Download Renal05-Supplement-kidneys, ureters, suprarenal glands

Supplement for Renal #5
Mon, 03/17/03 2pm
Dr. Rosales
J. Uxer for Prateek Chadhaury
1
KIDNEYS, URETERS, AND SUPRARENAL GLANDS
Components of the Urinary System
1. kidneys – produce urine
2. ureters – convey urine from the kidneys to the urinary bladder
3. urinary bladder – temporary storage of urine
4. urethra – expels urine from the urinary bladder; in males, part of both urinary and
reproductive systems
*urinary bladder and urethra – to be taken up in the next region
KIDNEYS
Functions
1. contribute to maintenance of homeostasis by producing urine, in which various metabolic
waste products are eliminated
2. regulate fluid and electrolyte balance of the body
3. site of production of hormones renin and erythropoietin
a. rennin (angiotensinogenase) – secreted under conditions of hypovolemia by the
juxtaglomerular (JG) cells as part of the rennin-angiotensin system to increase blood
volume and elevate blood pressure; angiotensin I, by itself, is a potent vasoconstrictor
b. erythropoietin (hemopoietin, hematopoietin) - stimulates production of rbc's
Location and Description
 retroperitoneal, on each side of vertebral column, at level of T.V. 12 – L.V. 3
 reddish-brown, ovoid organs with indented medial margins giving them a bean-shaped
appearance
 right kidney at a slightly lower level than left kidney owing to large size of right lobe of liver
 superior parts protected by thoracic cage and tilted medially (superior poles nearer median
plane than inferior poles)
Development
 develop in the pelvic cavity and ascend to their final position high up in the posterior
abdominal wall
 inferior mesenteric artery – would arrest the ascent of a horse-shoe shaped kidneys
 suprarenal glands – stop the ascent of normal kidneys
Anatomical Relations
1. Right Kidney
a. anterior – suprarenal gland, liver, 2nd part of duodenum, right colic flexure
b. posterior – diaphragm, costodiaphragmatic recess of pleura, 12th rib, psoas major,
quadratus lumborum, transversus abdominis, subcostal nerve, iliohypogastric and
ilioinguinal nerves
2. Left Kidney
a. anterior – suprarenal gland, spleen, stomach, pancreas, left colic flexure, coils of jejunum
Supplement for Renal #5
Mon, 03/17/03 2pm
Dr. Rosales
J. Uxer for Prateek Chadhaury
2
b. posterior – diaphragm, costodiaphragmatic recess of pleura, 11th and 12th ribs, psoas
major, quadratus lumborum, transversus abdominis, subcostal nerve, iliohypogastric and
ilioinguinal nerves
 costovertebral angle (CVA) – angle formed by the 12th thoracic vertebra with the
vertebral column; in cases of inflammation of the kidneys and upper part of the ureter
(pyelonephritis), gentle fist percussion over the angle, called “kidney punch”, will elicit
pain and is described as “positive CVA tenderness”
 psoas muscle – closely related to the kidneys and other organs (pancreas, appendix); in
inflammations of the kidneys, psoas muscle is also irritated. In performing the “psoas
test”, the patient is lies down on the unaffected side and is asked to extend the thigh
against resistance; elicitation of pain is interpreted as a “positive psoas sign”
Coverings
1. Fibrous Capsule – strong; surrounds kidney and closely applied to outer surface giving fresh
kidney glistening appearance; easily strips
2. Perirenal Fat – covers fibrous capsule
3. Renal Fascia (of Gerota) – condensation of connective tissue outside perirenal fat enclosing
kidney and suprarenal gland; continuous laterally with fascia transversalis
4. Pararenal Fat – external to renal fascia; forms part of retroperitoneal fat; lower specific
gravity than kidney ( kidney outline usually seen on radiographs)
*2, 3, & 4 – support kidneys and hold them in position on posterior abdominal wall
Gross Structure
1. surfaces – anterior and posterior
2. margins (borders) – medial and lateral
3. poles – superior and inferior
4. renal hilum – vertical slit on medial concave border
5. renal sinus – large cavity in hilum; transmits from anterior to posterior, renal vein, renal
