ABD - Unit VIII (renal/urinary) (3/29)

What are the two primary functions of the urinary system?

1. Excrete waste

2. Control the composition of blood (removing harmful wastes and conserving water and metabolites)

What is the normal length of the kidneys?

9-12 cm

What in the kidney might commonly be mistakened as a stone?

Arcuate arteries when they are calcified

The renal artery arises ___ from the ___ and runs to the kidney

laterally, aorta

Just before entering the renal pelvis, the renal artery branches into 2-3 ___ ___

segmental arteries

The segmental arteries branch inside the kidney to form ___ ___, which then branch into several ___ ___

lobar arteries, interlobar arteries

The interlobar arteries run through the renal ___ into the renal ___

columns, cortex

At the bases of the renal ___, the ___ arteries branch off

the interlobar arteries

pyramids, arcuate

___ arteries branch off the arcuate arteries and feed the

renal ___

Interlobular, cortex

What is the arterial supply to the kidneys? (7)

1. Aorta

2. Renal artery

3. Segmental arteries

4. Lobar arteries

5. Interlobar arteries

6. Arcuate arteries

7. Interlobular arteries

What do the renal veins empty into?

IVC

What is the major function of the kidney?

The excretion of urine

The composition of the ___ depends on what the kidney has to filter out of the ___ to maintain ___.

urine, blood, homeostasis

Serum Creatinine: ___ levels of creatinine in the blood indicate ___ ___

increased, renal failure

What lab value is the most reliable indicator of renal dysfunction/failure?

(Serum) creatinine

If creatinine clearance is LOW (indicating glomerular malfunction), the serum creatinine will be ___

HIGH

The right renal artery runs ___ to the IVC.

posterior

What normal variant of the kidney may mimic a renal mass or duplicated urinary system?

Hypertrophied Column of Bertin

Prominent folds of renal cortical tissue that protrude down into the medulla towards the renal sinus

• Clearly separated from the renal sinus

• Continguous with renal cortex

• Echogenicity is the same as the cortex/renal parenchyma

• Not over 3 cm in size as a rule

Hypertrophied Column of Bertin

A dromedary hump is usually on the ___ kidney. And the echogenicity is the ___ as the rest of the renal ___.

left, same, parenchyma

What normal variant of the kidney is a bulge of the renal cortex on the lateral surface of the kidney thought to be a result of pressure on the developing fetal kidney from the spleen?

Dromedary hump

What normal variant of the kidney is an echogenic, triangular indention in the upper pole of the renal parenchyma, which is a result of partial fusion of the two embryonic ranunculi that form the kidney?

Junctional parenchymal defect

Horseshoe kidney is the ___ of the polar regions of the kidneys during fetal development. Almost always involves the ___ poles. Usually located ___ in the ___ than usual. Associated with ___ pelvis, dilated ___ that are prone to infection (pyelocaliectasis), and ___.

fusion, inferior, lower, retroperitoneum, extrarenal, calyces, stones

Fusion of the polar regions of the kidneys during fetal development. Almost always involves the inferior poles. Usually located lower in the retroperitoneum than usual. Associated with extrarenal pelvis, dilated calyces that are prone to infection (pyelocaliectasis), and stones.

Horseshoe kidney

What renal congenital anomaly is when the right and left kidneys are fused and located on one side?

Cross-fusion

What renal congenital anomaly is when the kidneys fuse completely and remain in the midline?

Cake kidney

What congenital anomaly of the lower urinary tract results from when the prostatic urethra is dilated due to an obstruction?

Posterior urethral valves

What congenital anomaly of the lower urinary tract is the most commonly cause of urinary obstruction in male infants?

Posterior urethral valves

With posterior urethral valves, you may see an overly distended (enlarged) ___ with ___ hydroureter and hydronephrosis on ultrasound.

bladder, bilateral

Posterior urethral valves are a common indication for a ___ ___ ultrasound.

pediatric renal

Polycystic Renal Disease

• Multicystic Dysplastic Kidney is a ___ developmental disorder.

nonhereditary

Multicystic Dysplastic Kidney is usually ___ and if it is ___, it is typically ___.

unilateral, unilateral, asymptomatic

If Multicystic Dysplastic Kidney is bilateral, it is ___.

fatal

The kidney affected by Multicystic Dysplastic Kidney disease is usually ___.

nonfunctional

A kidney affected by Multicystic Dysplastic Kidney is ___ and made up of multiple ___ and little if any normal renal ___.

small, cysts, tissue

What is the most common source of palpable abdominal mass in infants?

