34 patients with analgesic nephropathy (AN) were investigated by real-time ultrasonography. In 11 out of 14 patients on maintenance dialysis and in 16 out of 20 patients with renal insufficiency calcified renal papillae were documented surrounding the central sinus in a typical garland pattern. Moreover, by surveying a group of patients with renal insufficiency of unknown origin, AN was assumed in 10 patients and was then confirmed by a hitherto unknown history of analgesic abuse as well as by laboratory findings. In 37 patients radiologic or autopsy data were additionally available. A close correlation to the scanning pattern was found in 31 of these patients. In 30 healthy volunteers and 56 patients with renal insufficiency due to chronic glomerulonephritis (n = 24) or diabetic nephropathy (n = 32) calcified renal papillae were found only in 1 case. 5 out of 20 patients on maintenance dialysis due to other diseases than AN showed renal calcifications forming an approximate garland arrangement. In these patients sonography may therefore indicate AN only in very characteristic cases. We believe that renal papillary calcifications surrounding the central sinus in a garland pattern may indicate AN in most cases and thus may be helpful in establishing the diagnosis of AN.