The optimal induction therapy for patients presenting with newly diagnosed myeloma and advanced renal failure is not known. Previous reports on the combination of bortezomib, thalidomide, and dexamethasone (BTD) have demonstrated high response rates. Herein, we report on a patient who presented with aggressive myeloma and severe renal failure requiring hemodialysis. The patient was treated with BTD. He had a rapid response, achieved a complete response, and no longer required dialysis. We review the data on treatment approaches for patients with renal failure and focus on the use of aggressive induction therapy with novel therapeutics.