<p>Pediatric nephrology patients have high rates of treatment nonadherence, thus increasing their risk for poor health outcomes. Key modifiers of adherence among pediatric nephrology patients include local environment (place of residence, school setting, clinic setting), socioeconomic status, and health literacy. Where patients live affects access to health care, community, and school resources that support adherence and disease management. Socioeconomic challenges, such as lower income, food insecurity, and housing instability, may lead patients and families to prioritize immediate survival needs over adherence. Lower health literacy is common among pediatric nephrology patients and their caregivers and may contribute to difficulties communicating with care teams, understanding health information, and implementing medical recommendations. This educational review aims to (1) conceptualize local environment, socioeconomic status, and health literacy, as well as their interconnections, within an established socio-ecological framework of the individual, family, community, and health care system factors impacting pediatric adherence, (2) synthesize recent literature on the influence of these domains on adherence in pediatric nephrology, and (3) highlight strategies to mitigate barriers within each domain and promote adherence among pediatric nephrology patients and their families.</p> Graphical abstract <p></p>