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KIDNEY & RENAL PELVIS

Presented by: Dr. Isha Jaiswal

Moderator: Dr. Madhup Rastogi

Date:20th august 2014

KIDNEY : location

• pair of organs located in the abdominal cavity on either side of the spine in a retroperitoneal position.

• Approx. at vertebral level T12 to L3,• right kidney being slightly lower than the left.• Left kidney is little nearer to median plane

than right

• Long axis of kidney is directed downward and laterally &runs parallel to the lateral margin of the psoas muscle

• The kidneys are mobile organs that move vertically within the retroperitoneum on average 0.9 cm to 1.3 cm and as much as 4 cm during normal respiration

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KIDNEYS :external features

• Shape :Bean shaped

• poles: upper & lower• Border: medial & lateral• Surface: anterior & posterior

• Size: approx. 11–14 cm in length, 6 cm wide and 3cm thick

• Weight: around 150 gm. in males & 135 gm. in females

External Features

• Hilum of the kidney,• Concave medial border of

the kidney• Structures enter / leave

through the hilum (from anterior to posterior),

» Renal vein» Renal artery» Pelvis» Ureter» Renal nerves» Lymphatics.

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Relations of kidney Upper pole: adrenal gland

Lower pole: about 2.5 cm above iliac creast

Posterior relations: Diaphragm Muscles: psoas major,

quadratus lumborum,

transv.abdominis Ribs: 11th &12th ribs on left ,

only 12th on right side

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Anterior relationsRight kidney: Rt. adrenal gland

Liver 2nd part duodenum Hepatic flexure colon jejunum

Left kidney Lt. adrenal gland Spleen Stomach Pancreas splenic flexure colon jejunum

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Coverings of kidney

fibrous tissue, the renal capsule,

perinephric fat, renal fascia (of Gerota

) paranephric fat.

Internal features

parenchyma, of the kidney is divided into two major structures: Renal cortex: lobules & column

medulla: pyramid,papilla,calyx

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Functional unit of kidney: nephron

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URINARY DRAINAGE

Pyramids

Papillae

Renal pelvis

Major calyces

Minor calyces

Blood supply of kidney

Arterial supply: renal artery Venous drainage: renal vein

• Lymph Drainage :

• Nerve Supply: • Through sympathetic plexus (T10 – L1) fibres• Afferent nerves T10 to T12 thoracic nerves.

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The right kidney drains predominantly into the paracaval and interaortocaval lymph nodes

left kidney drains exclusively to the para-aortic lymph nodes

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CANCERS OF KIDNEY

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Renal Tumors: incidenceIn U.S in 2011 (ref:parez)

• 60,920 cases diagnosed(4 % of all new cancers)

• 13,120 deaths (2% of cancer related death)

• Approx 88% of solid renal masses are malignant• RCC comprise 80-85%of primary kidney tumors• Transitional cell carcinoma acoount for 7 % of kidney tumors• Rest are lymphoma, sarcomas, oncocytoma

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Renal Cell Carcinoma• First described by Konig in 1826.

• In 1883 Grawitz, noted the fatty content of cancer cells similar to that of adrenal cells. (Also called as Grawitz’s tumor)

• All these tumors arise from Renal proximal tubular epithelium

• The incidence of RCC is increasing & the size decreasing because of increased use of abdominal CT scans

• Male predominance (1.6:1.0 M:F)

• Highest incidence between age 50-70-Median age of diagnosis is 66 years

-Median age of death 70 years

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Risk Factors • Tobacco smoking contributes to 24-30% of RCC cases

Tobacco results in a 2-fold increased risk

• Environmental:Cadmium, thorium-di-oxide,

petroleum

aresenic

phenacetin analgesics.

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• Occupational:

leather tanners, shoe workers, asbestos workers, petroleum,

blast furnace, iron & steel industry

• Hormonal: diethylistillbestrol,

• Dietary: fried meats,(vegetables, fruits & alcohol are protective)

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• Obesity,

• HTN,

• DM

• ACKD:• 50% Pt. on long term dialysis(>3 yrs)

develop Acquired polycystic kidney disease, out of which 5.8% develops RCC

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A sarcomatoid variant represents1% to 6% of renal cell carcinoma and these tumors are associated with a significantly poorer prognosis. BHD=Birt-Hogg-Dubé; FH=fumarate hydratase; VHL=von Hippel-Lindau.

RCC variant

Clear cell

75%

Type

Incidence (%)

Associated mutations

VHL

Papillary type 1

5%

c-Met

Papillary type 2

10%

FH

Chromophobe

5%

BHD

Oncocytoma

5%

BHD

It is made up of no. of different types of cancers with different histology, different clinical courses and caused by different gene.

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Hereditary Renal Cancer SyndromesSyndrome Chromosome

Location (Gene)Renal

ManifestationsOther Manifestations

Von Hippel-Lindau (VHL)

3p25 VHL

Clear cell renal carcinoma: solid and/or cystic, multiple and bilateral28%-45%

Retinal and central nervous system hemangioblastomas; pheochromocytomas; pancreatic cysts and neuroendocrine tumors; endolymphatic sac tumors; epididymal and broad ligament cystadenomas

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Syndrome ChromosomeLocation (Gene)

Renal Manifestations Other Manifestations

Hereditary papillary renal carcinoma type1(HPRC)

7q31 MET

Papillary renal carcinoma type 1: solid, multiple and bilateral

None

Hereditary leiomyomatosis and renal cell carcinoma (HLRCC)

1q42-43 FH

Papillary renal carcinoma type 2, collecting duct carcinoma: solitary, aggressive

Uterine leiomyomas and leiomyosarcomas; cutaneous leiomyomas

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Syndrome ChromosomeLocation (Gene)

Renal Manifestations Other Manifestations

Birt-Hogg-Dubé syndrome (BHD)

17p11.2BHD

Hybrid oncocytic renal tumors, chromophobe and clear cell renal carcinomas, oncocytomas: multiple, bilateral

Benign tumors of hair follicle (fibrofolliculomas); lung cysts, spontaneous pneumothoraces

Constitutional chromosome 3 translocation

3p; Not known; VHL somatic mutations 84% - 98%

Clear cell renal carcinoma: multiple, bilateral

None

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Spread of renal cancer

Local Infiltration :through the renal capsule to involve the

perinephric fat and Gerota's fascia.

Venous: The tumor may grow directly along the venous channels to

the renal vein or vena cava.

Lymph node metastases :involve the renal hilar, para-aortic, and paracaval lymph nodes

Distant metastasis: lung, bone, bone, liver ,adrenal

Natural History7% diagnosed incidentally45% present with localized disease at time of diagnosis 25% with locally advanced disease at diagnosis30% with metastatic disease at diagnosisLymph node metastases- 9% to 27% (renal hilar, para-

aortic and paracaval)Renal vein – 21% & IVC 4%Distant metastases- lung (75%), soft tissue (36%), bone

(20%), liver (18%), skin (8%) and CNS (8%)

Ref: DeVita

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• CLINICAL FEATURES

50 % of RCC are now detected incidentally: Radiologist's tumor’

Triad of presentation: seen in only 10% pt., poor prognosis  Pain (80%),

 Hematuria (45%)

palpable mass (15%) 

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Other signs and symptoms

Weight loss (33%)

Fever (20%) Hypertension (20%) Hypercalcemia (5%) Night sweats Malaise Varicocele usually left sided, due to obstruction of the testicular

vein (2% of males)

Stauffer’s syndrome: Non metastatic hepatic dysfunction reported in 3-20% of cases Hepatic function normalizes in 60 to 70% of cases after nephrectomy.

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Paraneoplastic syndromes are found in 20% of patients with RCC

Elevated E.S.R.HypertensionAnemiaCachexiaPyrexiaAbnormal liver functionHyper calcemiaPolycythemiaNeuromyopathy

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Clinical presentation• History taking:

• age, Sex,Occupation

• Chief coimplains:

Pain :onset, duration, progress, nature, radiation, relation with micturition

Renal pain: painless or dull ache, at renal angle radiating along subcoastal area towards umbilicus along with fever loss of weight malaise

Ureteric pain: colic, start at renal angle radiate downward along course of ureter,referred to groin inner part of thigh, penis etc

Bladder pain is midline suprapubic dull,

Urethral pain: during or at end of micturition

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Haemeturia:

• Amount,• Relation to micturition

• Association with pain

Beginning: urethralToward end: vesicalThroughout: prerenal,renal,vesical

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Renal lump

• History:site onset duration progression• Examination• Inspection,• Palpation• Percussion• auscultation

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Inspection

in recumbent position fulleness in lumbar regionmoves slightly with respiration

palpation

murphy’s punch testpatient sits up press over the renal angle to see for tenderness

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Palpation of kidney: bimanual method

• Features of a renal lump• Lies in loin• Can be moved in loin• Reniform shape• Ballotable• slightly move with respiration • fingers can be insinuated between coastal margin and swelling

• To palpate the left kidney,• reach across the client • place your left hand under the client’s left flank with your palm upward.• Elevate the left flank with your fingers, displacing the kidney upward.• Ask the client to take a deep breath • use the palmer surface of your right hand to palpate the kidney • Repeat the technique for the right kidney

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Percussion

features of a renal lump

resonant anteriorly due to bowel loopsdull posteriorly: enlarged kidney displaces colon

Auscultation: bruit may be heard

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Diagnostic Work-Up • Laboratory studies   

– CBC, LFT's, alkaline phosphatase, BUN, creatinine, urinalysis

• Radiographic studies- Increased use of imaging has increased the detection of renal lesions most of which are simple cysts.– X-Ray KUB region– Ultrasonography- Excellent in distinguishing cystic from solid masses– Intravenous Urography - Starting point for hematuria evaluations and

function of contralateral kidney– Computed tomography- Provides an excellent assessment of the parenchyma

and nodal status.– Magnetic Resonance Imaging - excellent demonstration of solid renal masses

and is image test of choice to demonstrate extent of vena caval involvement with tumor. Useful in patients with renal insufficiency

– MRI has no advantage compared with contrast enhanced CT for the diagnosis of RCC but it is better for staging of locally advanced cases

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Metastatic Work-Up

• Chest X-ray or Chest CT • CT/MRI scan of abdomen or pelvis • Bone scan with plan films (for elevated alkaline

phosphatase or bone pain).

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Radiological anatomy

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Figure : Computed tomography demonstrates a right renal carcinoma (m) with a large contralateral adrenal metastasis (a).

Figure: CT scan shows large left renal mass with calcification (m) invading the left renal vein (arrow).

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Figure: T1-weighted magnetic resonance image demonstrates tumor (m) and vascular invasion (arrow). Flowing blood (v) in the left renal vein is black on this scan.

Figure A: Axial T1-weighted image demonstrates a large left renal carcinoma with extension into the left renal vein (m) with protrusion into the IVC (v). B: Sagittal T1-weighted image shows the relation of the tumor thrombus (m) to the IVC (v) in the lateral projection.

Renal Cell Carcinoma• 3D CT scan showing a left lower pole RCC extending into the

renal hilum

Renal Cell Carcinoma• Multifocal renal cell carcinoma in a patient with Von Hippel Lindau disease.

Patient had already undergone a right nephrectomy. Contrast-enhanced CT

scan

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Renal cell carcinoma of left kidney involving renal vein & inferior vena cava

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Thank you !