By Faisal Alomar 1

Anatomy of the
Kidney
____________
Renal Block

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Male’s Slides
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Important
Doctor’s Notes
Extra Info
Objectives

Anatomical features of the kidneys :

position, extent, relations, hilum, peritoneal coverings, surface anatomy

Internal structure of the kidneys:

Cortex, medulla and renal sinus.

The vascular segments of the kidneys.

The blood supply and lymphatics of the kidneys.

Know the components of the urinary system

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Team’s Summary!
 1 Introduction Only in boys slides

The human body has two kidneys, each around the size of a fist.
They are located at the back of the abdominal cavity just below the rib cage on each
side of the spine.

Every day, each kidney filters liters of fluid from the bloodstream.
Although lungs and skin also play roles in excretion, the kidneys handle the major
responsibility for eliminating nitrogenous (nitrogen-containing) wastes, toxins, and drugs
from the body.

Functions

1 Excretes most of the waste products of metabolism.

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2 Controls water & electrolyte balance of the body.

3 Maintain acid-base balance of the blood.

4 Erythropoietin hormone stimulates bone marrow for RBCs formation.
5 Rennin enzyme regulates the blood pressure.
6 Converts vitamin D to its active form.
 12 Anatomical Features of the Kidney

Position the kidneys lie in the retroperitoneal

cavity against the posterior abdominal wall on
either side of the vertebral column.

The right kidney lies approximately

1 cm lower than the left due to the large size of the right lobe of the
liver.
Extent In the supine position, the kidneys extend
from approximately upper border of T12 vertebra
to center of body of L3 vertebra.

With contraction of the diaphragm during respiration, both kidneys move

downward in a vertical direction, high of one vertebra, 1 inch, 2.5 cm.

Color of the kidney : reddish brown

Shape: bean-shaped

Dimensions: 12 x 6 x 3cm.

Although they are similar in size and shape, the left kidney is slightly
longer and slenderer than the right kidney, and nearer to the
midline.

Each kidney has:

● Convex upper & lower ends.
● Convex lateral border.
● Convex medial border at both ends, but
its middle shows a vertical slit called the hilum.
Internally the hilum extends into a large cavity called the renal sinus.

They (the kidneys) are largely under cover of the costal margin.

The upper border of the right kidney is at the level of 12th intercostal
space while the left kidney is at the level of 11th rib.
 13 Hilum and Renal Sinus
● The hilum transmits, from anterior to posterior, the renal vein, renal artery
& the ureter (VAU). and the third branch of renal artery from the front
backward (V.A.U.A.)
● Lymph vessels & sympathetic fibers also pass through the hilum.

● The renal sinus contains the upper expanded part of the ureter called the renal
pelvis.
● Perinephric fat is continuing into the hilum and the sinus and surrounds all these
structures.

What Covers the Kidney?

From within outwards the coverings are:
Fibrous Capsule

● Thin membrane surrounds the kidney and is closely adherent to its outer surface.
●
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Can be easily separated from the surface of the kidney.

Perirenal (Perinephric) Fat

● Covers the fibrous capsule.
● The fat is abundant at the borders of the kidney & extends
into the renal sinus.
● loss of this fat results in nephroptosis kidneys.

Renal Fascia
● Condensation of areolar C.T that lies outside the Perirenal fat and
encloses the kidney and the suprarenal gland.
● It extends medially and surrounds the large vessels (IVC, aorta), it extends down and
wraps around the ureter and go down towards the pelvis
● Blood from ruptured kidney or pus from perinephric abscess go down the renal
fascial compartment into pelvis.
● The midline attachment of renal fascia to the large vessels prevents inward
movement.

Pararenal (Paranephric) Fat

● Lies external to the renal fascia, is more abundant posteriorly & towards
the lower pole of the kidney.
● Is part of the retroperitoneal fat.
● The Perirenal fat, Renal fascia and Pararenal fat support the kidneys and hold
them in position on the posterior abdominal wall.
 14 Relations of the Kidney
Anterior Relations of the kidneys
The anterior surface of both kidneys are related to numerous structures, some with an intervening layer of
peritoneum and others lie directly against the kidney without peritoneum.

Left Kidney Right Kidney

the anterior surface of left kidney is partly covered by peritoneum: the anterior surface of right kidney is partly covered by peritoneum:
• A small part of the superior pole, along the
medial border, is covered by left suprarenal • A small part of the upper pole is covered
gland. by right suprarenal gland.

