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. Variables analyzed using χ2 test or Mann-Whitney U test as appropriate. Multivariable logistic regression analysis was performed for the abnormal KBUS findings and OR and 95% CI were calculated. Results: Our cohort included 415 children (830 kidney units) with median age of 5 months (1 month to 5 years) and 80% were female. One hundred thirty-two (31.8%) patients had abnormal KBUS, including increased echogenicity in 45 patients. Overall, 42.2% of patients with increased echogenicity had VUR vs 23.3% with normal ultrasound (P =.013) and 31.1% of patients with increased echogenicity had high-grade III-V VUR vs 8.1% with normal ultrasound (P =.001). In total, 24.3% of kidneys with increased echogenicity had VUR vs 20% with normal ultrasound (P =.246) and 20% of kidneys with increased echogenicity had high-grade III-V VUR vs 9.9%with normal ultrasound (P =.005). Conclusions: These data support adding increased kidney echogenicity to the list of other KBUS findings that are helpful in decision making about a need for voiding cystourethrography in young children with first febrile UTI.