Background: Malnutrition is commonly detected in end-stage renal disease (ESRD) and is a key predictor of their survival. In ESRD patients on hemodialysis protein-energy, malnutrition is significantly observed. The plasma and mRNA expression levels of ghrelin are dysregulated in ESRD. Objective: The current study aimed to investigate the plasma and mRNA expression levels of ghrelin among Egyptian patients with ESRD on regular hemodialysis and to assess their relations with anthropometric measures and laboratory tests as well as nutritional status. Patients and methods: A case-control study enrolled 45 healthy control and 50 patients with ESRD on regular hemodialysis. Nutritional assessment was done by subjective global assessment scores (SGA). Patients with ESRD were classified according to their nutritional status into mild, moderate, and severe malnutrition groups. Plasma ghrelin levels were measured using an ELISA and mRNA expression of ghrelin was measured using real-time PCR. Results: The plasma and mRNA expression levels of ghrelin were significantly higher in ESRD patients with mild and moderate malnutrition compared to the control group. However, the levels of plasma ghrelin were meaningfully lower in ESRD patients with severe malnutrition compared to the control group. plasma and ghrelin mRNA expression levels significantly positively correlated with serum creatinine and BUN and significantly negatively correlated with MAMC, Hb, albumin, transferrin and total iron-binding capacity (TIBC) (P<0.001). Serum creatinine transferrin, as well as triceps skin fold, were independently correlated with plasma ghrelin. While serum creatinine transferrin and triceps skin fold, as well as TIBC, were independently correlated with ghrelin mRNA expression levels. Conclusion: Ghrelin plasma and relative expression levels were significantly higher in ESRD patients with mild and moderate malnutrition compared to control subjects. While the levels were significantly lower in the severe malnutrition group.