A 19-year-old man presents to the emergency department after a motor vehicle accident. The patient reports left shoulder pain that worsens with deep inspiration. Medical history is significant for a recent diagnosis of infectious mononucleosis. His temperature is 99°F (37.2°C), blood pressure is 80/55 mmHg, pulse is 115/min, and respiratory rate is 22/min. On physical exam, there is abdominal guarding, abdominal tenderness in the left upper quadrant, and rebound tenderness. The patient’s mucous membranes are dry and skin turgor is reduced. Which of the following most likely represents the acute changes in renal plasma flow (RPF) and glomerular filtration rate (GFR) in this patient?

Decreased RPF and decreased GFR

No change in RPF and decreased GFR

No change in RPF and increased GFR

Decreased RPF and no change in GFR

A 45-year-old female is undergoing renal transplantation for management of chronic renal failure secondary to glomerulonephritis. The transplant surgeon placed the donor kidney in the recipient and anastomosed the donor renal artery to the recipient's external iliac artery as well as the donor ureter to the recipient's bladder. After removing the clamps on the external iliac artery, the recipient's blood is allowed to perfuse the transplanted kidney. Within 3 minutes, the surgeon notes that the kidney does not appear to be sufficiently perfused. Upon further investigation, an inflammatory reaction is noted that led to clotting off of the donor renal artery, preventing blood flow to the transplanted organ. Which of the following best describes the pathophysiology of this complication?

Type III hypersensitivity reaction

Type IV hypersensitivity reaction

Type I hypersensitivity reaction

An 11-year-old girl is brought to the office by her mother due to complaint of intermittent and severe periumbilical pain for 1 day. She does not have any significant past medical history. She provides a history of a recent school trip to the suburbs. On physical examination, there is a mild tenderness around the umbilicus without any distension or discharge. There is no rebound tenderness. Bowel sounds are normal. An abdominal imaging shows enlarged mesenteric lymph nodes, and she is diagnosed with mesenteric lymphadenitis. However, incidentally, a mass of tissue was seen joining the inferior pole of both kidneys as shown in the image. Which of the following best describes this renal anomaly?

Association with ureteropelvic junction obstruction (UPJO)

Fused kidneys ascend beyond superior mesenteric artery.

Rapid progression to acute renal failure

Kidneys are usually non-functional.

Increased risk of developing renal vein thrombosis

A 37-year-old woman presents to the Emergency Department after 8 hours of left sided flank pain that radiates to her groin and pelvic pain while urinating. Her medical history is relevant for multiple episodes of urinary tract infections, some requiring hospitalization, and intravenous antibiotics. In the hospital, her blood pressure is 125/83 mm Hg, pulse of 88/min, a respiratory rate of 28/min, and a body temperature of 36.5°C (97.7°F). On physical examination, she has left costovertebral tenderness and lower abdominal pain. Laboratory studies include a negative pregnancy test, mild azotemia, and a urinary dipstick that is positive for blood. Which of the following initial tests would be most useful in the diagnosis of this case?

Fractional excretion of sodium (FeNa+)

Contrast abdominal computed tomography

Blood urea nitrogen (BUN): serum creatinine (SCr) ratio

A 42-year-old man comes to the physician for a health maintenance examination. He has had generalized fatigue and muscle aches since his previous visit 6 months ago. He has hypertension and gastroesophageal reflux disease. Current medications include amlodipine and omeprazole. His temperature is 37.1°C (98.1°F), pulse is 88/min and blood pressure is 156/102 mm Hg. Physical examination shows no abnormalities. Serum studies show: Na+ 143 mEq/L K+ 2.3 mEq/L Cl- 100 mEq/L HCO3- 31 mEq/L Urea nitrogen 14 mg/dL Creatinine 1 mg/dL His blood pressure medication is discontinued. One week later his plasma aldosterone concentration is 35 ng/dL (N=3.6 - 24.0 ng/dL) and plasma renin activity is 0.4 ng/mL/h (N=0.3 to 4.2 ng/mL/h). An oral sodium loading test over 3 days fails to reduce aldosterone. A contrast-enhanced CT scan of the abdomen and pelvis shows a 3-cm, homogenous, right-sided adrenal mass with rapid contrast washout. He is counseled about his treatment options and chooses to pursue surgery. Which of the following is the most appropriate next step in management?

