Metabolic syndrome, an etiological factor in non-alcoholic fatty liver disease (NAFLD), is often present in hemodialysis patients. Little is known about the prevalence of, and factors associated with, liver fibrosis in hemodialysis populations. We used transient elastography (TE) to investigate these phenomena. 659 patients treated with chronic hemodialysis were enrolled. We excluded those with excess alcohol intake, liver stiffness measurement (LSM) failure, or unreliable LSM values. LSM ≥8.0 kPa was used as a cutoff suggesting clinically relevant fibrosis. Controlled attenuation parameter (CAP) ≥ 232.5 dB/m was used as a cutoff suggesting steatosis. 333 patients (50.5%) had steatosis, 159 (24.1%) had hepatitis B or C, and 149 (22.6%) had LSM ≥8.0 kPa. In multivariable analyses, male gender (OR: 2.16; 95% CI: 1.29-3.63; P = 0.004), overweight body habitus (OR:2.31; 95% CI: 1.35-3.94; P = 0.002), high AST level (OR:1.08; 95% CI: 1.04-1.12; P < 0.001), low albumin level (OR: 0.25; 95% CI: 0.12-0.53; P < 0.001), low creatinine level (OR: 0.89; 95% CI: 0.79-1.00; P = 0.05) and low platelet count (OR: 0.99; 95% CI: 0.99-1.00; P < 0.001) were associated with LSM ≥8.0 kPa. We thus conclude that hemodialysis patients have a high prevalence of NAFLD and clinically relevant fibrosis. NAFLD may be an important determinant of clinically relevant fibrosis in hemodialysis populations.