Contrast-Enhanced Ultrasound as a Next-Step Tool After Indeterminate CT in ESRD

This study evaluates whether contrast-enhanced ultrasound (CEUS) serves as an effective next-step imaging modality for patients with end-stage renal disease (ESRD) who have indeterminate renal lesions on computed tomography (CT), assessing its diagnostic performance and potential impact on surgical decision-making. A retrospective chart review was conducted on patients with ESRD who underwent both CEUS and CT between 2021 and 2024 within the VCU Health System. The primary lesion analyzed in each case was the one most concerning for malignancy per the radiology report. If no malignancy was suspected, the largest lesion was selected. Imaging findings from CEUS and CT were assessed based on radiology reports and compared against histopathological results and clinical follow-up. A total of 76 patients met the inclusion criteria. There was no significant difference in lesion characterization accuracy between CEUS and CT (P=0.51), lesion diameter (P=0.70), or location (P=0.87). Among the 12 patients who underwent surgery due to suspected lesion malignancy, 11 (91.7%) were referred for surgery based on CEUS findings, with 100% confirmed malignancy on histopathology. CEUS demonstrates diagnostic performance comparable to CT for characterizing indeterminate renal lesions in patients with ESRD. When used as the next step after noncontrast CT, CEUS can reliably guide surgical decision-making while minimizing contrast and radiation exposure. Early integration of CEUS into structured clinical pathways may streamline evaluation, reduce delays to definitive management, and support timely progression toward transplant eligibility. Its safety, accessibility, and cost-effectiveness make CEUS a valuable tool for guiding care in this complex population.