The administration of systemic chemotherapy to patients with moderate‐to‐severe organ impairment remains a challenge. In renal failure, guidelines for dose adjustments exist for very few chemotherapy agents. Subsequently, oncologists typically withhold treatment with systemic chemotherapy for patients with severe renal dysfunction. We present the case of a patient with metastatic transitional cell carcinoma of the bladder and renal failure who underwent successful systemic chemotherapy with paclitaxel and carboplatin. The data on systemic chemotherapy in patients with severe renal dysfunction are reviewed.