*Purpose: Nonadherence to immunosuppressive therapy is a risk factor for poor clinical and economic outcomes after kidney transplantation (KT). Brazil, having the largest public and full coverage transplantation program in the world, is a unique opportunity to understanding the multilevel correlates of non-adherence (patient, health care provider, transplant center, and healthcare system levels) independent from patients’ financial burden, currently understudied in KT.

*Methods: Applying a multi-staged sampling approach, we included 1,105 patients from 20 KT centers. Nonadherence to immunosuppressives (implementation phase) was defined as any deviation in taking or timing adherence and/or dose reduction assessed by the BAASIS^©. Based on Bronfenbrenner’s ecological model, we analyzed multilevel factors through sequential logistic regression analysis.

*Results: Prevalence of immunosuppressive nonadherence was 39.7%. Factors associated with nonadherence were: at patient level – stable partner (OR:0.73; CI:0.565-0.95), taking immunosuppressives once a day (OR:2.57; CI:1.23-5.37), nonadherence to appointment keeping (OR:3.05; IC:2.07-4.48), nonadherence to physical activity recommendations (OR:1.82; CI:1.37-2.43); at transplant center level: centers of more than 500 beds (OR:0.62; CI:0.50-0.77), dissatisfaction with waiting room structure (OR:1.80; CI:1.38-2.33), consultation longer 30 minutes (OR:1.60; CI:1.19-2.14), patients’ perceived adequacy of consultation´s frequency (OR:0.64; CI:0.44-0.92).

*Conclusions: This is the first multicenter study to show multilevel correlates of nonadherence in KT patients. Multilevel strategies to tackle nonadherence should also address the post-transplant care.

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