End Stage Renal Disease is a well-known global public health problem. Maintenance hemodialysis is considered a life-saving treatment for patients with such disease. This treatment method that requires patients to be adherent to hemodialysis attendance, dietary and fluid recommendations as well as adherence to prescribed medications to ensure success. The aim of the current study was to assess adherence, perception, and counseling among hemodialysis patients to different modalities of treatment (fluid restriction, dietary recommendations, medications, and hemodialysis schedules). A cross-sectional study carried out on hemodialysis patients who attended to the dialysis centers at al- Karama teaching hospital and Madinat Al- Imamain Al- Kadhimain teaching hospital. The  Arabic version  of the “ end stage renal disease-adherence questionnaire ” was used in assessing adherence, perception, and counseling. The number of recruited patients were 200 adult patients (113 men and 87 women). The average of the total adherence score lies within the moderate adherence (984.9 ±174.2). Patients adherence to the hemodialysis session was good as representing by high scores of adherence for (hemodialysis-attendance, episode of hemodialysis-shortening and duration of hemodialysis-shortening) while the lowest adherence score (126.0 out of 200) was for following the fluid restriction. In terms of adherence categories, the majority (61%) of the patients had good adherence, 33.0% had moderate adherence with 6% had poor adherence. Age had significant positive association with the total adherence score. All patients perceived their hemodialysis management as highly/very important. On the other hand, some patients perceived their adherence to the recommended diet as moderately (7%) or less important (7%). Regarding the frequency of counseling received by patients for different treatment modalities.  The negative answers represented 58.5% of answers about the how important is to follow a proper diet, and 25.0% of answers about the importance of taking prescribed medications as ordered. Accordingly, the overall adherence of hemodialysis patients to different treatment modalities was less than optimum with fluid and diet adherence representing most challenging tasks in the health care of hemodialysis patients.