Abstract: This study aims to systematically identify the key climate-related risk characteristics faced by cities on the Qinghai-Xizang Plateau and develop adaptation pathways to enhance regional climate resilience. Based on the risk framework of the IPCC, we constructed a hazard-exposure-vulnerability assessment system integrating permafrost processes, urban exposure patterns, and social vulnerability factors. Using Xining City as a case study, we applied the system to conduct a comprehensive risk assessment and spatial mapping, utilizing data from meteorological observations, permafrost monitoring, demographics, and infrastructure. The results showed that high-risk urban areas on the Qinghai-Xizang Plateau were concentrated in river valley basins and main urban centers, driven by intensified extreme heat and heavy precipitation, dense population and infrastructure concentration, and overlapping vulnerabilities of marginalized communities. Permafrost degradation and ice-lake expansion further amplified the systemic citywide risks. Based on these findings, we proposed a suite of ecology-engineering-governance integrated adaptation pathways tailored for plateau cities: restoring wetlands and riparian buffer zones, enhancing infrastructure safety in permafrost areas, and establishing a multi-tiered early warning and risk-sharing mechanism. This study provides scientific support and policy guidance for plateau cities confronting ongoing warming and compound hazards.