Multicystic dysplastic kidney disease

If a patient has autosomal recessive polycystic kidney disease, what will the kidneys look like on ultrasound (Infantile)?

Large and echogenic due to many tiny cysts

Autosomal recessive polycystic kidney disease is usually diagnosed when patients are ___ whereas autosomal dominant polycystic kidney disease is usually diagnosed when patients are in their ___.

young, 30s-40s (adults)

If a patient has autosomal dominant polycystic kidney disease, what will that look like?

Kidneys become enlarged and are slowly replaced by large cysts

What is the most common inherited renal disorder?

Autosomal dominant polycystic kidney disease

When is autosomal dominant polycystic kidney disease usually diagnosed?

30s-40s

What are onset symptoms of autosomal dominant polycystic kidney disease?

Hypertension and renal failure

___% of patients with autosomal dominant polycystic kidney disease will also have ___ ___

50, liver cysts

___% of adults over the age of ___ have renal cysts.

50, 50

The parapelvic cyst is going to be located in the ___ ___, originate from the ___ ___, and protrude into the ___ ___.

renal hilum, renal parenchyma, renal sinus

A parapelvic cyst may cause ___.

hypertension (because it compresses on those arteries in the hilum)

Which kidney cyst may cause hypertension?

Parapelvic cyst (because it compresses on those arteries in the hilum)

Which cyst is NOT located in the renal hilum? Where is it located?

Peripelvic cyst; It is located in the sinus around the edge of the hilum

Both parapelvic cysts and peripelvic cysts do NOT communicate with the ___ ___.

collecting system

Genetic disorder that affects many parts of the body (*Under Cystic Masses Associated with Systemic Disease)

Von Hippel-Lindau Disease

What renal manifestations often appear with Von Hippel-Lindau disease?

• Renal ___

• Renal ___ (benign, solid)

• Renal ___ (malignant)

• Usually ___, often _lateral

cysts, adenomas, adenocarcinomas, multiple, bi

If a renal tumor is malignant, what area do you want to closely look at?

the venous system (renal vein, IVC, right atrium)

tumor will typically extend here

What is the most common malignancy of the kidney?

renal cell carcinoma (RCC)

What are the 3 most common symptoms associated with renal cell carcinoma?

- hematuria

- weight loss

- flank pain

What are the sonographic appearances of renal cell carcinoma? (11)

o Solid

o Most often isoechoic (86%)

o May be hypoechoic (10%)

o May be echogenic to renal parenchyma (more often in tumors measuring <3cm)

o Small tumors often have a hypoechoic rim

o Occasionally complex

o Cystic (5-15%)

o May be Unilocular with thick walls, multi-locular with septations, or necrosis of solid mass

o May see calcifications (8-18%)

o Irregular borders

o Disrupts renal contour, corticomedullary border, and/or renal sinus

What indicates major progression of renal cell carcinoma? What stage of RCC is this considered?

invasion to the IVC. Stage 3

What is another name for Wilm's tumor?

nephroblastoma

Is a Wilm's tumor benign or malignant?

malignant

What is the most common pediatric solid renal mass?

wilm's tumor/nephroblastoma

The wilm's tumor is rare in __________ , 50% appear by age ___, most patients approx __ years old.

newborns ; 3 ; 2

What is a wilm's tumor associated with? (4)

o Beckwith-Wiedemann Syndrome

o Sporatic Aniridia (no color of iris)

o Omphalocele

o Hemihypertrophy

What is the most common symptoms of Wilm's tumor?

palpable abdominal mass

What is the difference between a UPJ and UVJ?

o UPJ (Ureteropelvic Junction) Obstruction: occurs where the ureter joins the renal pelvis

o UVJ (Ureterovesicle Junction) Obstruction: occurs where the ureter joins the bladder

What can cause acquired hydronephrosis? (8)

What can cause intrinsis hydronephrosis? (4)

What are the causes of congenital hydronephrosis? (4)

Bilateral or unilateral hydronephrosis? Bladder or urethra obstruction?

bilateral

Bilateral or unilateral hydronephrosis? Stone in the right kidney?

unilateral

What grade of hydronephrosis is this?

splaying of the calyces—distinguish from peripelvic cyst by

imaging in two planes and showing communication with the ureter. Use

color Doppler to distinguish from renal vessels.

