To the Editor: Ten percent of the 1500–2500 liver transplants (LT) done in India per year are pediatric [1]. Studies in pediatric LT recipients showed that nonadherence to clinic attendance and immunosuppression were 45% and 39%, respectively, and were related to older age, self-management, social and mental problems, and higher standard deviation of tacrolimus levels, contributing to rejection, graft loss, and mortality [2,3,4]. However, there are no data in Indian children. We studied adherence and predictors of nonadherence to immunosuppression in 40 pediatric LT recipients—31 males (median age at transplant: 60 mo). After an informed consent/assent, an in-house constructed questionnaire on 4 domains (administration of immunosuppressive drugs, financial problems, treatment schedule, and ingestion issues) was applied, scored on a 5-point Likert scale, and converted to percentage of maximum. Rejection was defined pathologically as acute cellular, late acute, or chronic. Acute liver failure and end-stage chronic liver disease were present in 12 and 28. Two were deceased-donor, while the rest were living-donor LT. Eighteen (45%) children had 30 (range: 1–5) rejection episodes, while 5 children had > 1 rejection episodes. Median adherence was 87.6% (83.6%, 94.1%)—majority (72.5%) of LT recipients had average adherence score of 80%–95%; poor adherence (< 80%) was seen in 5 (12.5%). Adherence scores were worst for treatment schedule (80.0%), followed by ingestion issues (86.0%). On univariate analysis, poor adherence to immunosuppression was associated with older age, longer duration from LT, poor socioeconomic status (modified Kuppuswamy’s scales ≥ 3), presence of rejection, and > 1 rejection episodes, but not with other demographic factors, usage of >/= 3 immunosuppressives, serum 12-h trough tacrolimus levels, or their standard deviation. On multivariate binary logistic-regression analysis, poor adherence was associated with longer duration post-LT [Exp (B) = 1.064, 95% CI = 1.007–1.125, p = 0.028] and occurrence of > 1 rejection episodes [Exp (B) = 39.50, 95% CI = 1.93–808.52, p = 0.017]. Identification of predictors of nonadherence with increasing duration post-LT and application of appropriate interventions is essential for long-term success of an LT program.