Renal Anatomy

and Physiology
By: Wong Ann Cheng
MD (UKM) MRCPCH (UK)
 Renal Anatomy and
Physiology
 Macroscopic  Physiology
anatomy  Excretory function
 Embrology  Nitrogenous
 Gross metabolic waste:
 Procedures urea, uric acid, creat
 Investigations
 Homeostatic
function
 Microscopic  Water and salt
anatomy regulation
 Glomerular  Renin angiotensin
 Tubular mechanism
 Acid/ base balance
 Endocrine function
 Erythropoeitin
 Embrology

◆Early development and

evolution
◆Pronephros

◆Mesonephros

◆Metanephros

◆Ascent and abnormalities

 Metanephros –
definitive
 The metanephros or kidney
definitive kidney of
higher vertebrates,
begins when the
metanephric ducts
(ureteric buds) sprout
from the distal end of
the mesonephric duct
at about 5 weeks.
 The ureteric buds
induce intermediate
mesoderm in the
sacral region to form a
metanephric blastema
which forms the
Evolution of the Kidneys:

Metanephros
The ureteric buds bifurcate again
and again to form the calyces and
collecting duct system of the
definitive kidney.
 The kidneys begin producing urine
by week 12, and it adds to the
volume of the amniotic fluid. The
fetus drinks this fluid in utero.
 The fetal kidneys are not
responsible for excretion as the
placenta serves this function
 Ascent of
the
Kidneys

 In the 6th week the kidneys begin to ascend from the

sacral region to their position in the upper
abdomen.
 The metanephric ducts elongate and become the
ureters.
 As the kidney ascends it receives new segmental
arteries from the aorta and loses those vessels
below (“climbing a ladder”). Thus sometimes there
is more than one renal artery.
 Sometimes one kidney fails to ascend => pelvic
 Position of
kidneys
 Kidneys lie on the psoas
muscle beside the vertebral
bodies.
 The diaphragm and 11th and
12th ribs lie behind the upper
half of each kidney.
 Therefore they move with
breathing
 Left is higher than right (liver)
 Upper poles T12
 Hilum is at L1/2
 Lower poles at L3
 Upper poles are more medial It crosses the aorta
(psoas). Is crossed by the SMA
 In the hilum: Receives left gonadal vein
 Anterior relations
 Right ◆Left
 Adrenal ◆Adrenal
 Liver
 bare area ◆Stomach
 Hepatorenal
pouch
◆Spleen
 Duodenu
m ◆Pancreas
 Pancreas
 Right ◆Descending

colic Colon
flexure ◆Jenunum

Macroscopic anatomy
Nephrology / Urology

Renal

Upper urinary tract

Lower urinary tract

Perirenal Fat A layer of adipose tissue (fat) partially surrounds the kidney.
It is usually a radilogy finding but occassional a tumor can arise from it.

Renal Capsule The thin but tough covering of the kidney. It helps protect the kidney.
During a kidney biopsy, may feel a "pop" as the needle goes through the renal
capsule

Renal Cortex The outer shell of the kidney between the renal capsule and the renal medulla.
The renal cortex contains the renal corpuscles (particularly the glomeruli) and
most of the renal tubules (except for the loop of Henle). It is about 1 centimeter
thick and also goes down between the renal pyramids. Many kidney diseases
affect the glomeruli so the goal of a kidney biopsy is to sample this area.

Renal Medulla The innermost area of the kidney. It is separated into 8 to 18 cone-shaped
sections called the medullary pyramids. If the biopsy needle goes in too far, you
may only get medulla and the biopsy will likely have to be repeated.

Medullary Pyramid An important part of the inner kidney. It consists primarily of collecting tubules
as well as loops of Henle. The base of the medullary pyramid is next to the
cortex and it tapers to form the renal papillae. There are between 8 to 18
medulla pyramids in each kidney.
Calyx An extension of the renal pelvis that surrounds the renal papillae. It collects
urine from the papillary ducts. Several minor calyces drain into a major calyx
and then onto the renal pelvis.

Renal Pelvis The area where the urine collects before entering the ureters. Two or three
major calices come together to enter the renal pelvis. Cancers and kidney
stones can form in renal pelvis and cause blood to be lost in the urine.

Renal Sinus A cavity in the kidney that contains the calices and the renal pelvis. It also
contains the blood vessels, nerves, and fat.
 Physiologic anatomy

Retroperitoneal organ
Weight: 150gm each
Size: ~clenched fist size
Location
Right: hilum at L1-2
Left: hilum at L1
Divided into cortex and medulla
Each ~1million unit nephrons and kidney
cannot regenerate new nephrons.
paired organs.
(1 in 1,000) only one kidney develops called congenital
agenesis.

