It really adds a huge bonus to the game, and makes for an interesting second playthrough.
The Malkavian playthrough changes everything from basic dialogue and interactions to adding a whole suite of unique, Malkavian-only interactions that change based on how you perceive the world as a complete, stark raving madman. The Fledgling can then express disappointment. In addition, if you have a low Humanity, LaCroix will tell the Fledgling before the museum mission not to kill anyone. If you only have one Masquerade point left, there is a special line in which he says that you'll be in big trouble if you only do it again once. During LaCroix's briefings, if you lose Masquerade points before talking to him, he will in some instance chew the player character for violating the Masquerade. OR, if you are a Malkavian/Ventrue, you can use Dementation/Domination against him to make him forget. 
Or you can avoid Humanity loss completely by sending the dismembering serial killer Gimble, which also saves you the trouble of having to fight him yourself. The obvious solution is to send a girl from Asylum to the blood bank, but if you hold off on the quest you can instead send the annoying Masquerade-breaking ghoul Patti, killing two birds with one stone.
The quest Replanting A Lily is a great example. It also grants less XP and a humanity loss. 
Attacking the latter just results in a fight with a stronger than average human that is entirely possible to win invoked bypassing the later fight with him entirely. Attacking the former results in him assuming his war form and most likely killing you horribly.
It's possible to find two future boss fight characters, the serial killer and the wereshark, respectively hanging out in their human forms in a couple of restaurants. 
There are two doors that lead straight to the Hollywood sewer system, and can be used to go back and forth to the surface for blood refill/needed supplies.
The hated sewer level actually has chances to leave before completion, if the player is willing to explore a bit around the sewers.
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