Managing poor graft function after stem cell transplantation

Introduction Poor graft function (PGF) remains an important cause of morbidity and non-relapse mortality following allogeneic hematopoietic stem cell transplantation. Increasing evidence indicates that PGF is a multifactorial syndrome resulting from the interplay between hematopoietic stem cell dysfunction, bone marrow niche impairment, endothelial injury, oxidative stress, and immune dysregulation. A better understanding of these pathogenic mechanisms has broadened current therapeutic perspectives and prompted the investigation of novel treatment approaches.Areas covered This review provides a comprehensive overview of current therapeutic strategies including CD34+-selected stem cell boost, thrombopoietin receptor agonists, mesenchymal stromal cell therapy, and emerging approaches aimed at restoring the hematopoietic microenviroment and counteracting inflammatory and oxidative injury. The literature was identified through a comprehensive PubMed search of clinical, translational, and preclinical studies focusing on the pathophysiology and treatment of PGF.Expert opinion Current evidence supports a shift from viewing PGF as a uniform complication toward recognizing biologically distinct phenotypes requiring individualized treatment. Rather than relying on isolated hematopoietic stimulation, future strategies will likely move toward mechanism-based combination approaches, guided by the predominant biological mechanisms in each patient. Improved biological characterization of PGF will be important to refine patient stratification, optimize therapeutic sequencing and enable more personalized treatment strategies.