Shaped Like Beans:

The kidneys are bean shaped.
(1 in 400), the two kidneys fuse into a single horseshoe
kidney

Located in Your Lower Back:

The kidneys lie in the retroperitoneum on either side of
the spine.
Some people are born with ectopic kidney, not proper
location.

Roughly the Size of Your Fist:

On the average, the kidneys are about 11-12 cm in
length, 7-8 cm wide, 2-3 cm thick and weigh about 1/4 to
1/3 pound each.
Microscopic anatomy
 Renal blood supply
Total blood flow ~25% cardiac output.(1.2L/min)
Renal arterysegmentalinterlobararcuate
interlobularafferent
Glomerulusefferentperitubular (vasa recta)
veins
2 capillary beds
High presure system
hydrostatic pressure 60mmHg minus (32mmHg
oncotic pressure + 18 mmHg bowman hydrostatic
pressure)
Renal cortex receives the most of the blood flow.
Renal medulla only receives 1-2% total blood flow
Substance Mol wt Filterability
H2O 18 1.0
Na 23 1.0
Glu 180 1.0
Inulin 5 500 1.0
Myoglobin 17 000 0.75
Albumin 69 000 0.005
GFR depends on

Starling force net pressure

1= capillary hydrostatic
pressure.
2= bowman capsule
hydrostatic pressure
3= capillary oncotic
pressure
 GFR depends on

1. Glomerular permeability
-capillary and bowman capsule endothelium, glomerular
basement mambrane.

2. Number of functioning glomeruli and total capillary

surface area

3. Glomerular capillary plasma flow

 ultrafiltrate: plasma minus protein/fat
Use of clearance method to
quantify kidney function
 The rates at which different
substance are cleared from plasma
provide a useful way of quantifying
the effectiveness of which the kidney
excrete various substances
 Renal clearance of a
substance
 Volume of plasma completely cleared
of the substance by the kidney per
unit time
 Provides a useful way to quantify the
excretory function of the kidneys
 Can be used to quantify the rate at
which blood flow through the kidneys
as well as the basic function of the
kidney, glomerular filtration rate,
tubular reabsorption and tubular
 Cs x Ps = Us x Vs
 Cs = clearance rate of a substance s
 Ps = plasma concentration of the
substance
 V = urine flow rate
 Us = urine concentration of the
substance
 Cs = Us x V / Ps
 Renal clearance of a substance is
calculated from the urinary
excretion rate (Us x V) of the
substance divided by its plasma
concentration
 Inulin clearance
 Can be used to estimate GFR
 Substance existed that was freely
filtered, not absorped or secreted by
the renal tubules, then the rate at
which the substance was excreted in
the urine (Us x V) is equal the rate at
which the substance was filtered by
the kidneys (GFR x Ps)
 GFR x Ps = Us x V
 GFR = US x V / Ps = Cs
 Inulin – polysaccharide molecule
which molecular rate of 5200
 Not produced in the body
 Found in the roots of certain plants.
 Must be administered IV to a patient
to measure GFR
 Other substances used to
estimate GFR
 Radioactive iothalamate
 Creatinine
 By product of skeletal muscle metabolism
 Present in plasma at relatively constant
concentration
 Does not require IV infusion
 Creatinine clearance
 Most widely used method for estimating
GFR clinically
 Creatinine not a perfest marker for GFR
 A small amount is excreted by the tubules
 The amount of creatinine excreted in the urine
slightly exceeds the amount filtered
 Overestimation of the plasma concentration

 The creatinine clearance provides a

reasonable estimate of the GFR
 Formula
GFR (total plasma volume/min from capillary to bowman capsule)
 38× Ht( cm )/ plasma Creatinine (mcmol/L)
Normal adult- 120ml/min/1.73m2

Creat. clearance (plasma volume removed /min by kidney)

 Urine creatinine (mmol/L) × Urine volume (ml/min)/
plasma creatinine(mmol/L)

Normal: ♂ 90-140ml/min
♀ 80-125ml/min
Creatinine clearance
Physiologic control of GFR and
Renal blood flow
1. Sympathetic NS Hormone or Effect on GFR
activation: all blood autocoid
vessels are richly Norepinephrine ↓
innervated.
Most important during Epinephrine ↓
severe acute
disturbances Endothelin ↓

