The advent of ultrasonography and computed tomography has facilitated the imaging of kidneys in patients with chronic renal failure. Patients with diffuse renal parenchymal disease present with small, shrunken end-stage kidneys, while those with autosomal-dominant polycystic kidney disease have very large kidneys. Renal parenchyma echogenicity in patients treated with dialysis is increased compared to that in patients with normal renal function. Yet, the underlying cause of renal failure cannot be inferred from the degree of parenchymal echogenicity. Acquired cystic disease of kidney affects up to 79% of dialysis patients, while cystic changes occur invariably in all patients treated after 9 years of dialysis treatment. Renal cell carcinoma is the most important complication of acquired cystic disease. On ultrasound, the lesion is usually solid and poorly echogenic, but it may also be hyperechogenic or cystic in apperance. Parenchimal renal calcifications and stones can develop before or during renal replacement therapy. Ultrasonic is a non-invasive, repeatable, readily available and inexpensive diagnostic tool, which does not depend on function, but rather on competence and skill of the operator.