22 - Urine Osmolality

Urine osmolality is an important test for the concentrating ability of the kidney. Interpretation of urine osmolality must always be made in the light of the appropriate physiological response to the state of hydration of the patient. The test is useful in the following areas:

• For determining the differential diagnosis of hyper- or hyponatraemia.
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• For identifying SIADH (urine osmolality > 200 mmol/kg, urine sodium > 20 mmol/L, low serum sodium, patient not dehydrated and no renal, adrenal, thyroid, cardiac or liver disease or interfering drugs)
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• For differentiating pre-renal from renal kidney failure (high urine osmolality is consistent with pre-renal impairment, in renal damage the urine osmolality is similar to plasma osmolality).
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• For identifying and diagnosing diabetes insipidus (low urine osmolality not responding to water restriction).

17 - Osmolality physiology

The osmolality of plasma is closely regulated by anti-diuretic hormone (ADH). In response to even small increases in plasma osmolality (usually rises in plasma sodium), ADH release from the pituitary is increased causing water resorption in the distal tubules and collecting ducts of the kidney and correction of the increased osmolality. The opposite happens in response to a low plasma osmolality with decreased ADH secretion and water loss through the kidneys. Note that ADH is also secreted in response to hypovolaemia and this stimulus will over-ride any response to serum osmolality.


Urine osmolality may vary between 50 and 1200 mmol/kg in a healthy individual depending on the state of hydration. The urine osmolality is the best measure of urine concentration with high values indicating maximally concentrated urine and low values very dilute urine. The main factor determining urine concentration is the amount of water which is resorbed in the distal tubules and collecting ducts in response to ADH. In a dehydrated patient with normally functioning pituitary and kidneys, a small volume of highly concentrated urine will be produced. In a patient with fluid overload the opposite will be an appropriate response. Note that there is no reference interval ("normal range") for urine osmolality as the interpretation depends on the clinical condition of the patient to determine an appropriate response.