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Kidney Echogenicity and Vesicoureteral Reflux in Children with Febrile Urinary Tract Infection. OBJECTIVE: To evaluate increased kidney echogenicity as a predictor of vesicoureteral reflux (VUR) in young children with first febrile urinary tract infection (UTI). STUDY DESIGN: We performed a single center retrospective study of hospitalized children with first febrile UTI diagnosed in accordance with the American Academy of Pediatrics guidelines. All patients had kidney bladder ultrasound (KBUS) and voiding cystourethrography (VCUG). Variables analyzed using Chi-square test or Mann-Whitney U test as appropriate. Multivariable logistic regression analysis was performed for the abnormal KBUS findings and odds ratio (OR) and 95% confidence Interval (95%CI) were calculated. RESULTS: Our cohort included 415 children (830 kidney units) with median age of 5 months (one month to 5 years) and 80% were females. 132 (31.8%) patients had abnormal KBUS, including increased echogenicity in 45 patients. Overall, 42.2% of patients with increased echogenicity had VUR versus 23.3% with normal ultrasound (P=0.013) and 31.1% of patients with increased echogenicity had high-grade III-V VUR versus 8.1% with normal ultrasound (P=0.001). In total, 24.3% of kidneys with increased echogenicity had VUR versus 20% with normal ultrasound (P=0.246) and 20% of kidneys with increased echogenicity had high-grade III-V VUR versus 9.9%with normal ultrasound (P=0.005). CONCLUSION: These data support adding increased kidney echogenicity to the list of other KBUS findings that are helpful in decision making about a need for VCUG in young children with first febrile UTI.