Delving Into the Multifaceted Role of Exosomal Cargo in Kidney Diseases: Mechanistic Pathways, Diagnostic Potential, and Therapeutic Applications

Exosomes are nanoscale extracellular vesicles (EVs) that have recently garnered significant attention owing to their crucial role in orchestrating cell-to-cell communication. Through the transfer of heterogeneous molecular cargo encompassing lipids, proteins, cytokines, growth factors, and RNAs (including mRNAs, lncRNAs, miRNAs, and circRNAs), they modulate a wide spectrum of physiological and pathological processes. Exosomes have been extensively investigated as diagnostic tools, therapeutic agents, as well as innovative platforms for drug delivery in metabolic, oncological, cardiovascular, and neurological disorders. Culminating evidence has demonstrated the pivotal role of exosomes in renal pathophysiology. Depending on their cargo content, exosomes represent potential biomarkers for early disease detection and survival prediction across various renal pathologies. While current therapeutic interventions are largely confined to attenuating disease progression, exosomes hold the potential to promote regeneration in both acute kidney injury and chronic kidney diseases. The current review comprehensively examines the clinical utility of exosomal cargo as diagnostic and prognostic biomarkers as well as therapeutic agents in kidney diseases, highlighting their crosstalk with critical signaling pathways implicated in renal pathophysiology. Addressing the current challenges in exosome isolation and standardization, and the development of advanced exosome engineering technologies are crucial for the transformation from experimental research settings to clinical practice. This should be augmented by preclinical validation and well-designed clinical trials, ultimately paving the way for a new era of precision medicine.