• The rest of the superior pole is covered by the • The rest of the upper part of anterior surface is
intraperitoneal stomach and spleen. related to the liver and is
separated by a layer of peritoneum.
• The retroperitoneal (body) of pancreas and
splenic vessels cross the middle part of the • The 2nd part of duodenum lies directly
anterior surface. in front of the kidney close to its hilum.

• Its lower lateral part is directly related to the • The lower lateral part is directly related
left colic flexure and beginning of descending to the right colic flexure and, on its
colon. lower medial side, is related to the
• Its lower medial part is covered by the intraperitoneal small intestine.
intraperitoneal jejunum.

Posterior Relations of the Kidneys

Posteriorly, the right and left kidneys are almost related to similar structures.

Left Kidney: Right Kidney:

Muscles: Muscles:
1- Diaphragm 1- Diaphragm
2- Psoas major 2- Psoas major
3- Quadratus lumborum 3- Quadratus lumborum
4- transversus abdominis. 4- transversus abdominis.
Nerves: Nerves:
1- Subcostal (T12), 1- Subcostal (T12),
2- iliohypogastric 2- iliohypogastric
3- ilioinguinal nerves (L1). 3- ilioinguinal nerves (L1).
Ribs and recess: Ribs and recess:
Costodiaphragmatic recess of - Costodiaphragmatic recess of
the pleura the pleura
11th & 12th ribs; last - 12th ribs; last intercostal space
 intercostal space

51 Vertebrocostal & Renal Angles

Only in girls slides
The angle between the last rib and the lateral border of erector
spinae muscle is occupied by kidney and is called the ‘Renal
angle’.

The Vertebrocostal angle is occupied by the lower part of

the pleural sac.

What care should be taken in exposure of kidneys from

behind when 12th rib is to be excised?
Push up the pleura which crosses the medial half of the 12th rib.

Nephron
Only in boys slides

Each nephron is associated with two capillary beds:

The glomerulus
The peritubular capillary bed.

The glomerulus is both fed and drained by arterioles:

-The afferent arteriole, which arises from an interlobular artery, is the feeder vessel.
-The efferent arteriole receives blood that has passed through the
glomerulus.
 61 Internal Structure

Each kidney consists of an outer renal cortex and an inner renal medulla. Medulla is composed of
about 12 renal pyramids.
The renal cortex is a continuous band of pale tissue that completely surrounds the renal
medulla.

Extensions of the renal cortex, the renal columns project into the inner aspect of the kidney,
dividing the renal medulla into discontinuous aggregations of triangular-shaped tissue, the renal
pyramids.

The bases of the renal pyramids are directed outward, toward the cortex, while the apex of each
renal pyramid projects inward, toward the renal sinus.

The apical projection (renal papilla) is surrounded by a minor calyx.

In the renal sinus, several minor calices unite to form a major calyx, and two or three major
calices unite to form the renal pelvis, which is the funnel-shaped superior end of the ureters.

Extending from the bases of the renal pyramids into the cortex are
striations known as medullary rays.

Apex, Renal Papila

Base
 Segmental Branches & Vascular
71
Segments of Kidneys

Each kidney has 5 segmental branches and is

divided into 5 vascular segments:
1. Apical. (superior)
2. Caudal. (inferior)
3. Anterior Superior.
4. Anterior Inferior.
5. Posterior.

What is the clinical importance of vascular segments of kidney?

The vascular segments of the kidney provide avascular planes in between
them forming the bloodless line, making it possible to remove individual or
multiple diseased segments or for doing a partial nephrectomy.
Useful in doing incisions for segmental resection of the kidney or opening to
remove a stone from pelvicalyceal system.

Blood Supply of the Kidney

The renal artery arises from the aorta at the level of the
second lumbar vertebra.

Together, the renal arteries direct 25% of the cardiac

output towards the kidneys.

The right renal artery passes behind the IVC.

Arterial Supply

Afferent
Abdominal Renal Segmental Lobar Interlobar Arcuate Interlobular
Glomerular
Aorta Artery Arteries Arteries Arteries Arteries Arteries
Arterioles

Venous Drainage

Inferior vena cava Renal vein Interlobar veins Arcuate veins Interlobular veins
 18 Arterial Supply
Arcuate
Each renal artery divides into 5 segmental arteries that Lobar
Arteries Interlobar
Arteries
enter the hilum of the kidney, 4 in front of the renal Arteries

Abdominal Aorta pelvis and one behind it.

