Insulin dependent diabetes mellitus (IDDM) is known to be one of the major risk factors for patient survival after the development of end-stage renal failure (ESRF). Simultaneous pancreas/kidney (SPK) transplantation has been pioneered by a number of units. The Westmead transplant program has demonstrated that SPK transplantation yields a technically successful result in comparison to the alternative of kidney transplantation alone. In Australian patients with IDDM and ESRF, the treatment of choice is to undergo SPK transplantation before the need for dialysis and before the development of severe neuropathy. Diabetic retinopathy must have been adequately treated by laser photocoagulation and the ideal patient will be young and normotensive, with no pre-existing carotid or femoral atherosclerotic plaque. This approach may, for a small proportion of patients with ESRF and IDDM, return their prognosis to that of the non-diabetic.