Myelodysplastic syndrome is primarily a disease of older age, and hematopoietic cell transplantation is the only treatment modality that offers the potential of cure and long-term survival to a substantial proportion of patients. Transplantation is used with increasing frequency in older patients, and patients in the seventh or even eighth decade of life have been transplanted successfully. However, transplant outcome strongly depends on the disease characteristics and comorbid conditions, which tend to be common in older individuals and profoundly affect nonrelapse mortality. This is a major reason why in patients older than 60 years, typically only conditioning regimens of reduced intensity are used. However, although these regimens are associated with little acute toxicity, the probability of relapse tends to be higher than with high-intensity regimens. In addition, chronic graft-versus-host disease occurs in as many as 50% to 60% of patients. Manifestations are mild in a proportion of patients; others require long-term treatment, generally with glucocorticoids, which often are not well tolerated in older individuals. Although considerable progress has been made over the past decade, more work is needed, particularly to reduce the incidence of severe graft-versus-host disease and prevent posttransplant relapse.