1 Flashcards
Describe the position of kidneys
- Left kidney has superior lobe right at 12th rib
- Right kidney has superior lobe just below 12th rib because of liver
- lower poles of kidneys are around L3-L4 vertebrae
- hylum is at around L1 where the ureter comes out
Describe the size of kidneys
- length: 9-14cm
- width: 6-7cm
- males have bigger kidneys than females
- if the difference in the size of kidneys is >2cm then it’s concerning
- if length of kidney is <8cm then also concerning
- each kidney weighs about 200g
What are the bony landmarks and anatomical position of the kidneys?
- Retroperitoneal
- Upper pole: T11-12 (L) and T12 (R)
- Lower pole: L2-L3 (L) and L3-L4 (R)
- Hilum: L1
What is the renal angle?
- area just between 12th rib and erector spinae muscle
- where you can palpate the kidney
- if pt. Has inflammation in and around the kidneys, then the renal angle would be tender
What does it mean to balate a kidney?
-to palpate the kidney
Why do the kidneys move up and down upon respiration?
- because they’re not attached to anything
- only fat and fascia anchor them down
What are the fascial layers of the kidney from out to in and describe them
- paranephric fat: external to the posterior layer of the renal fascia, extra peritoneal, associated with the lumbar region
- renal fascia (Garota’s fascia)
- perinephric fat: surrounds the kidney within renal fascial layers, continuous with the fat found in the renal sinus of the kidney
Describe the appearance of the ureter
- smooth muscle fibres that propel urine (peristaltic waves) to the urinary bladder
- ureter is 25-30cm long
- retroperitoneal
- located lateral to the tips of the transverse processes of the L-spine
- crossed by gonadal vessels
What are the 3 sections that the ureter is divided into at the pelviureteric junction (PUJ)?
- proximal (abdominal) segment
- middle (pelvic) segment
- distal (intramural) segment
What are the most common areas of ureteric injury?
- near the pelvic brim
- at the level of gonadal vessels
Describe the intramural segment of the ureter
- runs obliquely through the bladder wall (prevents urine reflux)
- near the bladder the ureter coalesces with bundles of destructor muscle in bladder wall
- no sphincter at the VUJ (vesicular uretile junction)
What substance is only found in the urinary system? Describe it
- urothelium
- continuous lining of the bladder, ureter and pelvis of kidney
- lines of smooth muscle around wall of ureter
- peristaltic tube
What are some positional changes of the ureter? Describe them
- retrocaval: when right ureter goes around IVC
- duplexed ureter (one not entering bladder): cause of urinary infection, if enters urethra then pt. Will constantly dribble urine
- duplexed ureter (both entering bladder): usually goes unnoticed
Describe the trigone.
- region in bladder which is connected by
- internal urethra entrance
- internal urethral meatus (exit point)
What is the muscle surrounding the bladder?
-detrusor muscle
What is the cavity superior to the bladder in males and females respectively?
- Males: recto-vesicle pouch
- Females: uterine-vesicle pouch
Why can’t you palpate an empty bladder?
- Because of the pubic symphysis in the way, empty bladder wont poke up above the symphysis
- if the bladder is full, then you can palpate
What is the function of the internal urinary sphincter (IUS) in males and females?
- male: innervated by sympathetic nerve to prevent retrograde ejaculation
- female: not much function
What is the function of the external urinary sphincter (EUS) in males and females?
-both: controls when you urinate and sits in the urogenital diaphragm
What are the two things that control urinary continence in females?
Pelvic floor and the EUS
Where is the glomerulus found within the kidney?
In cortex
Describe the microscopic structure of the kidney
- inferior to the cortex are renal pyramids
- there are stripes on the pyramids which are formed by collecting ducts
- tips of the pyramids are called papillae, where the collecting ducts empty out into the calyx
- the minor calyx form together to make a major calyx
- major calyx form to make renal pelvis
- all the structures are lined with urothelium
- encased in a renal capsule
- see a diagram
Describe a nephron
- contains glomerulus which filters huge volumes of ECF, enters into afferent arteriole and leaves through efferent arteriole
- obligatory reabsorption of most substances in proximal convoluted tubule
- controlled reabsorption of salts and water in DT (distal tubule)
- controlled secretion of hydrogen ions
- passive loss of waste products
What is the difference between cortical and juxtamedullary nephrons?
