Anatomy of Kidney and Blood Supply Medical Presentation

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Published on : May 24, 2018 | Views : 2360 | Downloads : 10

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Anatomy of Kidney and Blood Supply The kidneys lie on either side of the spine in the retroperitoneal space between the parietal peritoneum and the posterior abdominal wall, well protected by muscle , fat and ribs (Wallace, 2006). Oxygenated blood pumped by the heart passes through the aorta on its way to the kidneys. In the abdomen, the renal arteries branch from the abdominal aorta inferior to the superior mesenteric artery and extend laterally toward the kidneys. Just before reaching the kidney, each renal artery divides into five segmental arteries, which provide blood to the various regions of the kidney (Wallace, 2006). 1
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Cont… Figure 1. Anatomy of kidney blood supply (Wallace, 2006). 2
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Nutcracker Syndrome Nutcracker syndrome (NCS) is a rare condition that refers to compression of left renal vein (LRV) between abdominal aorta and superior mesenteric artery. The syndrome occurs in relatively thin patients and adolescents who often have an otherwise healthy medical history (Dever et al., 1986). Two types of nutcracker syndrome have been defined: anterior NCS: the compression of a normally situated LRV by the abdominal aorta and the SMA. posterior NCS: very rare anomaly in which the left renal vein passes behind the aorta which compresses it against the vertebral column, restricting the venous drainage of the left kidney (Dever et al., 1986). 3
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Causes of Nutcracker Syndrome Nutcracker syndrome is a genetic anatomic variant, not really a disease. It is due to the aorta, or another artery going to the intestine most often the superior mesenteric artery compressing the left renal vein, or the blood from draining from the left kidney back to the heart. It is present from birth, but can be exacerbated kinking blood vessels and affecting flow by a variety of situations, including weight loss which cause the blood vessels to be more close than normal or surgery which shifts the contents of the abdominal contents (Nyc Surgical, 2008) 4
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Sings & Symptoms of Nutcracker Syndrome The symptoms of NCS are mostly silent until it is quite severe, because the human have two kidneys, the human are often not aware of kidney failure as the other one compensates. Symptoms that are early indicators of the disease include: protein in the urine. microscopic blood in the urine. kidney malfunction. Flank pain and pelvic pain. Chronic fatigue. lack of energy, and hormonal disturbances can occur due the blockage of the adrenal gland (Nyc Surgical, 2008). 5
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Cont… NCS also commonly causes pelvic congestion syndrome in women and varicocele (enlarged testicular veins) in men due to the backing up of blood in branches of the kidney veins. It can also cause problems with urine flow and backing up of urine into the left kidney due to the pressure of the distended vein on the urine drainage system, or what is called hydronephrosis. This can cause things like recurrent urinary tract infections and kidney stones (Nyc Surgical, 2008). 6
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Diagnosis of Nutcracker Syndrome The first diagnostic need must be clinical examination. Existence of the clinical features constitutes a basis for the diagnosis. The presence of microscopic hematuria and proteinuria must evaluate by: Urine analysis. Urine phase contrast microscopy. Urine culture. Imaging of kidneys should be performed. Several imaging methods are used to diagnose NCS include: Doppler ultrasonography, computed tomography angiography (CTA), magnetic resonance angiography (MRA), retrograde venography and Cystoscopy are utilized (Gulleroglu et al., 2014). 7
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Cont… Doppler ultrasound (U/S) Doppler ultrasonography can be used as the first diagnostic test in patients with suspected NCS. In figure 2, shown abdomen U/S image that appear An lift renal vein blockage and abnormal blood flow appear in blue and yellow colors (Gulleroglu et al., 2014). Figure 2. Abdomen Doppler (U/S) (Guzzo & Hassoun, 2010). 8
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Cont… Angiography Computed tomography angiography (CTA) and magnetic resonance angiography MRA provide visualization of the anatomy. These tests can demonstrate the precise LRV compression point and/or prestenotic dilatation of the LRV together with perirenal and/or gonadal vein varices. (Beak sign) is the abrupt narrowing of the LRV with a triangular shape at the aortomesenteric portion. 9
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Cont… In figure 3, shown abdomen CTA and MRA two image that appear compression of left renal vein (LRV) between abdominal aorta and superior mesenteric artery (Gulleroglu et al., 2014). A B Figure 3. A. Axial abdomen CTA, B. Axial abdomen MRA (Guzzo & Hassoun, 2010). 10
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Cont… Retrograde venography Retrograde venography is the gold standard for the diagnosis of NCS. It is not only confirming anatomic change, but also show a pressure gradient across the area of entrapment. Reflux of contrast into adrenal and gonadal veins from periureteral and perirenal venous collaterals, and pooling of contrast into the renal vein can be demonstrated. 11
