BACKGROUND Transplant physicians have tried to avoid graft rejection and early graft loss for many years. However, physicians are now aware about improving long-term kidney and patient survival, a challenge that needs to focus on cardiovascular risk management. One major contributor of this risk is the development of posttransplant diabetes mellitus (PTDM). METHODS We performed a literature search based on PubMed, covering prevalence, risk factors, prevention and treatment of PTDM. CONCLUSIONS We need good quality clinical trials on PTDM prevention and management. In addition, basic and translational-targeted studies should be encouraged, as high-quality molecular and mechanistic analyses are not frequent in this area. Hard end points such as patient and graft survival, cardiovascular and other microvascular complications in patients with PTDM are very difficult to reach, so we need good surrogate end points. The currently used ones are extrapolations from the general population. The target glucose or HbA1c levels to achieve are largely unknown. We need strategies to delay or prevent PTDM, and tailoring immunosuppression and antidiabetic management including early insulin and oral agents from the early transplant surgery could be essential. Treatment of established PTDM with the new families of oral hypoglycemic agents--secretagogues and incretins--needs higher levels of evidence to prove their short- and long-term safety and efficacy, even at early PTDM stages.