ANATOMY AND BASIC PHYSIOLOGY
The kidneys lie in the paravertebral grooves at the level of the T12 to L3 vertebrae. The medial margin of each is concave, whereas the lateral margins are convex, giving the organ a bean-shaped appearance. In the adult, each kidney measures 10 to 12 cm in length, 5 to 7.5 cm in width, and 2.5 to 3.0 cm in thickness. In an adult man, each kidney weighs 125 to 170 g; in an adult woman, each kidney weighs 115 to 155 g.
On the medial surface of the kidney is the hilum, through which the renal artery, vein, renal pelvis, a nerve plexus, and lymphatics pass. On the convex surface, the kidney is surrounded by a fibrous capsule, which protects it, and a fatty capsule with a fibroareolar capsule called the renal fascia, which offers further protection and serves to anchor it in place.
The arterial supply begins with the renal arteries, which are direct branches of the aorta. On entering the hilum, the arteries subdivide into branches supplying the 5 major segments of each kidney: the apical pole, the anterosuperior segment, the anteroinferior segment, the posterior segment, and the inferior pole. These arteries subsequently divide within each segment to become lobar arteries. In turn, these vessels give rise to arcuate arteries that diverge into the sharply branching interlobular arteries, and then the afferent arterioles that directly supply the glomerular capillary tufts. The capillaries are then drained by the efferent arterioles, and peritubular capillaries, which also supply the vasa recta. Eventually, all are combined into the renal veins, which empty into the inferior vena cava.
The cut surface of the kidney reveals a pale outer rim and a dark inner region corresponding to the cortex and medulla, respectively. The cortex is 1 cm thick and surrounds the base of each medullary pyramid. The medulla consists of between 8 and 18 cone-shaped areas called medullary pyramids; the apex of each area forms a papilla containing the ends of the collecting ducts. Urine empties from each papilla into a calyx, and the calyces join together to form the renal pelvis. Urine is drained from the pelvis into the ureters and, subsequently, into the urinary bladder.
The kidneys serve 3 major functions: (1) homeostasis of fluids, acid–base balance, and electrolytes; (2) excretion of nitrogen, as urea, and other waste products; and (3) endocrine production such as 1,25-dihydroxy vitamin D, renin, and erythropoietin.
The kidneys maintain the constancy of the extracellular fluid by creating an ultrafiltrate of the plasma that is virtually free of cells and larger macromolecules, and then processing that filtrate, reclaiming what the body needs and letting the rest escape as urine. Every 24 hours, the adult’s glomeruli filter nearly 180 L of water (total body water is ~25–60 L) and 25,000 mEq of sodium (total body Na+ content is 1,200–2,800 ...