Personalized allogeneic hematopoietic stem cell transplantation in myelodysplastic syndromes: Integrating molecular risk, donor selection, and post-transplant strategies.

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains the only treatment with curative potential for myelodysplastic syndromes (MDS). This review synthesizes MDS-specific evidence on transplant indication and timing, conditioning, donor choice, molecular predictors, and post-transplant surveillance. Prospective biologic-assignment studies support a survival benefit in fit older adults with higher-risk MDS. The Molecular International Prognostic Scoring System (IPSS-M), transplant-specific cytogenetic and mutational factors, comorbidity, and transfusion burden refine selection beyond the Revised International Prognostic Scoring System (IPSS-R). Alternative donors expand access, including haploidentical transplantation with post-transplant cyclophosphamide. Conditioning intensity should reflect both disease risk and patient fitness, with regimen-level scoring emerging for cord blood transplantation. Although non-relapse mortality has decreased over time, relapse remains the major unresolved cause of failure. MDS-specific measurable residual disease, graft-versus-host disease, cytomegalovirus assessment, and risk-adapted post-transplant interventions provide a practical framework for individualized care.