Grade 1

What grade of hydronephrosis is this?

Fluid extends into major and minor calyces. "Bear Claw" or

"Cauliflower" effect.

Grade 2

What grade of hydronephrosis is this?

Severe dilatation of the renal pelvis with loss of renal

parenchyma

Grade 3

When evaluating hydronephrosis on US, you must scan the patient ___ and _______ _____.

pre ; post void

What syndrome is medullary nephrocalcinosis associated with?

Cushing's syndrome

With medullary nephrocalcinosis there are _______ deposits in the renal _______.

calcium ; pyramids

What is classified as an abrupt decrease in renal function?

acute renal failure

What is the main symptoms associated with acute renal failure?

oliguria (decreased urine output)

What are causes of acute renal failure? (4)

o Acute inflammatory process in the kidney

o Renal Vein Thrombosis

o Renal Artery Occlusion (rare)

o Also caused by some drug overdoses and antifreeze intake

What is the US appearance of acute renal failure? (3)

- Large kidneys

- Hypoechoic or echogenic kidney

- Loss of corticomedullary junction

What are the lab values that indicated chronic renal failure?

high BUN and Creatinine

What will the kidney look like on US with Acute Glomerulonephritis? (2)

large and echogenic

What is Acute Glomerulonephritis associated with? (4)

• Pharyngitis

• Edema

• Oliguria

• Hematuria

What is an auto-immune connective tissue disorder that affects many parts of

the body?

Lupus nephritis/systemic lupus erythrematosus

______ ________ generally affects the blood vessels, joints, liver, kidneys, and causes retroperitoneal fibrosis.

Lupus nephritis

Lupus nephritis rarely affects what?

the central nervous system

What is lupus nephritis associated with?

butterfly shaped rash on the face

What renal symptoms will somone with lupus nephritis have? (5)

o Hematuria

o Proteinuria

o HTN

o Renal Vein Thrombosis

o Renal Insufficiency - increased BUN and creatinine

What is the sonographic appearance of lupus nephritis? (2)

- renal atrophy

- echogenic kidneys

What is the most common medical renal disease that causes acute renal failure?

acute tubular necrosis

What is the name for herniation of the bladder wall?

bladder diverticulum

What is the US appearance of bladder diverticulum? (3)

o Cystic protrusion from the wall of the bladder

o May remain filled with fluid even after bladder is emptied

o Urine stasis predisposes patients to bladder stones and infections

Infectious cystitis typically occurs in ______.

women

(From E.coli bacteria from the rectum. Why women wipe from front to back)

What are the symptoms with infectious cystitis? (2)

- hematuria

- urinary frequency and burning

What is the US appearance of Emphysematous Cystitis? (2)

o Echogenic foci

o Dirty or ring-down shadow within bladder wall

What type of cystitis will have the lining of the bladder inflamed and starts to bleed and is associated with fever, abnormal urinalysis with RBC's and WBC's present?

hemorrhagic cystitis

What are masses of urothelium in the lamina propria (connective tissue) of the bladder wall? And what is this associated with?

Brunn's Nests

Chronic cystitis

Sites that scan any pediatric patients will scan a LOT of kidneys. We are typically following up _________ or looking for any abnormality associated with ____ ______.

hydronephrosis ; bed wetting

If a patient has a _______ based on urine analysis, we may see nothing abnormal on ultrasound.

UTI

_____ ______ ______ is a very typical indication for a renal ultrasound

acute renal injury

________ patients are known to have kidney problems and vascular issues.

diabetic

If a patient complains of frequent urination, leaking, or the order specifies, it is necessary to obtain _____-______ bladder images to calculate the ____-______ residual. In an adult we want the amount of urine left in the bladder after urination to be _____ than ___cc

post-void ; post-void ; less ; 40