This is Part 4 in my series on creatine supplements. Today, I focus on creatine supplementation in people receiving dialysis. For background on creatine basics, special populations, and kidney safety, see Part 1, Part 2, and Part 3 of this series.
Key References for today’s post are:
- van der Veen, Yvonne, et al. “Chronic dialysis patients are depleted of creatine: review and rationale for intradialytic creatine supplementation.” Nutrients 13.8 (2021): 2709.
- Bernales-Delmon, Waldo, et al. “Oral creatine in hemodialysis patients increases physical functional capacity and muscle mass, an open label study.” Plos one 20.7 (2025): e0328757.
- Marini, Ana Clara B., et al. “Effect of Creatine Supplementation on Body Composition and Malnutrition-Inflammation Score in Hemodialysis Patients: An Exploratory 1-Year, Balanced, Double-Blind Design.” Nutrients 16.5 (2024): 615.
Why Might Someone with ESKD Benefit from Creatine Supplements?
Some evidence suggests that creatine supplementation may:
- Aid in muscle recovery
- Augment fat-free mass
- Improve muscle performance
People with end-stage kidney disease (ESKD) are more likely to experience low muscle mass and reduced functional capacity, so creatine supplementation could theoretically provide benefits similar to those observed in athletes.
Is Creatine Safe for Kidneys in ESKD?
This is complex and covered in detail in Part 3. However, an important distinction is that for people with ESKD on dialysis, renal recovery is generally not expected. Thus, preserving kidney function is less relevant, and the potential kidney-related risks of creatine supplementation may be less concerning.
Why Might Someone on Dialysis Have Low Creatine Levels?
Several mechanisms may contribute to low creatine in dialysis patients:
- Losses during dialysis – creatine is not fully reabsorbed by the dialysis filter.
- Reduced dietary intake – low phosphorus, or plant-based diets may provide less creatine.
- Decreased enzymatic activity – ESKD can impair synthesis from amino acids.
Evidence of Low Creatine Levels in Dialysis Patients
Studies have demonstrated that, compared to healthy populations:
- Plasma levels: Fasting plasma creatine and guanidinoacetate (GAA) are lower.
- Muscle biopsies: Reduced ATP and phosphocreatine content.
- Imaging studies: Lower phosphocreatine/ATP energy charge ratios in heart and skeletal muscles.
Studies on Creatine Supplementation in Dialysis
I identified four key studies on creatine supplementation in dialysis patients:
| Reference | Population | Protocol | Outcome |
|---|---|---|---|
| Chang et al, 2002 (summarized in van der Veen et al, 2021) | 10 HD patients with muscle cramps | Oral 12g creatine monohydrate before HD for 4 weeks vs placebo | 60% reduction in cramping; cramping returned to baseline after stopping creatine |
| Marini et al, 2021 (summarized in van der Veen et al, 2021) | 30 HD patients | Oral 40g creatine for 1 week, then 10g/day for 3 weeks vs placebo | Increased lean body mass; improved MIS scores |
| Marini et al, 2024 | 40 HD patients | 5g creatine + 5g maltodextrin vs placebo (10g maltodextrin/day) for 12 months | Enhanced fat-free mass likely due to intracellular water; no change in MIS scores; |
| Barneles-Delmon et al, 2025 | 18 HD patients | Open-label, 5g creatine for 8 weeks | Increased SPPB scores, skeletal muscle mass, fat-free mass, total body weight; no impact on hand-grip strength |
Creatine After Kidney Transplant
No studies directly investigate creatine supplementation post-transplant. One study reported lower creatine synthesis in transplant recipients compared to controls, suggesting potential benefit, but this remains hypothetical.
A separate report highlighted a practical concern: creatine supplementation may increase creatinine levels and potentially trigger unnecessary kidney biopsies. Patients should be counseled around this if considering creatine post-transplant.
Key Takeaways
- Creatine supplementation has been investigated in dialysis patients with small sample sizes.
- Safety: No significant adverse events reported; long-term doses of 5g/day appear safe.
- Effectiveness: Limited benefits observed. Increases in fat-free mass are likely due to intracellular water, not true muscle gain. Functional outcomes like hand-grip strength or MIS scores were largely unchanged.
- Clinical Recommendation: Given the limited benefit, creatine supplementation is not currently recommended for routine use in dialysis patients.
Missed my previous posts? Check them out here:
