Background: Urinary density (UD) has been routinely used for decades as a surrogate marker for urine osmolality (U-osm). We asked if UD can accurately estimate U-osm both in healthy subjects and in different clinical scenarios of kidney disease. Methods: UD was assessed by refractometry. U-osm was measured by freezing point depression in spot urines obtained from healthy volunteers (N = 97) and in 319 inpatients with acute kidney injury (N = 95), primary glomerulophaties (N = 118) or chronic kidney disease (N = 106). Results: UD and U-osm correlated in all groups (p < 0.05). However, a wide range of U-osm values was associated with each UD value. When UD was <= 1.010, 28.4% of samples had U-osm above 350 mOsm/kg. Conversely, in 61.6% of samples with UD above 1.020, U-osm was below 600 mOsm/kg. As expected, U-osm exhibited a strong relationship with serum creatinine (S-creat), whereas a much weaker correlation was found between UD and Screat. Conclusion: We found that UD is not a substitute for U-osm. Although UD was significantly correlated with U-osm, the wide dispersion makes it impossible to use UD as a dependable clinical estimate of U-osm. Evaluation of the renal concentrating ability should be based on direct determination of U-osm.16