Nepal’s hydrological regime, shaped by steep topography, monsoon-dominated rainfall, and extensive cryospheric systems, offers a useful testbed for understanding how climate change and human activities are reshaping water resources in mountain regions globally. Despite abundant water sources, Nepal faces persistent water security challenges driven by extreme seasonality, rising temperatures, shifting precipitation patterns, and rapid land-use change. In this review, we synthesize current evidence on anthropogenic drivers of hydrological change in Nepal and draw lessons relevant to other data-sparse, high-mountain and monsoon-influenced regions. We find that warming-induced glacial retreat, altered snowmelt timing, and changing monsoon dynamics are intensifying wet-season flood risks while heightening dry-season water scarcity, patterns increasingly observed across the Himalaya, Andes, and other mountain systems. Human activities, including urban expansion, agricultural intensification, hydropower, and extraction of sediments from rivers, further modify river flows, reduce groundwater recharge, and increase vulnerability to extremes. Yet major uncertainties persist, especially concerning high-elevation hydrology, permafrost dynamics, sediment extraction, and the cumulative impacts of expanding infrastructure. Nepal’s pronounced topographic and climatic gradients limit broad generalizations, underscoring the need for region-specific hydrological monitoring and modeling. These challenges mirror global limitations in mountain hydrology, where sparse observations and rapidly changing conditions constrain predictive capacity. By identifying key knowledge gaps and highlighting cascading impacts on agriculture, hydropower, domestic water supply, and aquatic ecosystems, this review emphasizes the urgency of strengthening monitoring networks and integrating uncertainty into water management and climate adaptation strategies. Nepal’s experience offers broader insights for countries facing similar pressures at the intersection of climate change, development, and fragile mountain water systems.

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