Background: Renal disease can be the first presentation of multiple myeloma (MM) or develop during the disease process. Aim: To define the mode of presentation of MM to nephrologists and determine the association with patient characteristics and outcome. Methods: MM patients referred to a tertiary renal unit were studied retrospectively. Group I presented to nephrologists prior to MM diagnosis (n = 36); group II was referred to nephrology after diagnosis (n = 27), and group III was known only to haematology and never referred (n = 91). Age at presentation, gender, paraprotein type, need for dialysis, haematological and biochemical parameters, and survival were examined. Results: Of the 154 MM patients, 23.4% presented with renal impairment (group I), 17.5% were referred to nephrology after MM diagnosis (group II) and 59.1% did not receive renal input (group III). On presentation, group I had a median serum creatinine (sCr) of 700 (range 341–1,023) µmol/l and 80% required dialysis. Although the median sCr on presentation for group II was 131 (range 103–373) µmol/l, median sCr on renal referral was 554 (range 181–807) µmol/l and 57% needed dialysis. In contrast, the median sCr on presentation for group III was only 99 (range 85–117) µmol/l. Group I was more anaemic (p < 0.001) and had higher β<sub>2</sub>-microglobulin levels (p < 0.0001) on presentation compared to groups II and III. For groups I and II, the median survival after diagnosis (10.2 vs. 24.7 months, p = 0.11) and renal referral (10.5 vs. 20.0 months, p = 0.68) was not significantly different. Conclusion: Survival in myeloma renal disease remains poor regardless of the mode of presentation to nephrologists.