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Vast hydropower resources remain untapped globally, the deployment of which could provide energy-economic benefits but impact riverine ecosystems. Across eco-sensitive river basins, it is unclear how drivers of hydropower expansion, such as rapid economic growth and a low-carbon energy transition, could interact with countervailing forces, such as increasingly cost-competitive variable renewable energy (VRE). Using an integrated energy-water-economy model, we explore the effects of these forces on long-term hydropower expansion in the world's 20 most eco-sensitive basins, which have high ecological richness and untapped hydropower potential. We find that a low-carbon transition exerts the strongest development pressure, causing deployment exceeding 80% of exploitable potential in more than 72% of eco-sensitive basins by 2050, most of which have limited deployment today. Rapid economic growth induces such extensive deployment in only 44% of eco-sensitive basins. Enhanced integration of VRE reduces deployment, alleviating the impacts of rapid economic growth but not the low-carbon transition.