Muscle wasting, low protein intake, hypoalbuminemia, low body mass, and chronic fatigue are prevalent in hemodialysis patients. Impaired creatine status may be an often overlooked, potential contributor to these symptoms. However, little is known about creatine homeostasis in hemodialysis patients. We aimed to elucidate creatine homeostasis in hemodialysis patients by assessing intradialytic plasma changes as well as intra- and interdialytic losses of arginine, guanidinoacetate, creatine and creatinine. Additionally, we investigated associations of plasma creatine concentrations with low muscle mass, low protein intake, hypoalbuminemia, low body mass index, and chronic fatigue. Arginine, guanidinoacetate, creatine and creatinine were measured in plasma, dialysate, and urinary samples of 59 hemodialysis patients. Mean age was 65 +/- 15 years and 63% were male. During hemodialysis, plasma concentrations of arginine (77 +/- 22 to 60 +/- 19 mu mol/L), guanidinoacetate (1.8 +/- 0.6 to 1.0 +/- 0.3 mu mol/L), creatine (26 [16-41] to 21 [15-30] mu mol/L) and creatinine (689 +/- 207 to 257 +/- 92 mu mol/L) decreased (all P871 mu mol arginine, 37 +/- 20 mu mol guanidinoacetate, 719 [399-1070] mu mol creatine and 15.5 +/- 8.4 mmol creatinine. In sex-adjusted models, lower plasma creatine was associated with a higher odds of low muscle mass (OR per halving: 2.00 [1.05-4.14]; P=0.04), low protein intake (OR: 2.13 [1.17-4.27]; P=0.02), hypoalbuminemia (OR: 3.13 [1.46-8.02]; P=0.008) and severe fatigue (OR: 3.20 [1.52-8.05]; P=0.006). After adjustment for potential confounders, these associations remained materially unchanged. Creatine is iatrogenically removed during hemodialysis and lower plasma creatine concentrations were associated with higher odds of low muscle mass, low protein intake, hypoalbuminemia, and severe fatigue, indicating a potential role for creatine supplementation.