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Background: Nonadherence to immunosuppression is common among pediatric and young adult kidney transplant recipients and a leading cause of graft loss. Barriers to adherence are tightly linked with medication adherence and clinical outcomes across chronic conditions, including rejection in solid organ transplantation. Assessing barriers to adherence (e.g., difficulty swallowing pills, dislikes taste) in clinical practice may identify patients at risk for allograft rejection and provide therapeutic targets.Design/Methods: Patients and their caregivers were assessed for 14 barriers to adherence using the barriers assessment tool (BAT) during post-transplant clinic visits from January 2015 through August 2016 and followed from time of assessment through December 2016 for subsequent biopsy-proven acute cellular or antibody-mediated rejection. For patients < 10 years old, only caregivers completed the BAT; for patients > 10 years old, both patient and a caregiver (if present) completed the BAT. We compared rejection rates between patients and caregivers who reported at least one adherence barrier and those who did not using univariate analysis. Multivariable logistic regression was used to identify predictors for acute rejection. Data were also analyzed separately for patients and caregiver groups. Results: Sixty-one patients and 82 caregivers completed the BAT. Twenty-six (43%) patients and 28 (34%) caregivers identified at least 1 barrier to adherence. Twenty-three of 75 patients (31%) experienced acute rejection following barriers assessment. Twelve of 33 patients (36%) with an identified barrier by patient or caregiver report experienced rejection compared to 11 of 65 patients (17%) who did not identify a barrier (RR= 2.2; 95% CI 1.06 – 4.34; p = 0.032). Multivariable logistic regression revealed that the presence of adherence barriers was the only statistically significant predictor for acute rejection [OR 2.92 (95% CI 1.01 – 8.76); p=0.049]. Subgroup analyses indicated no significant differences in acute rejection between those who endorsed versus did not endorse adherence barriers when patients and caregivers were analyzed separately. However, the caregiver group approached significance (p = 0.053).Conclusions: Pediatric and young adult kidney transplant recipients with at least one barrier to adherence are at increased risk for subsequent acute rejection. This provides a potential therapeutic target that can be assessed in the clinic that may be amenable to barrier-specific interventions. These interventions present an opportunity to address medication adherence in clinic with the aim to decrease acute rejection.