"Primed for Repair: Harnessing Hypoxia, Mechanobiology, and Gene Editing to Enhance MSC Potency and Clinical Translation".

Mesenchymal Stem/Stromal Cells (MSCs) hold substantial promise for regenerative medicine; however, their clinical translation has been limited by inconsistent efficacy, poor survival after transplantation, and highly variable functional potency. Preconditioning, defined as the ex vivo manipulation of MSCs before administration, has emerged as a key strategy to address these shortcomings. This review catalogues and critically evaluates the major preconditioning techniques developed between 2000 and 2025, aimed at improving the overall fitness of undifferentiated MSCs or steering their commitment toward specific therapeutic lineages, including osteogenic, chondrogenic, adipogenic, cardiomyogenic, and neurogenic outcomes. We grouped these strategies into two broad categories: (1) non-genomic manipulations, which rely on transient exposure to physical, chemical, or biological cues, such as hypoxia, mechanical forces, small molecules, cytokine treatment, and extracellular matrix engineering; and (2) genomic or gene-modifying manipulations, which involve more stable alterations through microRNA/siRNA modulation, CRISPR/Cas-based gene editing, and viral or non-viral gene transfer. For each modality, we synthesized the relevant molecular mechanisms, evaluated evidence from in vitro, preclinical, and clinical studies, and examined key translational barriers. We also considered important evaluation metrics, including safety, engraftment efficiency, and functional recovery, across disease models. Finally, we integrate perspectives on the evolving clinical trial landscape, regulatory developments from the FDA and EMA, and the intellectual property environment, concluding with a discussion of future research priorities that may accelerate the development of next-generation, potency-enhanced MSC therapeutics.