Patients undergoing simultaneous pancreas-kidney transplantation are at risk for a variety of serious perioperative complications. These are related to the chronic and acute problems associated with end-stage renal disease and insulin-dependent diabetes mellitus and the prolonged, vascular and ductal surgery required to implant the two allografts. A number of strategies need to be integrated and diligently implemented to minimize the physiologic perturbations and complications related to the recipient's comorbid conditions and revascularization of the allografts. A major objective of the perioperative anesthetic management of simultaneous pancreas-kidney transplantation is to maximize cardiovascular performance in a way that provides optimum graft perfusion and recovery, while avoiding myocardial ischemia. Adherence to this objective, along with very effective immunosuppressants, surgical refinements, meticulous anesthetic preparation, extensive and frequent physiologic and metabolic monitoring, and quick response to abnormal findings has resulted in remarkably low recipient morbidity and mortality, and very high graft survival rates. (C) 2000 Lippincott Williams and Wilkins.