Pancreas transplantation is now performed as a routine treatment for uremic diabetic recipients of kidney transplants either simultaneously with or after the kidney. Such patients are obligated to immunosuppression and with a successful pancreas transplant can achieve insulin independence as well as a dialysis-free state. Pancreas transplants alone are less commonly applied because of the need for immunosuppression, but the trade off to achieve an insulin-independent state may be worthwhile for individual patients, particularly those who are labile with hypoglycemic unawareness. This option should certainly be a part of the treatment armentation of the modern diabetologist. A positive effect on secondary complications will certainly occur with an early transplant, and even late can have an impact as has been shown for neuropathy. Whether the simpler procedure of islet transplantation will replace pancreas transplants remains to be seen. Of more than 200 islet allografts performed in the 1990s, less than 10% of the recipients have achieved insulin independence at 1 year. Clinical islet trials are ongoing but limited to patients who accept a low individual probability of success to assist in development, or to those in whom the surgical risks of a pancreas transplant is high. Islet transplantation has held promise for over 25 years, but candidates for endocrine replacement therapy must honestly be told the difference in success rates, which are currently much higher with the pancreas.