*Purpose: Medication nonadherence (MNA) is a major contributor to late allograft loss in transplantation (txp). Immunosuppression therapy is highly effective at preventing rejection yet presents a substantial toxicity burden on txp recipients. There is limited data assessing the correlation between MNA and med tolerability in txp.

*Methods: This was a single center prospective observational longitudinal cohort study including adult txp recipients. After consent, txp patients were administered a validated MNA assessment (Morisky Med Adherence Survey, MMAS) and a validated medication tolerability assessment (Med Side Effect Survey, MSES). Those consenting were also emailed the same surveys every 2 months for up to 36 months post-enrollment (repeated longitudinal component). Generalized linear models were used for analyses, accounting for correlation by repeated measures and time.

*Results: There were 472 assessments (152 in kidney or panc, 234 in liver and 186 in thoracic) done in 268 txp recipients (106 kidney/panc, 73 liver, 89 thoracic). Mean post-txp time was 4.0±5.4 years and low med adherence was reported in 22.6% of responses. Self-reported medication side effect burden averaged a score of 36±29 (range 0-180, median 29, IQR 12,54) which was higher in liver and thoracic txp as compared to kidney/panc (Fig 1 line; p=0.0131); there were similar rates of self-reported low med adherence across organ type (Fig 1 bars; p=0.3682). Reported med side effect burden improved over time (2.94 reduction in symptom score per txp year; Fig 2; p=0.0110), while low med adherence had an increasing trend over time (5.3% increase per year; Fig 3; p=0.093). Importantly, self-reported medication side effect burden significantly correlated with low medication adherence. For every one-point increase in side effect burden there was a 1.3% corresponding increase in odds of reporting low med adherence (Fig 4; OR 1.013, 95% CI 1.001-1.022; p=0.004). Those with high medication side effect burden (above the mean) had more than twice the odds of reporting low med adherence (OR 2.35, 95%CI 1.39 to 4.00; p=0.0016, model C-statistic 0.656).

*Conclusions: Low medication adherence is reported in nearly one in four transplant recipients, regardless of transplant type. Self-reported medication side effect burden is significantly correlated with low medication adherence and this offers a potential area of intervention for clinicians to improve non-adherence rates.

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