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Cont… In figure 4, shown kidney retrograde venography image that appear Catheterization of the left renal vein. Contrast venography by injection through the introducer located in the renal vein shows dilatation of the left gonadal vein. (Gulleroglu et al., 2014). Figure 4. Kidney Retrograde venography (Guzzo & Hassoun, 2010). 12
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Cont… Cystoscopy Another invasive test such as cystoscopy may be helpful to identify hematuria from left ureteral origin. Notching from varicosities of the renal pelvis and ureters may be seen. Cystoscopy is an indirect diagnostic method for NCS diagnosis (Gulleroglu et al., 2014). 13
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Treatment of Nutcracker Syndrome Treatment of nutcracker syndrome is debatable, but there are both clinical and surgical options, depending on the severity of the symptoms exhibited, i.e. the treatment of choice is intimately related to the severity of symptoms. Figure 5. surgical procedure for nutcracker syndrome (Guzzo & Hassoun, 2010). 14
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Case study A 22 years old male patient without a medical history and surgical history was came to the emergency department of specialized Arab hospital on April 24, 2018.At that time, the patient suffered from left flank pain. The onset was sudden, intermittent and radiating to the left testis. The pain also associated with dysuria and dark urine (tea color). During the physical examinations the patient was conscious, oriented and cooperative. The patient`s abdomen was soft, left flank tenderness, there is moderate tenderness on left testis with dilated blood vessels and no mass. Based on the existing findings the patient was referred to do abdominal ultrasound as shown in figure (6) and laboratory tests as shown in table (1) which performed at specialized Arab Hospital on 24/04/2018. 15
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Laboratory test Table 1. Laboratory test (Specialized Arab hospital, 2018). 16
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Ultrasound test Figure 6. The report of abdomen U/S (Specialized Arab hospital, 2018). Abdominal ultrasound was normal. so, the patient was referred to do abdominal CT with and without contrast media (C.M). 17
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Computed tomography (CT) examination On the same day, patient came to the X-Ray department of specialized arab Hospital and abdominal CT was performed to the patient on April 24, 2018. The protocol that was used is abdominal CT as shown in table (2). The procedure was done with contrast media as shown in figure (7) and report (8). 18
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Cont… Table 2. the protocol of abdomen CT with and without C.M (Philips 16 SL) (Specialized Arab hospital, 2018). 19
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Cont… In figure 7, shown abdomen CT with and without C.M image that appear the left renal vein measure 16 mm in maximum anteroposterior diameter with a stenotic part seen between the aorta and superior mesenteric artery in the center of image. 20
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Cont… Figure 7.A. Abdomen CT Scout Image (Specialized Arab hospital, 2018). 21
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Cont… Figure 7.B. Axial abdominal CT without C.M (Specialized Arab hospital, 2018). 22
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Cont… Figure 7.C. Axial abdominal CT with C.M during arterial phase (Specialized Arab hospital, 2018). 23
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Cont… Figure 8. The report of abdomen CT with and without C.M (Specialized Arab hospital, 2018). 24
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Cont… The abdomen CT showed the left renal vein measure 16 mm in maximum anteroposterior diameter with a stenotic part seen between the aorta and superior mesenteric artery, the arta-SMA angel is about 24 degrees, findings mostly represent nutcracker syndrome. However both kidneys are of normal size, shape, position and enhancement, no masses, stones or hydronephrosis. patent renal veins. Delayed scan ( at 10 min ) show symmetrical excretory phase of both kidneys with normal course and diameter of both ureters, no duplication of the collecting system. After an abdomen CT scan, the patient was discharged from the hospital and not treated until now. 25
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Discussion & Conclusion Often the diagnosis is reached by exclusion. As with any other condition, assessment begins with the history and exploration. The findings of laboratory results are nonspecific. With regard to imaging studies, it is usual start with an abdominal ultrasound due to its utility, safety and low cost. On ultrasound, the renal pedicle can be seen with a dilated vein and slightly enlarged kidney due to renal congestion. The next step would be a diagnostic CTA or MRA. Both could have demonstrated the presence of a greater angulation in the superior mesenteric artery leaving the abdominal aorta, trapping the left renal vein. Conservative approach, open surgical procedures, intra or extra vascular stents, intra-pelvic chemical cauterization have been proposed for the treatment. 26
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Recommendations The first line diagnosis for NCS is Doppler U/S but in this case the doctor done abdominal U/S only without Doppler U/S to show blood flow and size of left renal vein. Since the syndrome is linked to weight, recommend eating healthy foods that contain fiber to strengthen your body muscles and exercise continuously. Patients should undergo routine scans on an annual basis so that they can treat the disease early before complications occur. If the disease is detected, the operative procedure must be performed immediately before kidney problems develop into kidney failure. 27