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We report the case of a woman in her late 70s with frailty and treatment-resistant hypertension who presented with marked albuminuria, purpuric rash and elevated serum free light chains. Renal biopsy confirmed monoclonal gammopathy of renal significance (MGRS) with Type I cryoglobulinaemia. She was treated with bortezomib and dexamethasone, resulting in clinical and biochemical remission. However, she experienced a relapse within months, requiring re-initiation of therapy with additional agents. Despite supportive measures, she later developed complications of infection and fluid overload, which proved fatal. This case illustrates the importance of timely diagnosis and initiation of clone-directed therapy in MGRS with organ-threatening features. Comprehensive geriatric assessment played a key role in individualising treatment, anticipating toxicity and preserving function, while the course also highlights the difficulties of relapse management in older patients.