Renal insufficiency in patients with multiple myeloma represents a major challenge for the treating physician. In patients with etiologically unclear renal failure it is important to consider multiple myeloma as a possible cause of such renal failure. The diagnosis and treatment of these patients is interdisciplinary, in cooperation with hemato-oncologists, radiologists, nephrologists and intensive care specialists. The main goal of all treatment methods is the rapid reduction of pathological free light chains in the serum, resulting in an improvement of renal function. Equally important is the avoidance of nephrotoxic drugs and iodinated contrast agents in patients with renal insufficiency and multiple myeloma. A few new drugs have been used in the systemic treatment of patients with multiple myeloma (MM) and renal failure with much success, especially the beneficial use of pomalidomide is interesting and other drugs will follow soon.