Renal ischemia reperfusion (IR) presents a common challenge for organ graft and function after transplantation. In the kidney, although there are several mechanisms involved in the IR injury, some studies have pointed to angiogenesis as an important process in the pathophysiology of IR and, therefore, as a possible target mechanism to reduce IR damage. Angiogenesis can be modulated by different molecules and recent evidence has shown that opioids are among these molecules. Angiogenesis preconditioning with opioids is a useful and non-invasive strategy to increase the transplant success rate. Although some results have suggested an interaction between the opioid system and VEGF-mediated angiogenesis, more studies are required to fully elucidate the specific mechanisms involved in these actions. The present review summarizes the recent findings on kidney IR-related mechanisms, with as special emphasis on vascular changes. Finally, the evidence about the modulation of angiogenesis by opioids in a preconditioning scheme will be addressed.