelvic splanchnics control detrusor muscle
- somatic: pudendal and sacral nerves control external urethral sphincter and skeletal pelvic floor muscles
49
which centre of the brain regulates inhibition of voiding until an appropriate time?
- pontine micturition centre
(in pons of brain stem)
50
biggest risk factors for CKD
- diabetes - causes atherosclerosis and loss of vessel elasticity
- HTN - high pressure damages glomeruli > proteins leak out
51
kidney function tests
- eGFR = GOLD STANDARD (uses
- EUC: electrolytes, urea (waste product of protein metabolism), creatinine (waste product of creatine breakdown)
- EPO (erythropoietin): production of RBC
- FBC: WCC, platelets, Hb (measures EPO secretion)
- lipid profile: triglycerides, HDL/LDL, cholesterol - dyslipidaemia is a complication of CKD and can predispose to CVS issues
- ACR (first morning albumin:creatinine ratio): glomerular damage causes albuminuria, taken first thing in morning because you can get orthostatic proteinuria which is not pathologic but can lead to false positive - therefore we need to measure it relative to something thats excreted at a constant rate (creatinine)
- phosphate and PTH: indicates Ca2+ reabsorption function
52
structure of cortex of medulla
- cortex: cortical labyrinth (contains glomeruli and tubules) and medullary rays (straight segments of loop of henle and collecting ducts)
- outer medulla: outer stripe and inner stripe
- inner medulla: papilla
53
3 cell types in glomerulus
- endothelial cells (form tuft of fenestrated capillaries)
- mesangial cells: forms the core of the glomerulus along with mesangial matrix, allowing for capillary attachment
- podocytes (glomerular epithelial cell): sit on basement membrane outside of capillaries and have foot processes with filtration slits in between (incapable of mitosis)
54
2 types of mesangial cells
- smooth muscle-like
- bone marrow-derived
55
structure of proximal convoluted tubule
- simple cuboidal or columnar epithelium
- microvilli (brush border) + folding for SA
- canaliculi
- many mitochondria for Na+/K+ ATPase pumps
56
structure of loop of henle
- thick/thin descending/ascending limb
- juxtamedullary nephrons have long loops of henle which extend deep into medulla - establish hypertonicity gradient
57
structure of DCT
- no microvilli or canaliculi but has folds in basal membrane
- many mitochondria
58
juxtaglomerular apparatus
- structure close to the vascular pole (arterioles) of the glomerulus
- includes macula densa (detects Na+), juxtaglomerular cells and mesangium (causes constriction/dilation of arterioles)
59
juxtaglomerular cells
- modified smooth muscle cells in tunica media of afferent arteriole
- part of juxtaglomerular apparatus
- store and release renin (converts ang > ang I)
60
retroperitoneal fibrosis
- can compress structures e.g. ureter (reduced urine output), lower limb oedema and claudication (abdominal aorta)
61
functions of the kidney
- A WET BED
- Acid/base
- Water balance
- Toxin removal
- Blood pressure (RAAS)
- EPO
- D vitamin
62
nutcracker syndrome
- SMA loops over L renal vein and can cause obstruction
63
arterial supply of ureters
- proximal: renal a.
- middle: gonadal and common iliac aa.
- distal: superior and inferior vesical aa.
64
venous drainage of ureters
- upper: renal v.
- middle: gonadal v.
- lower: vesicular v.
65
lymph drainage of kidneys, ureters, suprarenal glands
- kidneys, suprarenal glands, upper ureters: lateral aortic L/N
- lower ureters: common, internal, external iliac L/N
66
protection of kidneys
- L kidney covered by 2 ribs (11-12), R kidney covered by 1 rib (12) = provide protection, but rib fractures can damage kidneys
- quadratus lumborum covers large section of posterior kidney - protection from posterior damage, e.g. stab wounds
67
definition of AKI
- how is it measured?