artery, and ureter (V.A.U.) together with lymph vessels and sympathetic fibers and varying
amounts of fat
6. on sagittal section:
a. renal cortex – dark brown, outer
b. renal medulla – light brown, inner
c. renal pyramids – compose the medulla (~12), each with base oriented toward cortex
d. renal papilla – apex of renal pyramid projecting medially
e. renal columns (of Bertin) – extensions of cortex into medulla between adjacent pyramids
f. medullary rays – extensions of medulla into cortex from bases of renal pyramids; give
cortex a striated appearance
g. renal pelvis – expanded, funnel-shaped proximal end of ureter within the hilum
h. major calyces (calyx) – cup-shaped divisions of renal pelvis
i. minor calyces – divisions of major calyces; indented by renal papilla; receive the first
drops of urine
Blood Supply
1. Arteries
Supplement for Renal #5
Mon, 03/17/03 2pm
Dr. Rosales
J. Uxer for Prateek Chadhaury
3
a. renal arteries – arise at right angles from the aorta at level of L.V.2; right renal artery
passes posterior to the IVC
b. segmental arteries – divisions of each renal artery as it enters the hilum (4 anterior and 1
posterior to the renal pelvis)
c. lobar arteries – arise from each segmental artery, one for each renal pyramid
d. interlobar arteries – given off by the lobar arteries before entering renal substance; run
toward the cortex on each side of the renal pyramids
e. arcuate arteries – given off by the interlobar arteries at the junction of the cortex and
medulla that arch over the bases of the pyramids
f. interlobular arteries – given off by the arcuate arteries; ascend in cortex
g. afferent glomerular arterioles – branches of the interlobular arteries; supply blood to
the capillaries of the glomeruli
2. Veins
a. renal v. – emerges from hilum anterior to renal artery; drains into IVC
Lymphatic Drainage – follow renal artery to lateral aortic (paraaortic) lymph nodes around
origin of renal artery
Nerve Supply
 originate in renal sympathetic plexus
 distributed along branches of renal vessels
 afferent fibers that travel through the renal plexus enter spinal cord in the 10th, 11th, and 12th
thoracic spinal segments
URETERS
Function – convey urine from kidney to urinary bladder
Location and Description
 thick-walled, muscular tubes with narrow lumina extending from kidneys to posterior surface
of urinary bladder
 upper half – abdominal; retroperitoneal; descends almost vertically anterior to psoas major
muscle
 lower half – pelvic; passes over pelvic brim anterior to origins of external iliac arteries 
courses posteroinferiorly on lateral pelvic wall external to parietal peritoneum anterior to
internal iliac arteries  curves anteromedially to pierce posterior wall of urinary bladder

injuries to the ureters
 ureteric injuries (transection, crushing, kinking, ligation)  may occur during
gynecologic operations, e.g., hysterectomy, because of the proximity of the ureter to
the uterine vessels
 identification of the ureters during their full course through the pelvis  important
preventative measure
Supplement for Renal #5
Mon, 03/17/03 2pm
Dr. Rosales
J. Uxer for Prateek Chadhaury
4
Anatomic Constrictions – potential sites where renal calculi may be impacted  obstruction
1. ureteropelvic junction (UPJ) - where the renal pelvis joins the ureter
2. where it crosses the brim of the pelvic inlet
3. ureterovesical junction – where it pierces the bladder wall

renal and ureteric calculi
 may be located in the renal calices, ureters, or urinary bladder
 a renal calculus may pass from kidney to renal pelvis to ureter
 ureteral calculus  severe rhythmic, sharp, stabbing pain or ureteral colic, as it is
gradually forced down the ureter by waves of contractions  may cause complete or
intermittent obstruction of urinary flow
 depending on level of obstruction, pain may be referred to cutaneous areas from loin
to groin (lumbar region, hypogastric region, external genitalia, testis)  corresponds
to innervation of ureter, (T11 – L2)
Blood Supply
1. Arteries
a. upper end – renal a.
b. middle portion – gonadal aa.
c. pelvic portion – superior vesical a.
