The records of 22 patients in whom wall thickening of the renal collecting system was seen at ultrasound (US) were retrospectively reviewed. Wall thickening was found in 15 patients with renal transplants and seven with native kidneys. Severe thickening occurred with transplant rejection, but thickening also occurred with urinary tract infection, reflux, or chronic obstruction in both transplanted and native kidneys. As such, thickening of the renal collecting system seen at US is a nonspecific finding that must be correlated with the clinical and laboratory findings.