Fludrocortisone suppression test

A 63-year-old man comes to the physician because of a 1-month history of difficulty swallowing, low-grade fever, and weight loss. He has smoked one pack of cigarettes daily for 30 years. An esophagogastroduodenoscopy shows an esophageal mass just distal to the upper esophageal sphincter. Histological examination confirms the diagnosis of locally invasive squamous cell carcinoma. A surgical resection is planned. Which of the following structures is at greatest risk for injury during this procedure?

Bronchial branch of thoracic aorta

Esophageal branch of thoracic aorta

A 22-year-old Caucasian male is stabbed in his left flank, injuring his left kidney. As the surgeon undertakes operative repair, she reviews relevant renal anatomy. All of the following are correct regarding the left kidney EXCEPT?

The left kidney has a longer renal artery than the right kidney

The left kidney has a longer renal vein than the right kidney

The left kidney underlies the left 12th rib

The left kidney moves vertically during deep breathing

The left kidney lies between T12 and L3

Kidneys and suprarenal glands — USMLE Lesson

Kidney Gross Anatomy - Bean Scene Investigation

Kidney and Adrenal Gland Anatomy

Location: Retroperitoneal organs at T12-L3 vertebral levels. The right kidney is slightly lower than the left due to the liver's position.
Coverings (Outermost to Innermost):
- Pararenal fat: Outermost layer of extraperitoneal fat.
- Renal fascia (Gerota's): Encloses kidney and adrenal gland.
- Perirenal fat: Cushions the kidney.
- Fibrous capsule: Adheres directly to the kidney surface.
Hilum (Anterior to Posterior): Renal Vein → Renal Artery → Renal Pelvis.
- 📌 Mnemonic: VAP.
Parenchyma:
- Cortex: Outer granular region containing glomeruli & convoluted tubules.
- Medulla: Inner region with 8-18 renal pyramids.
- Urine Flow: Papilla of pyramid → Minor Calyx → Major Calyx → Renal Pelvis → Ureter.

⭐ The left renal vein passes between the superior mesenteric artery (SMA) and the abdominal aorta, creating a risk for compression (Nutcracker Syndrome), which can cause hematuria and flank pain.

Renal Vasculature - Blood Flow Blowout

Arterial Supply: Renal arteries arise from the abdominal aorta, branching into segmental arteries.
- Segmental arteries are end-arteries; occlusion leads to infarction.
- Path: Aorta → Renal a. → Segmental a. → Interlobar a. → Arcuate a. → Interlobular a. → Afferent arteriole.
Venous Drainage: Follows arterial path in reverse, ultimately draining into the Inferior Vena Cava (IVC).

Kidneys, ureters, and major renal blood vessels diagram

⭐ Left Renal Vein: The longer left renal vein passes between the aorta and SMA. It receives the left suprarenal and left gonadal (testicular/ovarian) veins, unlike the right side. This can lead to "Nutcracker Syndrome."

Suprarenal Glands - Gland Stand

Adrenal Glands: Arterial Supply and Venous Drainage

Arterial Supply: Rich and redundant from three sources:
- Superior suprarenal a.: from inferior phrenic a.
- Middle suprarenal a.: from abdominal aorta.
- Inferior suprarenal a.: from renal a.
Venous Drainage: A single vein per gland.

Feature	Cortex	Medulla
Embryology	Mesoderm	Neural Crest Cells
Function	📌 G-F-R for layers; Salt-Sugar-Sex for products	Synthesizes & secretes catecholamines
Layers	Glomerulosa, Fasciculata, Reticularis	Chromaffin cells
Products	Aldosterone, Cortisol, Androgens	Epinephrine, Norepinephrine

The left renal vein, unlike the right, receives the left suprarenal and left gonadal veins before draining into the IVC.

Nutcracker syndrome involves compression of the left renal vein between the aorta and the superior mesenteric artery.

Ureters have three physiological constrictions where stones often lodge: ureteropelvic junction, crossing the common iliac artery, and the ureterovesical junction.

The adrenal cortex (mesoderm) secretes steroids, while the medulla (neural crest) secretes catecholamines.

A horseshoe kidney gets trapped under the inferior mesenteric artery (IMA) during ascent.

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