The relative roles of pancreas transplantation and islet transplantation in the management of diabetes are perhaps best examined in the context of the American Diabetes Association (ADA) position statement - revised in 2003. Given the growing success of islet transplantation, it seems worthwhile to examine whether the ADA recommendations should be reconsidered. In this article, R Paul Robertson compares the proven benefits of pancreas and islet transplantation in the context of five major problems faced by people with diabetes: high blood sugar (hyperglycaemia), low blood sugar (hypoglycaemia) with poor symptom recognition, micro- and macrovascular complications of diabetes, poor quality of life, and autonomic dysfunction (including symptoms such as gastroparesis, low blood pressure episodes, and diabetes-related diarrhoea).