Vascularized pancreas transplantation is currently the only treatment for insulin-requiring diabetes mellitus that can consistently achieve an insulin-free, euglycemic state. Due to the operative risks, requisite immunosuppression, and limitations of insurance coverage, pancreas transplantation is usually performed in the setting of advanced diabetic nephropathy, either simultaneous with or sequential to a kidney transplant. In the recent past, the results of simultaneous kidney–pancreas transplantation were superior to sequential pancreas after kidney transplantation. With advances in surgical techniques and clinical immunosuppression, however, the outcomes of pancreas after kidney transplantation are now nearly equivalent to simultaneous kidney-pancreas transplantation. Consequently, the uremic diabetic patient may be offered a number of potential transplant options including (1) simultaneous kidney-pancreas transplantation from a cadaver donor; (2) living donor kidney transplantation followed by sequential cadaver donor pancreas transplantation; (3) simultaneous living donor kidney-pancreas transplantation; or (4) simultaneous cadaver donor pancreas and living donor kidney transplantation.