Kidney functions
Filters blood, rebasorbs water, creates urine
Vessels associated with kidney (just see pic)
Blood supply of kidney
Renal arteries
Venous drainage of kidney
Renal veins drain into vena cava.
Relationship of kidneys to diaphragm, psoas major, quadratus lumborum, transversus abdominis aponeurosis, surrounding organs, and ribs 11&12
Kidneys in relation to the renal fascia, perirenal, and pararenal fat
Ureters - course and relationships
Blood supply to ureters
- Abdominal
- Upper: Renal, gonadal, aorta
- Middle: Gonadal & iliac
- Lower/distal: Internal iliac leading to vesical arteries
- Pelvic: superior & inferior vesical arteries.
Lymphatic drainage of ureters
Upper: joins renal lymphatics to lumbar nodes
Middle: to iliac nodes
Pelvic/distal: internal iliac and vesical nodes.
Autnomic Innervation of ureters
The ureter is a smooth muscle for peristalsis –> autonomic
Sympathetic - lumbar splanchnic
Parasympathetic - pelvic splanchnic
Sites of constriction of ureters
- Ureteropelvic junction: where ureter joins the renal pelvis
- Where it crosses the pelvic brim
- Ureterovesicular junction: Where it enters the wall of the urinary bladder
Renal entrapment syndrome (Nutcracker)
Left renal vein is obstructed between the SMA and the aorta. –> L renal vein & left gonadal vein blockage
–> swelling of the teste or ovary on the left + backup of flow in the left suprarenal vein.
Origin of the lumbar plexus
L1-L5
L1: Ilioinguinal/Iliohypogastric- dermatome runs along inguinal ligament and pubis
L1/L2: GFN
L2/L3: Lateral femoral cutaneous
L2-L4: Femoral/Obturator
L4/L5: Lumbosacral Trunk
Innervation of diaphragm
Phrenic nerve
Blood supply of diaphragm
Inferior phrenic artery
Pericardiacophrenic artery
Musculophrenic artery
Openings in diaphragm and approximate vertebral level
IVC: T8
Esophageal hiatus: T10
Aortic Hiatus: T12
Sympathetic trunks & Splanchnic nerves
Abdominal prevertebral plexus & ganglia
Foregut (greater splanchnic T5-T9)
Midgut (lesser T10-T11)
Kidneys and ureters (least T12)
Hindgut (lumbar L1-L2)
Pain from kidney stones- what innervates the ureters? where do the sensory fibers enter the spinal cord?
Pain comes from distention
- Innervation is from the renal, gonadal, and hypogastric plexus.
- Sensory fibers from ureters enter the spinal cord at T11-12.
In appendicitis or peritonitis, what causes the pain?
Parietal peritoneum
The purple space is
Retroperitoneal space.
Retroperitoneal structures
- Pancreas
- Ascending (Right) and Descending (Left) Colon
- Duodenum (2nd and 3rd part )
- Rectum
- Kidneys
- Ureters
- Bladder
- Uterus
- Great vessels
Branches off the aorta
- Celiac immediately branches
- SMA takes off at an angle -> often a site of emboli
-
Renals branches to left and right
- Right below it is the infra-aortic frequent site of aneurysm (AAA).
- Minor:
- Diaphragmatic, Adrenal, Gonalda, Lumbar, Ureteral
Birfucation of the aorta occurs around where?
The bellybutton
The iliac vein is a little to the right/left of the spine?
right.
This is why we often do central line placement ont he right side.
Veins draining into the vena cava
- Iliacs
- Renal
- Hepatic veins
- Gonadal on the right
- Adrenal on the right
Left gonadal & adrenal veins drain into the ___ to get to the vena cava; whereas, the right gonadal & adrenal veins ….
Left gonadal vein & left adrenal vein > left renal vein > vena cava
Right gonadal & right adrenal vein directly drains into vena cava.
Landmark for the left renal vein
The take off of the SMA
A woman want sto donate her kidney. The left kidney has 2 renal arteries; whereas, the right has one. Why did the surgeons decide to remove the left kidney?
The left renal vein is longer.
A woman wants to donate her kidney. Her left kidney has 3 renal arteries, 1 small superior pole, 1 large main pole, and 1 moderate inferior pole. Can we use this kidney? What considerations need to be made for a successful transplant?
- Decline the donor
- Implant all 3 arteries
- Sacrifice the superior pole and implant the main & inferior
- Sacrifice the inferior pole & hope for the best for the ureter
The superior pole (if small) doesn’t supply much to the kidney; whereas, the inferior pole is largely responsible for the pelvis and ureter.
A woman donates her kidney. A week later she feels full (early satiety) and bloated. On exam, she is distended with a fluid wave. What’s going on?
- Her cut ureter leak and she is full of urine
- She took too many pain pills and is constipated
- She has a pancreatic injury and leak
- None of the above
We then took a fluid sample and it’s cloudy and high in triglycerides. What is the fluid?
None of the above.
The ureter is unlikely to leak where it enters the kidney because there is a valve that prevents urine from coming out. A pancreatic injruy and leak would cause pain and sickness.
It’s lymph.
Lymphatic drainage of the kidney
Hilar nodes
Arterial dissection around the kidneys/ ureters will probably also dirsupt
lymphatic channels, because they run closely along the arterial vasculature.
The lymphatic channels of the kidney and ureters all coalesce where?
Cysterna chyli near the starting point of the thoracic duct in front of L1 and L2.
When you have a lymph leak, why do you put the patient on a lowfat diet?
To limit the in-flow into the lymphatics –> it will heal itself.
A woman has burning urination, some hematuria, and now-persistent backpain. She has costovertebral angle tenderness and is febrile. What is the pain from?
Costovertebral angle is on the back.
It’s inflammation of the peritoneum. Kidneys have got so inflamed that it’s touched the peritoneum.
What fibers are responsible for the referred pain felt by inflammation of the kidney?
Least splanchnics (T12, T12-L2 in lecture) are responsible for innervating the kidneys –> can refer to their dermatome in the back
An obese woman has excruciating back pain and urinates blood. 3 days later, the pain comes on worse and is more in her lower back. What’s going on?
Kidney stone
Kidney comes from __ derm
Mesoderm
The primitive kidney is ___. It depends on the ingrowth of the ___(from the cloacae).
Metanephros.
Depends on the growth of the ureteric bud from below; this bud eventually bifurcates.
What disease is caused by the ureteric bud not forming? If it’s incomplete?
No bud - Renal agenesis
Incomplete bud - dysplastic kidneys
A man with a history of diveritculitis of the left colon presented for interval left colectomy. There’s a lot of inflammation, and after some time dissecting, teh oeprative field begins to continuously fill with clear fluid. What happened?
His ureter got cut - he is full of urine.
Renal collecting system
- Filtration
- Reabsorption
- Descending:
- Ascending:
- Reabsorption/Secretion
- Reabsorption OR secretion, depending on physiological need
- Filtration via afferent arteriole
- Rebasorb water, ions, organic nutrients
- Descending: reabsorb water
- Ascending: reabsorb Na & Cl
- Some reabsorption of water (ADH/Aldosterone), but mostly secretion of acids, drugs, toxins
- Variable reabsorption of water; reabsorption OR secretion of ions