2. Veins - correspond to arteries
Lymph Drainage – lateral aortic and external and internal iliac lymph nodes
Nerve Supply
 derived from renal and hypogastric plexuses
 afferent fibers travel with sympathetic nerves and enter spinal cord in the 1st and 2nd lumbar
spinal cord segments
SUPRARENAL GLANDS
LOCATION AND DESCRIPTION
 yellowish, retroperitoneal organs that lie between the superomedial aspects of the kidneys
and the diaphragm
 surrounded by renal fascia but separated from kidneys by perirenal fat
 yellow-colored cortex (derived from mesoderm)
 dark brown medulla (derived from neural crest cells, i.e. ectoderm)
DIFFERENCES BETWEEN RIGHT AND LEFT SUPRARENAL GLANDS
Right Suprarenal Gland
 triangular in shape
 "perches" on or caps superior pole of right kidney
 lies posterior to right lobe of liver and extends medially behind IVC
 rests posteriorly on diaphragm
Supplement for Renal #5
Mon, 03/17/03 2pm
Dr. Rosales
J. Uxer for Prateek Chadhaury
5
Left Suprarenal Gland
 semilunar in shape
 extends further inferiorly on medial margin of left kidney than does the right one
 lies in stomach bed
 related anteriorly to stomach and pancreas; posteriorly to diaphragm
BLOOD SUPPLY
Arteries - profuse blood supply from three sources
1. superior suprarenal artery – from inferior phrenic artery
2. middle suprarenal artery – from abdominal aorta
3. inferior suprarenal artery – from renal artery
Veins - each gland drained mainly by a single suprarenal vein
1. right (central) suprarenal vein  IVC
2. left (central) suprarenal vein  left renal vein
LYMPH DRAINAGE – lymph vessels pass into lateral aortic (paraaortic) nodes
NERVE SUPPLY
 predominantly preganglionic sympathetic fibers derived from celiac plexus and greater
thoracic splanchnic n.
 majority of fibers pass through hilum and synapse on cells in the medulla
 suprarenal cortex receives only vasomotor nerve supply
HORMONES
Adrenal Cortex
1. zona glomerulosa – secrete mineralocorticoids (aldosterone) for fluid and electrolyte balance
2. zona fasciculate – secrete glucocorticoids (cortisol) for control of metabolism of
carbohydrates, fats, and proteins
3. zona reticularis – secrete sex hormones for prepubertal development of sex organs
Adrenal Medulla – catecholamines
1. epinephrine
2. norepinephrine
CLINICAL CONSIDERATIONS
1. Cushing's Syndrome
 most common cause is suprarenal cortical hyperplasia  hypersecretion
 if occurs later in life, may result from adenoma or carcinoma of the cortex
 clinical manifestations:
a. moon-shaped face
b. truncal obesity
c. abnormal hairiness (hirsutism)
d. hypertension
Supplement for Renal #5
Mon, 03/17/03 2pm
Dr. Rosales
J. Uxer for Prateek Chadhaury
6
2. Addison's Disease
 adrenocortical insufficiency  hyposecretion
 may be caused by tuberculous destruction or bilateral atrophy of both cortices
 clinical manifestations:
a. increased pigmentation
b. muscular weakness
c. weight loss
d. hypotension
3. Pheochromocytoma
 medullary tumor  hypersecretion
 produces paroxysmal or sustained hypertension
 signs and symptoms result from production of a large amount of catecholamines which
are then poured into the blood stream