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OBJECTIVE To assess the relationship between arterial stiffness, an early marker of macrovascular cardiovascular disease, and microvascular complications in adolescents and young adults with youth-onset diabetes. RESEARCH DESIGN AND METHODS This study included 1,226 individuals (median age at initial visit 18 years; 58% female; 53% non-Hispanic White, 22% non-Hispanic Black, and 20% Hispanic) with youth-onset type 1 or type 2 diabetes from the SEARCH for Diabetes in Youth Study. Arterial stiffness measures included pulse wave velocity for carotid femoral, carotid radial, femoral foot, and augmentation index (AIx). Microvascular complications included microalbuminuria, peripheral neuropathy, and retinopathy. Participants were followed up once at ∼5 years. RESULTS Cross-sectionally, in type 1 diabetes, AIx was associated with higher odds of having any one microvascular complication (odds ratio [OR] 1.35; 95% CI 1.04–1.76), microalbuminuria (OR 2.76; 95% CI 1.78–4.39), neuropathy (OR 1.63; 95% CI 1.07–2.50), and retinopathy (OR 1.37; 95% CI 1.06–1.79). In type 2 diabetes, AIx was associated with higher odds of microalbuminuria (OR 2.05; 95% CI 1.04–4.33; all P < 0.05). In longitudinal analysis, in type 1 diabetes, a change in AIx was associated with the development of any one microvascular complication (OR 1.45; 95% CI 1.15–1.82), microalbuminuria (OR 5.42; 95% CI 1.98–14.80), neuropathy (OR 2.03; 95% CI 1.22–3.40), and retinopathy (OR 1.48; 95% CI 1.15–1.90). In type 2 diabetes, a change in AIx was associated with the development of microalbuminuria (OR 21.98; 95% CI 1.30–372.88; all P < 0.05). CONCLUSIONS Arterial stiffness is related to and predicts microvascular complications in youth-onset type 1 and type 2 diabetes.