OBJECTIVES: Given recent safety as well as cost concerns, an evidence-based guideline for erythropoiesis stimulating agents (ESA) in chronic kidney disease (CKD) was developed across a seven-hospital system. The purpose of this analysis was to evaluate adherence to the guideline. Specific objectives were to assess: whether 1) optimal hemoglobin levels (10-12 g/dL) were achieved, 2) ferritin or transferrin saturation (TSAT) was measured; and 3) iron therapy was administered, when appropriate. METHODS: The Research Patient Data Registry, a repository comprised of over four million patients and 900 million inpatient and outpatient encounters, diagnoses, medications, laboratory tests and results, and other medical care served as the data source. Data were available for three hospitals, two academic medical centers and a community teaching hospital. Patients were eligible for inclusion if they had a diagnosis of CKD based on ICD-9 diagnosis code and received at least two doses of ESA within three months. The analysis timeframe was November 2007 to April 2008. RESULTS: During the 6-month period, 344 eligible patients were identified. Of these, 54% achieved target hemoglobin levels within three months of therapy initiation. Approximately 4% did not have hemoglobin measured within three months. In the remaining patients, the hemoglobin level was less than 10 g/dL or more than 12 g/dL in 17% and 26% of patients, respectively. In 15% of patients neither ferritin nor TSAT were assessed. Among those with a ferritin <100 ng/mL, 9% did not receive iron supplementation. TSAT was recorded only in one patient. CONCLUSIONS: Approximately half of the patients achieved target hemoglobin levels, highlighting the difficulty in maintaining target hemoglobin. These data suggest that adherence to this guideline can be improved in hemoglobin and iron monitoring and with iron supplementation.