- key symptom
- abrupt (<48 hrs) reduction in kidney function (can be reversible)
- measured by increased serum creatinine, reduced urine output, need for dialysis
- main symptom = oliguria
68
prerenal AKI (most common)
- pathophys
- causes
- reduced renal blood flow (hypo perfusion) = decreased GFP and hence GFR = increased aldosterone + ADH secretion = increased Na+/H2O reabsorption = oliguria
- causes: HTN, CHF, sepsis, hypovolaemia, haemorrhage, cardiac surgery
69
intra-renal AKI
- pathophys
- causes
- damage to kidney parenchyma (usually due to prolonged hypoperfusion) = necrosis/apoptosis = cast formation = intratubular obstruction = increased intratubular pressure = decreased GFR = oliguria
- causes: radiocontrast media, drug toxicity
70
post-renal AKI
- pathophys
- causes
- BILATERAL obstruction to urine flow = increased pressure and release of inflammatory mediators = vasoconstriction = interstitial oedema = decreased GFR = oliguria
- causes: BPH, stones
71
chronic kidney disease
- definition
- are the early stages symptomatic or asymptomatic?
- Sx
- decreased kidney function for 3 or more months, not reversible
- early stages asymptomatic b/c we have 2 kidneys
- Sx (due to accumulation of urea or fluid): fatigue, oedema, pruritus, chest pain (uraemic pericarditis), oliguria, dyspnoea, asterixis, pallor
72
compare kidney size in AKI vs CKD
- AKI = likely to have normal sized kidneys
- CKD = likely to have shrunken kidneys
73
what makes the kidneys susceptible to injury?
- they process a lot of blood = exposure to toxins
- high intraglomerular pressure needed but capillaries are thin-walled
74
Ix for suspected AKI
- FBC + serum creatinine
- urinalysis
- fractional excretion of sodium
- renal U/S to check for obstruction
75
fractional excretion of sodium (FeNa) + how to interpret
- amount of Na that is excreted compared to reabsorbed
- if increased: kidney can't reabsorb as much Na+ so more excreted in urine = intra or post renal AKI
- if decreased: GFR decreased = kidney responds by increasing Na and H2O reabsorption = pre-renal AKI
76
long term prognosis of AKI
- can be reversible, but causes generalised inflammatory response which can affect other organs
- long-term risk of further morbidity or death
77
Ix for suspected CKD
- eGFR - below 60 (whereas AKI uses serum creatinine)
- urine albumin (likely high in CKD but doesn't confirm CKD)
- calcium - CKD causes hypocalcaemia
- ultrasound to check for reduced kidney size
78
causes of CKD and what do they all have in common
- tissue hypoxia and ischaemia (e.g. due to HTN, diabetes)
- immune reaction
- drugs
- genetics
- ALL cause glomerulosclerosis and tubulointerstitial fibrosis
79
CKD pathophys
- renal injury/ischaemia = loss of nephrons
- 1) compensatory increased glomerular permeability = abnormal filtration of proteins and macromolecules = proteinuria
- 2) kidney thinks there's less blood volume b/c reduced GFR = compensatory increased RAAS activity = HTN
- BOTH lead to nephrotoxic inflammation and remodelling = decreased GFR and urine output
80
renal reserve
- ability to maintain normal homeostatic function with only one kidney
- so when GFR drops or creatinine rises noticeably, a SIGNIFICANT portion of nephrons have been lost
81
normal urine output + anuria/oliguria definition
- minimum adequate output: 0.5 mL/kg/hr
- oliguria: <400mL/day
- anuria: <100mL/day
82
urinalysis components
- look at urine: check for colour (dehydration, drugs), debris, cloudy
- glucose: diabetes
- ketones: diabetes, dehydration, starvation
- bilirubin: jaundice
- specific gravity: concentration of urine (indicates hydration)
- leukocytes: infection
- blood: menstrual contamination, UTI, STI, stones, cancer
- nitrite: gram -ve bacteria convert nitrates > nitrites = use broad-spectrum antibiotic
- pH: high pH = proteus infection due to urease (urea > ammonia), or metabolic acidosis (therefore less H+ excreted so basic urine)
83
types of polycystic kidney disease
- autosomal dominant (most common): presents in adulthood as HTN, haematuria, flank pain, recurrent UTI, progressive renal insufficiency
- autosomal recessive (less common: presents in infancy/early childhood
84
glomerulonephritis
- not an infection (post-GABHS pharyngitis) - inflammation of glomeruli
- Sx: red cell casts in urine (very specific for glomerular bleeding), haematuria, proteinuria
