Protein-energy wasting is a common problem in pediatric patients with chronic kidney disease (CKD). Disturbances in appetite-regulating hormones have been suggested as causative factors. Acyl ghrelin is a potent orexigenic hormone, whereas desacyl ghrelin and obestatin have the opposite effect. The regulation of acyl ghrelin and its anorexigenic opponents and its role in the development of CKD-associated protein-energy wasting is poorly understood. We measured total and acylated ghrelin, obestatin, leptin, and adiponectin in children with CKD (n=29), children undergoing hemodialysis (HD) or peritoneal dialysis (PD; n=29), renal transplant recipients (RTx; n=91), and healthy controls (n=27), and analyzed the data in relation to body mass index (BMI) and height. Patients with renal insufficiency showed lower BMI standard deviation score (SDS) values and height SDS compared with controls and RTx patients. Total ghrelin was elevated in CKD and dialyzed patients compared with controls or transplant recipients (P<0.001). Acyl ghrelin did not differ between groups, and the acyl ghrelin/total ghrelin ratio was reduced in uremic patients (P<0.05). Obestatin plasma levels were increased in patients with renal insufficiency compared with controls and RTx patients (P<0.01). Uremia leads to an accumulation of the anorexigenic hormones desacyl ghrelin and obestatin. Orexigens like acyl ghrelin are not elevated. A disturbed balance between anorexigenic and orexigenic hormones may influence development of CKD-associated protein-energy wasting in pediatric patients.