They are distributed to the different segments of the
Renal Artery kidney.
Each segmental artery gives rise to number of lobar
Segmental Arteries arteries, each supplies a renal pyramid. Segmental
Arteries

Before entering the renal substance, each lobar artery

Lobar Arteries
gives off two or three interlobar arteries Interlobular
Arteries

Interlobar Arteries The interlobar arteries run toward the cortex on each
side of the renal pyramid.
Arcuate Arteries At the junction of the cortex and the medulla, the Interlobar arteries give off the
arcuate arteries, which arch over the bases of the pyramids.
Interlobular Arteries
The arcuate arteries give off several interlobular arteries that ascend in the cortex
and give off the afferent glomerular arterioles.
Afferent Glomerular
Arterioles
And extend further to become efferent arterioles.

Arterial Supply Variation

Only in boys slides
The kidneys present a great variety in arterial supply.

These variations may be explained by the ascending course of the kidney in the
retroperitoneal space, from the original embryological site of formation (pelvis) to the
final destination (lumbar area).

During this course, the kidneys are supplied by consecutive branches of the iliac vessels
and the aorta.
Usually the lower branches become atrophic and vanish while new, higher ones supply the
kidney during its ascent.

Accessory arteries are common (in about 25% of patients).

An accessory artery is any supernumerary artery that reaches the kidney.

If a supernumerary artery does not enter the kidney through the hilum,
it is called aberrant.
 19 Venous Drainage of the kidney
Both renal veins Renal vein emerges from the hilum in front of the renal artery and drain to the
inferior vena cava.
Kidneys are drained through interlobular veins and interlobar veins until these converge from
across the kidney to form the renal vein.

The left renal vein

- Three times longer than the right (7.5 cm and 2.5 cm) as it
courses in front of the aorta to drain into the IVC.
- So, for this reason the left kidney is the preferred side for live
donor nephrectomy.
- It runs from its origin in the renal hilum, posterior to the
splenic vein and the body of pancreas, and then across the
anterior aspect of the aorta, just below the origin of the superior
mesenteric artery. The Right Renal Vein
- The left gonadal vein enters it from below and the left
suprarenal vein, usually receiving one of the left inferior Behind the 2nd part of the

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phrenic veins, enters it above but nearer the midline. (The left
renal vein receives left gonadal and left suprarenal veins)
- The left renal vein enters the inferior vena cava a little above
duodenum and sometimes
behind the lateral part of the
head of the pancreas.
the right vein.

Venous Drainage

Inferior vena cava Renal vein Interlobar veins Arcuate veins Interlobular veins

Lymphatic Drainage and Nerve Supply

Lymphatic Drainage:
- The lymph vessels follow the arteries.
- Lymph drains to the lateral aortic lymph nodes around the origin
of the renal artery.

Nerve Supply:
- The nerve supply is the renal sympathetic plexus.
- The afferent fibers that travel through the renal plexus enter the
spinal cord in the 10th , 11th, and 12th thoracic nerves.
 10
1 Embryology of the Kidney
Only in girls slides

Kidneys develop in the pelvis then migrate up.

The Common Developmental Abnormalities of the Kidney:

- Aberrant renal arteries:

- Pelvic kidney: failure of The kidney has more than one
ascent of kidney from renal artery which supply the
lower lumbar or sacral kidney without passing
region. through hilum.

● Horseshoe kidney: Fusion of lower poles of two kidneys.

● It is where the two developing kidneys fuse into a single horseshoe-
shaped structure.
● This occurs if the kidneys become too close together during their ascent
and rotation from the pelvis to the abdomen, they become fused at their
lower poles (the isthmus) and consequently become ‘stuck’ underneath the
inferior mesenteric artery.
● This type of kidney is still drained by two ureters (although the pelvices
and ureters remain anteriorly due to incomplete rotation) and is usually
asymptomatic.

- Congenital polycystic kidney.

- Congenital absence of one kidney.
- Accessory kidney

How to identify that a given kidney is right or left?

- The hilum is directed medially.
- The renal vessels are anterior to the pelvis.
- The ureter is directed inferiorly.

Kidney location:
1- kidneys extends from T12-L3.
Anterior View Posterior View
2-kidney hilum is L2 (L1).
3-Ribs 11 & 12 envelop left kidney & Rib 12 envelops right
kidney.
11
1 Clinical Notes Only in boys slides

Chronic Kidney Disease

It is the preferred terminology for chronic renal failure.

