Mutations in either the mitochondrial or nuclear genomes can give rise to respiratory chain disease (RCD), a large class of devastating metabolic disorders. Their clinical management is challenging, in part because we lack facile and accurate biomarkers to aid in diagnosis and in the monitoring of disease progression. Here we introduce a sequential strategy that combines biochemical analysis of spent media from cell culture with analysis of patient plasma to identify disease biomarkers. First, we applied global metabolic profiling to spotlight 32 metabolites whose uptake or secretion kinetics were altered by chemical inhibition of the respiratory chain in cultured muscle . These metabolites span a wide range of pathways and include lactate and alanine, which are used clinically as biomarkers of RCD. We next measured the cell culture-defined metabolites in human plasma to discover that creatine is reproducibly elevated in two independent cohorts of RCD patients, exceeding lactate and alanine in magnitude of elevation and statistical significance. In cell culture extracellular creatine was inversely related to the intracellular phosphocreatine:creatine ratio suggesting that the elevation of plasma creatine in RCD patients signals a low energetic state of tissues using the phosphocreatine shuttle. Our study identifies plasma creatine as a potential biomarker of human mitochondrial dysfunction that could be clinically useful. More generally, we illustrate how spent media from cellular models of disease may provide a window into the biochemical derangements in human plasma, an approach that could, in principle, be extended to a range of complex diseases.biochemical genetics | biomarker | metabolomics | mitochondria T he respiratory chain (RC) of mammalian cells comprises a series of five enzymatic complexes embedded in the inner mitochondrial membrane and serves as the machinery for oxidative phosphorylation. Changes in RC activity influence key parameters such as the cellular energy charge and the NADH/ NAD + ratio and can impact the numerous metabolic pathways coupled to the RC directly or indirectly. In humans, inherited defects in mitochondrial (mt) or nuclear genes that encode RC proteins or factors necessary for its maturation and assembly lead to respiratory chain disease (RCD) (1). It is estimated that RCD affects at least 18.4 in 100,000 people (2) and represents the most common group of inborn errors of metabolism (3).The clinical presentation of RCD is highly variable in severity, age of onset, and the combination of organ systems involved, and the factors contributing to this variability are poorly understood (1). Consequently, the diagnosis can be challenging, and there are very limited means of objectively monitoring disease progression. A number of diagnostic algorithms have been proposed (4-6) that integrate clinical, biochemical, histological, and molecular findings. Abnormal concentrations of several metabolites in biological fluids, including the elevation of lactate, alanine, pyruvate, and the lac...