14 The Kidneys
Anatomy
General Facts
Size: 12cm long, 7cm wide, and 3cm thick.
Location
Posterior
Left kidney:
Upper pole: T11
Renal pelvis: L1
Lower pole: L3
The right kidney is located approximately 1–1.5cm lower than the left kidney.
Anterior
Left kidney:
Upper pole: rib 9
Lower pole: 1–2cm above the navel
Right kidney:
Upper pole: rib 9
Lower pole: level of the navel
The axis of the kidney runs slightly diagonally from cranial-medial to caudal-lateral.
Renal Fascia
This consists of an anterior leaf and a posterior leaf. Both leaves merge superior and lateral to the kidneys. This “fascial sac” is open on the bottom.
The fascias of both kidneys merge at the level T12-L1 in front of the spinal column.
Retrorenal lamina:
This covers quadratus lumborum and psoas major and is fixed anteriorly and laterally to the spinal column (medial to the psoas and diaphragm).
Prerenal lamina:
This lies next to the peritoneum and Toldt fascia. On the left side, it is associated with this fascia in a larger area. It covers the kidney, hilum, and the large prevertebral vessels.
Both laminae surround the adrenal glands, merge superiorly, and are attached to the diaphragm.
Inside the fascial layers and surrounding the kidney, we find fat (fat capsule). This exists from about age 10 on.
Topographic Relationships
Posterior
diaphragm and psoas arcade
pleura (indirectly in the area of the costodiaphragmatic recess up to the level of L1)
rib 12, on the left also rib 11
psoas major and its fascia
quadratus lumborum and transversus abdominis
subcostal, iliohypogastric, ilioinguinal nerves
Grynfeltt triangle
Anterior
Right kidney:
liver
hepatoduodenal ligament
right colic flexure
transverse mesocolon
duodenum, descending part
ascending colon
Left kidney:
spleen
stomach
pancreas
duodenojejunal flexure
jejunum
left colic flexure (stronger fixation than on the right)
The adrenal glands lie superior to both kidneys.
Attachments/Suspensions
turgor
pressure of other organs and tonicity of the abdominal muscles
fat capsule
hilar vessels and ureter (braking function)
thoracic suction effect and tonicity of the abdominal muscles during respiration
Circulation
Arterial
Renal artery (originates in the aorta, roughly 1 cm below the superior mesenteric artery; the left one is shorter than the right one).
Venous
Renal vein (left vein is longer than the right one, ends in the inferior vena cava).
Lymph Drainage
lumbar nodes
lumbar trunk
thoracic duct
Innervation
sympathetic nervous system from T10 to L1 via the lesser and lowest splanchnic nerves and the lumbar splanchnic nerves 1 and 2 to the celiac plexus, aorticorenal ganglion, renal plexus, and posterior renal ganglion
vagus nerves (via the celiac plexus)
sacral parasympathetic part (S2-S4) via the superior hypogastric plexus to the renal plexus
Organ Clock
Maximal time: 5-7p.m.
Minimal time: 5-7a.m.
Organ-Tooth Interrelationship
For basic information, see page 34.
Second incisor in the lower jaw on both sides
First incisor in the upper jaw on both sides
Movement Physiology according to Barral
Three factors determine the movement of the kidneys:
The renal fascia is open toward the bottom and medially.
The hilum vessels pull on the kidney.
The psoas is a slide rail.
Mobility
The engine of this movement is the diaphragm. During inhalation (20000/day, 600m/day), the kidney moves 3-4cmcaudally.
The upper pole is pressed forward during inhalation (psoas slide rail). In addition, the kidney moves in a caudal-lateral direction and rotates outward.
Motility
During inhalation, we feel a movement from medial-cranial to lateral-caudal in connection with an outward rotation (“windshield wiper”). During exhalation, the kidney completes the opposite movement.
Physiology
Functions of the Kidney
regulation of the fluids and electrolytes
regulation of the acid–base balance
excretion of substances through the urine (urea, creatinine, uric acid, etc.)
excretion of foreign substances (medications)
regulation of blood pressure (renin–angiotensin– aldosterone system)
hormone production (erythropoietin, renin, calcitriol, prostaglandins)
degradation of peptide hormones
Pathologies
Symptoms that Require Medical Clarification
Pain elicited by percussion in the kidney area
Hematuria
Nephrolithiasis
Definition. Urinary stones in the kidney and excretory urinary tracts.
Causes. Excessive amounts of stone-forming substances in the urine.
Risk factors include:
lack of physical movement
insufficient fluid supply
familial predisposition
medications (calcium, vitamin C and D therapy)
gout
diabetes mellitus
kidney disorders
hyperparathyroidism
Clinical. Asymptomatic if the calculi do not constrict the urinary tracts.
Obstructing stone causes:
colic with hematuria
nausea
vomiting
abdominal pain
flank pain
pain radiating into the genitals and inside of the thighs
Acute Pyelonephritis
Definition. Infection of the upper urinary tract caused by pathogenic organisms.
Causes. Highly virulent organisms coinciding with a weakened state of defense.
Precipitating factors include:
stricture of the urinary tract
vesicoureteral reflux
neurogenic disturbance of bladder voiding
calculi
diabetes mellitus
immunosuppressive therapy
Clinical
pain elicited by percussion in the kidney area
flank pain
headache
sweating
nausea
vomiting
fever >38.5°C
Nephrotic Syndrome
Definition. Complex of symptoms, consisting of:
proteinuria
hypoproteinemia
dysproteinemia
hyperlipoproteinemia
edemas
Causes. We find primary or secondary preexisting glomerular disorders, e.g.:
poststreptococcal glomerulonephritis
rapidly progressive glomerulonephritis
systemic disorders, e.g., lupus erythematosus
Clinical
microhematuria
edemas
hypertonicity
Renal Cell Carcinoma
Definition. Most common form of malignant tumor in the kidney, in most cases originating in the tubular cells.
Causes. Degeneration of proximal tubular cells.
Clinical
hematuria
elevated ESR
palpable abdominal mass
hypertonicity
weight loss
anemia
intermittent fever
asymptomatic in the early stages
Osteopathic Practice
Cardinal Symptoms
Pain elicited by percussion in the kidney area
Hematuria
Typical Dysfunctions
ptosis
adhesions/fixations
Theory of Kidney Ptosis according to Barral
Causes
ptosis up to the lesser pelvis is congenital
asthenic body
trauma (fall on the coccyx, vibrations)
rapid and extensive weight loss
depression
turgor effect decreases with increasing age
ptosis after childbirth
suction from below and pressure from above during delivery
loose ligaments
Ptosis of the Right Kidney
“Digestive kidney.” This name stems from the fact that the digestive tract has such a strong influence on the right kidney. See also “Notes for Clinical Application,” page 143.
The liver and ascending colon are the main factors affecting the kidney.
Ptosis of the right kidney is more common than ptosis of the left kidney because:
the large liver presses down more strongly
the Toldt fascia is weaker on the right side
the left colic flexure fixates more strongly
the scoliosis in the lumbar spinal column (LSC) brings the right kidney to anterior, which increases the pressure from the liver
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