CKD is diagnosed by blood test for creatinine to determine the
patient’s glomerular filtration rate.
High levels of creatinine means the glomerular filtration rate is
falling which means that the kidney’s ability to filter and
excrete waste products is inhibited.
In the early stages of CKD, creatinine levels may be normal,but
urinalysis demonstrates a loss of protein or red blood cells into
the urine.
There are five stages of CKD categorized according to the level of reduced kidney function
and evidence of kidney damage, such as blood or protein in the urine.
The most severe stage is end-stage kidney disease (ESKD), also called end-stage renal disease and
CKD stage 5, which is diagnosed when kidney function deteriorates to the extent that irreversible
kidney failure occurs, requiring kidney dialysis or kidney transplant.

Renal Failure

It refers to inability of the kidneys to maintain proper filtration function, excrete wastes
appropriately and to maintain electrolyte balance.
There are three main stages: acute, chronic (now called chronic kidney disease as discussed
above) and end-stage.
Acute renal failure (ARF) is the sudden loss of the ability of the kidneys to remove waste and
concentrate urine.

It is usually initiated by an underlying cause, such as severe dehydration, infection, trauma to the
Kidney or the chronic use of painkillers.
ARF is often reversible with no lasting damage.
ARF is also known as acute kidney injury (AKI).
End-stage renal disease (ESRD) is the complete failure of the kidneys to function, or where chronic
kidney disease has worsened to the point at which kidney function is less than 10% of normal.

See chronic kidney disease above.

ESRF is also called chronic kidney disease (CKD) stage 5.

12
1 Clinical Notes Only in boys slides

Glomerulonephritis

It is a kidney disease in which the glomeruli – the parts of the

kidneys responsible for filtering waste and fluids from the blood -
become inflamed.
This causes blood and protein to be lost in the urine.

Glomerulonephritis may be caused by specific problems with the

body’s immune system but often the cause is unknown.
Glomerulonephritis can be acute (a sudden attack of inflammation) - or chronic (beginning
gradually).

In some patients there is no history of kidney disease and the disorder first manifests as
chronic renal failure.

Kidney (Renal) Agenesis

It occurs when the kidneys do not form during fetal development.

Renal agenesis can be unilateral, with one kidney present, or

bilateral, with no kidneys or very little kidney tissue present
(dysgenesis).
If the agenesis is unilateral, the other kidney will usually hypertrophy to recover for the missing
kidney.

Unilateral agenesis is often asymptomatic and is often discovered later in life.

Renal Biopsy

It involves taking a sample of kidney tissue for laboratory examination.

It can be performed as an open procedure or percutaneously, using a biopsy needle (generally
under ultrasound guidance)

Renal Transplantation

Renal transplantation is a surgical procedure that involves the removal of a diseased kidney and
replacement with a donor organ (either from a living donor or a cadaver).
Living donor kidneys can be either from an identical twin (isograft) or other individual
(allograft), preferably from a close relative.
 Quiz

MCQs

Q1: The area where the renal artery enters the kidney and the Q4: Which layer encloses both the kidney and renal gland?
renal vein and ureter exits the kidney is called the ________.
A- Perirenal fat
A- renal hilus B- Renal fascia
B- cortex C- Pararenal fat
C- medulla D- Fibrous capsule
D- renal columns

Q2: The renal pyramids are separated from each other by Q5: Which of the following is the upper border of the right
extensions of the renal cortex called ________. kidney?

A- renal medulla A- 11th rib

B- minor calyces B- 11th intercostal space
C- medullary cortices C- 10th intercostal space
D- renal columns D- 12th rib

Q3: Which of the following structures lies directly in front of Q6: What artery does glomerular afferent arise from?
the left kidney?
A- Quadratus lumborum A- Arcuate arteries
B- pancreas B- Interlobar arteries
C- Right colic flexure C- Interlobular arteries
D- 2nd part of the duodenum D- Lobar arteries

SAQs Answers: 1. A 2. D. 3. B 4. B 5. D 6. C

Q1: Mention the FOUR coverings of the kidney?

Answer: Fibrous capsule, perirenal (perinephric) Fat, renal fascia, and pararenal (paranephric) fat

Q2: List the functions of the kidneys.

Excretes most of the waste products of metabolism.

Controls water & electrolyte balance of the body.
Maintain acid-base balance of the blood.
Erythropoietin hormone stimulates bone marrow for RBCs formation.
Rennin enzyme regulates the blood pressure.
Converts vitamin D to its active form.

Q3: There are 4 muscles related posteriorly to the kidney list them.
Quadratus lumborum Transversus abdominis Diaphragm Psoas major
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