Therapeutic algorithm for adult patients with MDS and poor IPSS-R scores.^@ indicates nonfit (patients with multiple comorbidities and/or poor performance) or fit (patients with no comorbidities and good performance status). * indicates nontransplant strategies according to most recent versions published by international MDS expert groups, including ELN and NCCN. & indicates failure of nontransplant strategies (for details of various nontransplant interventions [transfusions, ESAs, lenalidomide and cytoreductive therapy], see “Timing of transplantation.” Nontransplant interventions may include >1 line of nontransplant intervention, eg, treatment with ESAs, followed by lenalidomide in patients with 5q−). ** indicates poor-risk features (defined as poor-risk cytogenetic characteristics, persistent blast increase [>50% or with >15% BM blasts], life-threatening cytopenias [neutrophil counts, <0.3 × 10⁹/L; platelet counts, <30 × 10⁹/L], high transfusion intensity ≥2 units per months for 6 months; molecular testing should be seriously considered, in case of absence of poor-risk cytogenetic characteristics or persistent blast increase). # indicates transplant strategies (all forms of HSCT, for details of donor selection, type of conditioning and posttransplant strategies, see text; no upper age limit if patients are fit, without serious comorbidity and good Karnofsky status). ^@ indicates donor availability (the improved outcome of HSCT with haploidentical donors utilizing posttransplant cyclophosphamide increases the donor availability).