With the use of new sonographic technology, we have observed that the echogenicity of kidneys is often equal to that of the liver in patients in whom there is no evidence of renal disease; this observation conflicts with the generally accepted notion that a normal kidney is always less echogenic than the liver. In order to reassess renal echogenicity as an indicator of disease, three experienced radiologists blindly reviewed the sonograms of the right kidney and liver in 153 patients. The prevalence of renal disease was 26% (40/153). Accepted sonographic criteria for abnormal renal echogenicity (kidney echogenicity greater than or equal to liver) were neither sensitive (62%) nor specific (58%) for renal disease, with a positive predictive value of 35%. Most of these inaccuracies occurred because 43 (72%) of 60 patients in whom renal echogenicity was equal to that of liver had normal renal function. If stricter criteria for abnormality were adopted (kidney echogenicity greater than liver), specificity (96%) and positive predictive value (67%) rose; however, sensitivity was only 20%. We conclude that renal echogenicity equal to the echogenicity of liver is not a good indicator of disease. Use of stricter criteria (kidney echogenicity greater than liver) provides a specific but insensitive test.