Our study examined the results of coronary artery bypass (CAB) before simultaneous pancreas-kidney (SPK) transplant in type 1 diabetics in renal failure. Of 588 pancreas transplant patients from 1992 to 2002, 77 (24 females, 53 males) were candidates for SPK transplant. All 77 had coronary evaluation and were referred for pretransplant CAB. Among the 77 CAB patients, the mean age was 42 years (range: 30- 63 years), and the duration of diabetes was 28.52 years (range: 9-51 years). All had neuropathy, retinopathy, and nephropathy; 12.9% (n = 10) had angina; and 76% (n = 59) were on dialysis at the time of CAB. The creatinine level of the 18 nondialysis patients was 3.7 mg%; 42.8% (n = 33) had suffered myocardial infarction. The left ventricular ejection fraction (LVEF) was 49% (30-65%). At CAB surgery, 88% (n = 68) triple, 9% (n = 7) double, and 2.5% (n = 2) single arterial grafts were implanted. All 77 CAB patients had severe coronary artery disease (CAD); some vessels could not be bypassed in 9.8%. At surgery, 3.4 grafts/patient were implanted (range: 1-6 grafts). All 59 dialysis patients continued dialysis after CAB; 6 nondialysis patients required dialysis after CAB. The intensive care stay averaged 1.86 days (range: 1-10 days); the hospital stay averaged 10.5 days (range 6-28 days). There was no operative mortality. Eventually, 68 patients underwent SPK transplant; 9 await organs. The waiting period for 68 CAB patients who had SPK was 2 years, 5 months (range: 2 months to 10 years). The SPK operative mortality was 3.9% (n = 3). Significant CAD exists in patients > 30 years of age with type 1 diabetes and renal failure. Pretransplant CAB can be done safely and may reduce posttransplant mortality associated with cardiac events.