2. Hormonal (see table) Angiotensin II ↔ (prevents ↓)

Endothelial ↑
derived NO
Prostaglandin ↑
Autoregulation of GFR & Renal
blood flow
 Renin Angiotensin
Aldosterone System
 Powerful mechanism for controlling
pressure
 Renin: small protein released by
kidneys when arterial pressure falls
too low
 Synthesized and stored in an inactive
form called prorenin in the JG cells of the
kidneys
 JG cells are modified smooth muscle
cells located in the walls of the afferent
arterioles immediately proximal to the
 Two principal effects of
Angiotensin II that can
elevate AP
 Vasoconstriction –
 Decreased
occurs rapidly excretion of both
 Intense in the salt and water –
arterioles and less slowly increases
extent in veins the ECF volume,
 Constriction in increases AP over
arterioles increases period of hours and
peripheral
resistance, raising
days
AP  Even more powerful
than acute
 Mild constriction in
vasoconstrictor
veins promotes
mechanism in
increase venous
eventually returning
return to the heart,
AP back to normal
 Two ways by which
Angiotensin causes salt and
water retention
 Angiotensin acts directly on the
kidneys to cause salt and water
retention
 Angiotensin causes the adrenal
glands to secrete aldosterone, and
the aldosterone in turn increases salt
and water reabsorption by the
kidneys tubules
Procedure anatomy
 Orientation and

surroundings
The medial border of each kidney is anterior to
the lateral border (psoas). Thus the coronal
plane of the kidney is at 30 degrees to the
coronal plane of the body.
◆Layers surrounding
the kidney
◆Outside the renal
capsule is perirenal fat
◆Then is the renal
fascia which also
surrounds the adrenals
◆This is embedded in
extraperitoneal fat
(pararenal fat)
RENAL BIOPSY
Normal anatomy

The kidneys are paired

organs that lie posterior
to the abdomen, in the
area of the lower back.
The kidneys make
urine, which is
transported from the
kidneys to the bladder
by the ureters, long
muscular tubes which
connect the kidneys
with the bladder.
Kidney transplant
may be
recommended
for patients with
kidney failure
caused by:
severe,
uncontrollable
high blood
pressure
(hypertension)
infections
diabetes mellitus
congenital
abnormalities of
the kidneys
other diseases
which cause
renal failure,
such as
autoimmune
disease
Donor kidneys
Incision

While the patient is

deep asleep and pain-
free (general
anesthesia), an
incision is made in the
lower right quadrant
of the abdomen. The
donor kidney is
transplanted into the
right lower pelvis of
the recipient.
Procedure

The new kidney is

sutured into place. The
vessels of the new
kidney are connected
to the vessels leading
to the right leg (the iliac
vessels), and the ureter
is sutured to the
bladder.
Aftercare

In most cases, the

recipient's native
kidneys are left in
place, and the
transplanted kidney
performs all the
functions that both
kidneys perform in
healthy people.
Kidney transplant
recipients are
required to take
immunosuppressive
medications for the
rest of the lives, to
prevent immune
rejection of the
transplanted organ.
 RENAL ULTRASOUND

Kidney Structure
•Number of Kidneys: agenesis
•Shape of the Kidneys: horseshoe kidney
•Location of the Kidneys: ectopic kidney.

Finding Kidney Stones, Cysts, and Masses

•Kidney Stones: The kidney ultrasound is a useful screening test for kidney stones. Not all kidney stones can be seen on
ultrasound, but many can be. If a stone is causing ureter obstruction, there may be hydronephrosis.
•Ureter Obstruction: A kidney ultrasound is routinely ordered to rule out obstruction in kidney failure. Impeding the flow of
urine can cause it to back up and dilate the ureters and kidneys. It should be noted that finding hydronephrosis doesn’t
necessarily mean there is an obstruction.
•Kidney Cysts: The kidney ultrasound is very good at discovering kidney cysts, most of which are uncomplicated and
incidental findings. Some cysts look complicated or complex and may represent infection, bleeding or cancer. People with
polycystic kidney disease have multiple large cysts that replace normal tissue and destroys the kidneys.
•Kidney Masses: The ability of kidney ultrasound to detect a kidney mass depends on its size. It is very good for large
masses (> 3 cm) but not so good for small tumors.

Signs of Kidney Chronic Disease

•Kidney Size: On the average, the kidneys are about 11-12 cm in length, 7-8 cm wide, and 2-3 cm in thickness. If they are
very small, it suggests significant scarring and irreversible damage.
•Thickness of the Cortex: The cortex is the outer shell of the kidney (about 1 cm in thickness) and contains all the
glomeruli. If it particularly thin, it suggests chronic kidney disease and may make it hard to biopsy. If it is thick, it may mean
inflammation and congestion.
•Echogenicity of the Cortex: Echogenicity refers to how the sound waves look when they bounce off something. It is often
said that it is not normal if there is a lot of echogenicity (compared to the liver). In reality, it is not a very reliable indicator of
kidney disease.
THANK YOU