Secondary hyperparathyroidism (SHPT) is a common and progressive complication of chronic kidney disease (CKD), often intensifying as patients reach dialysis. Although alfacalcidol and other active vitamin D analogs are often used, improper administration can raise the risk of hypercalcemia and hyperphosphatemia. This study aimed to assess, using clinical criteria indicated by guidelines, whether alfacalcidol should be prescribed to hemodialysis patients with SHPT. Records of 136 adult patients treated in An-Naseria hemodialysis units were reviewed and analyzed using SPSS (version 26). The appropriateness of prescribing alfacalcidol was evaluated in accordance with KDIGO 2017 guidelines, taking into account levels of phosphate, calcium, and parathyroid hormone (PTH). Patients were divided into groups based on whether their prescriptions were appropriate or possibly inappropriate. Patients were 55.1% male and had an average age of 51.42 ± 11.5years. The majority of patients exhibited biochemical values (phosphate: 79.4%, calcium: 74.3%, and PTH: 77.2% normal) within goal ranges. 72 patients (52.9%) were categorized as potentially inappropriate for alfacalcidol medication, whereas 64 patients (47%) were recognized as having appropriate indications based on criteria consistent with guidelines. The mean PTH levels of patients in the appropriate group were substantially higher (923.14 ± 379.59 pg/mL) than those in the inappropriate group (274.71 ± 179.69 pg/mL, р < 0.001). Age, sex, calcium, and phosphate levels did not significantly correlate with prescription appropriateness. This cohort may have a significant percentage of alfacalcidol prescriptions that may not follow current guidelines. The sensible use of vitamin D analogs in hemodialysis patients may be improved by better adherence to evidence-based guidelines and routine biochemical monitoring.