- Cortical: located on outer part of cortex, has short loops of Henle, small glomerulus, rich sympathetic innervation, high concentration of renin, 90% blood perfusion
- Juxtamedullary: located on inner part of cortex next to medulla, has longer loops of Henle that penetrate right down to medulla, big glomerulus, poor sympathetic innervation, almost no concentration of renin, 10% blood perfusion
What is the main blood supply to kidneys?
- superior mesenteric artery
- inferior mesenteric artery
Why are kidney so vulnerable to ischaemic damage?
-They have a very high cardiac output, more blood flowing through
What is renal blood flow (rbf) and renal plasma flow (rpf)?
- standard rbf: about 1.1L/min
- all blood flows through glomeruli in the cortex
- rpf: the haematocrit which is normally about 0.45L/min
- how to calculate rpf: 0.55 x 1.1L/min= 605mL/min of plasma
- look at diagram
Where do the adrenal glands drain into?
Left renal vein
Why are left kidneys preferred for transplants?
They have longer vessels which help in operation
Where do the left and right gonadal veins drain into?
- left: drains into left renal vein
- right: drains into IVC
How are the blood vessels in the kidneys divided?
- From arch of aorta splits into left and right renal artery
- renal artery splits into 5 segmental arteries (apical, upper, middle, lower, and posterior)
- segmental artery splits into interlobar arteries which are BETWEEN the pyramids
- interlobar arteries split into arcuate arteries which are between the cortex and medulla
- arcuate arteries split into ascending interlobular arteries which are WITHIN the renal lobe
- Interlobular arteries give rise to millions of glomerular arterioles (afferent arterioles)
- afferent arterioles eventually rejoin and become efferent arterioles again
What are some symptoms of ESRD (end stage renal disease?)
- nausea
- vomiting
- fatigue
- anorexia
- weight loss
- muscle cramps
- pruritus
- lower extremities are uncomfortable and swollen
- dry cough
- shortness of breath
- urine in blood
What are some signs of ESRD?
- tachypnea: breath may smell uraemic
- tachycardia
- elevated BP: often >150/100
- dry skin: uraemic frost
- petechia: not uncommon since it will affect blood clotting, platelets, and coagulation factors
- moist rales posterior lung bases
- S3 on cardiac exam
- abd exam usually benign
- pitting oedema on extremities: painful when getting up
- msk pain occurs with pressure
Why do patients often experience fatigue with renal disease?
- describes of kidneys can lead to build-up of toxins and impurities in blood
- makes patients feel weak and less energy
- also anaemia due to kidney disease can cause fatigue
Why do patients with renal disease have trouble sleeping?
- kidneys dont filter properly so toxins stay in blood and dont leave body through urine
- sleep apnoea is very common with people who have chronic kidney disease
Why do patients with renal disease have dry and itchy skin?
- is a sign of the mineral and bone disease that is common with advanced kidney disease
- kidneys are no longer able to keep the right balance of minerals and nutrients in your blood
Why do patients with renal disease need to urinate more often (especially at night: nocturia)
- when kidney filters are damage it can cause an increase in the urge to urinate
- can also be a sign of urinary infection or enlarged prostate in men
Why do patients with renal disease have blood in their urine?
- when kidney filters are damaged, blood cells can start to “leak” into the urine
- blood in urine can be indicative of malignancy, kidney stones or infection
Why do patients with renal disease have foamy urine?
- indicates that there is protein in the urine
- looks like scrambled eggs
Why do patients with renal disease have persistent puffiness around their eyes?
-Sign that kidneys are leaking a large amount of protein in the urine, rather than keeping it in the body
Why do patients with renal disease have swollen ankles and feet?
- decreased kidney function will lead to sodium retention which causes swelling
- this swelling can also be a sign of heart disease, liver disease and chronic leg vein problems
Why do patients with renal disease have a poor appetite?
-build-up of toxins resulting from reduced kidney function
Why do patients with renal disease have cramping muscles?
- electrolyte imbalances can result from impaired kidney function
- ex: low calcium levels and poorly controlled phosphorous may contribute to muscle cramps
What lecture should I go over?
THE RENAL PATiENT
