*Purpose: Nonadherence to immunosuppressive medication after kidney transplantation is associated with a high risk of acute rejection and allograft loss. This study aimed to investigate the relationship between medication adherence and perceptions of immunosuppressive drugs and transplantation among Japanese kidney transplant recipients.

*Methods: This cross-sectional study included adult kidney transplant recipients recruited during outpatient visits at three medical centers in Hokkaido and used an anonymous four-part, self-reported survey of demographic data, treatment status, perceptions of immunosuppressive drugs and transplantation, and adherence to immunosuppressive medication. Adherence was measured using the Basel Assessment of Adherence to Immunosuppressive Medications Scale, which assesses medication use over the past four weeks. Patient perceptions were evaluated using a questionnaire on health-related beliefs regarding transplant rejection based on the Health Beliefs Model and a questionnaire developed by the researchers. Logistic regression was used to determine factors associated with nonadherence.

*Results: Among a total of 623 patients who completed the survey, 391 patients (62.8%) were male, the median age was 55.0 years, and 430 patients (69.2%) were employed. Living-donor kidneys were transplanted in 89.1% of cases. There were 269 patients (43.2%) who were categorized as nonadherent to immunosuppressive medication. Logistic regression analysis revealed that history of nonadherence (OR 5.57 [3.75, 8.28]), not taking immunosuppressive medication every 12 h (OR 3.87, [1.88, 7.96]), perceived barriers to adherence score ≥ 1.5 (OR 3.28, [1.56, 6.91]), living-donor kidney (OR 3.22, [1.58, 6.54]), and employment (OR 1.70, [1.09, 2.65]) were significantly associated with nonadherence. The perception of the value of kidney transplantation was high irrespective of the medication status. No significant relationship was found with the three items on the Health Beliefs Model other than perceived barriers.

*Conclusions: Perceived barriers to adherence were associated with nonadherence to immunosuppressive medication among Japanese kidney transplant recipients. Mitigating perceived barriers can potentially improve adherence.

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