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At the same time, CKD-related architectural distortion and hypoperfusion reduce lesion conspicuity on ultrasound and weaken enhancement-based interpretation on CT and MRI. In advanced CKD, restrictions on iodinated and gadolinium-based contrast agents further increase the proportion of renal masses that remain indeterminate after conventional imaging. Contrast-enhanced ultrasound (CEUS) addresses the key unmet need in this setting: a safe, direct assessment of microvascular perfusion. Microbubble agents are purely intravascular and non-nephrotoxic, enabling use across all CKD stages and in dialysis patients. By showing real-time enhancement of septa, wall thickening and mural nodules, CEUS distinguishes vascular tumour components from avascular hemorrhagic or proteinaceous material that can mimic enhancement on CT\/DECT or signal abnormalities on non-contrast MRI. This capability supports a CEUS-adapted Bosniak approach: lesion categorization is driven by enhancement of septa, wall and nodules rather than by attenuation or T1 hyperintensity of cyst contents, helping avoid misclassification in ACKD. We propose a structured workflow that integrates the triad of CKD stage\/eGFR, dialysis status and ACKD with pre- and post-CEUS Bosniak assessment to guide follow-up versus biopsy or nephron-sparing treatment. This article is a narrative review of the literature, complemented by an illustrative clinical case which demonstrates how CEUS can resolve ambiguity when CT\/DECT and non-contrast MRI remain inconclusive.<\/jats:p>","DOI":"10.1007\/s00261-026-05491-4","type":"journal-article","created":{"date-parts":[[2026,4,10]],"date-time":"2026-04-10T13:30:56Z","timestamp":1775827856000},"page":"5174-5185","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Diagnostic evaluation of renal masses in chronic kidney disease: a clinical and radiologic challenge"],"prefix":"10.1007","volume":"51","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4172-5126","authenticated-orcid":false,"given":"Laura","family":"Eusebi","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-4289-3289","authenticated-orcid":false,"given":"Federica","family":"Masino","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-1526-5047","authenticated-orcid":false,"given":"Manuela","family":"Montatore","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1231-5213","authenticated-orcid":false,"given":"Valentina","family":"Testini","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4325-8330","authenticated-orcid":false,"given":"Giuseppe","family":"Guglielmi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,4,10]]},"reference":[{"issue":"4","key":"5491_CR1","doi-asserted-by":"publisher","first-page":"S117","DOI":"10.1016\/j.kint.2023.10.018","volume":"105","author":"PE Stevens","year":"2024","unstructured":"Stevens PE, Ahmed SB, Carrero JJ, Foster B, Francis A, Hall RK, et al. 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