Small extracellular vesicles as liquid biopsy targets and precision therapeutics for metabolic dysfunction-associated steatotic liver disease

Table 2 Evidence-classified therapeutic roles and strategies of small extracellular vesicles relevant to metabolic dysfunction-associated steatotic liver disease

Source	Cargo	Experimental model/evidence directness	Mechanism/biological effect	Ref.
Native therapeutic sEVs in MASLD-related models
hUC-MSCs	miR-24-3p	In vitro and animal evidence: NAFLD models	Targets Keap-1 and reduces lipid accumulation, oxidative stress, and inflammation	[82]
hUC-MSCs	miR-627-5p	In vitro and animal evidence: NAFLD models	Represses FTO expression and improves hepatic glucose and lipid metabolism	[85]
hUC-MSCs	Not specifically identified	In vitro and animal evidence: Experimental NASH models	Regulates the Nrf2/NQO-1 pathway and reduces inflammation and oxidative stress	[87]
BM-MSCs	miR-96-5p	Animal evidence: Experimental NASH rat model	Downregulates caspase-2, enhances fatty acid oxidation, and reduces steatosis	[88]
Myeloid cells	miR-223	In vitro and animal mechanistic evidence: NAFLD-associated fibrosis	Myeloid IL-6 signaling promotes miR-223-enriched sEV release and attenuates liver fibrosis	[83]
Kupffer cells	miR-690	Cell-based and animal evidence: NASH models	Targets NADK and suppresses fibrogenesis, inflammation, and de novo lipogenesis	[90]
Engineered MASLD-specific interventions
GalNAc-modified RBC-EVs	PJ34; GalNAc surface modification	Animal evidence: NAFLD mouse model	Enhances hepatocyte-targeted delivery and reduces hepatic triglyceride accumulation through PARP-1 inhibition	[96]
RBC-sEVs	siNUP85	In vitro and animal evidence: MASLD models	Silences NUP85 and attenuates steatosis, inflammation, and oxidative stress, partly through SLC27A1/PPAR-γ signaling	[103]
cRGD-modified ADSC-EVs	Angiotensin-(1-7); cRGD targeting	In vitro and animal evidence: NAFLD-associated fibrosis	Activates Mas receptor signaling, enhances Akt/Foxo1-associated autophagy and metabolic reprogramming, and reduces lipid accumulation and fibrosis	[113]
Pathogenic sEVs as therapeutic targets
Adipocytes	miR-122	Animal and in vitro evidence: NAFLD models	Targets Sirt1 and promotes disease progression	[54]
Hepatocytes	miR-192-5p	Human, animal, and cell-based evidence: NAFLD/MASH	Activates proinflammatory macrophages through Rictor/Akt/FoxO1 signaling	[57]
Hepatocytes	RBP4	Human association, cell-based and animal evidence: NAFLD	Promotes Kupffer-cell M1 polarization, hepatic lipid accumulation, and inflammation	[68]
Transferable proof-of-concept approaches
hESC-derived sEVs	miR-6766-3p	Indirect non-MASLD evidence: In vitro and animal liver fibrosis models	Targets TGF-βRII/SMAD signaling and suppresses hepatic stellate-cell activation and fibrotic progression	[89]
5HT1D/CD47-engineered exosomes	miR-29b; 5HT1D antibody and CD47 surface modification	Indirect non-MASLD evidence: In vitro and animal liver fibrosis models	Enhances targeting of activated hepatic stellate cells and suppresses fibrotic signaling through the TGF-β/SMAD pathway	[114]

Evidence categories are assigned according to the experimental setting and disease model reported in the original studies. Studies conducted in liver fibrosis or other non-metabolic dysfunction-associated steatotic liver disease settings are explicitly classified as indirect non-metabolic dysfunction-associated steatotic liver disease evidence. Table 2 is intended to classify therapeutic evidence according to experimental setting and disease-model relevance; administration route, dose, and extracellular vesicle isolation protocols vary across studies and are not used here as evidence-ranking criteria. sEVs: Small extracellular vesicles; MASLD: Metabolic dysfunction-associated steatotic liver disease; hUC-MSCs: Human umbilical cord mesenchymal stem cells; Keap-1: Kelch-like ECH-associated protein 1; NAFLD: Nonalcoholic fatty liver disease; FTO: Fat mass and obesity-associated protein; NASH: Non-alcoholic steatohepatitis; NQO-1: NAD(P)H quinone oxidoreductase 1; Nrf2: Nuclear factor erythroid 2-related factor 2; IL-6: Interleukin-6; GalNAc: N-acetylgalactosamine; NADK: NAD kinase; RBC-EVs: Red blood cell-derived extracellular vesicles; PARP-1: Poly(ADP-ribose) polymerase 1; cRGD: Cyclic arginine-glycine-aspartic acid; ADSC-EVs: Adipose-derived mesenchymal stem cell-derived extracellular vesicles; RBP4: Retinol-binding protein 4; hESCs: Human embryonic stem cells; BM-MSCs: Bone marrow mesenchymal stem cells; TGF‑βRII: Transforming growth factor-beta receptor II; SMAD: Mothers against decapentaplegic homolog; 5HT1D: 5-hydroxytryptamine receptor 1D; CD47: Cluster of differentiation 47; TGF-β: Transforming growth factor-β.