Exosomes in hypertension: mechanisms, biomarkers, and therapeutic opportunities

Exosomes have emerged as important mediators in the pathophysiology of hypertension, facilitating intercellular communication through the transfer of bioactive molecules such as microRNAs. This review synthesizes current evidence on the multifaceted roles of exosomes in hypertensive vascular damage, highlighting their involvement in endothelial dysfunction, vascular smooth muscle cell phenotypic switching, renin-angiotensin-aldosterone system modulation, and renal ion transport regulation. Circulating exosomal microRNAs are identified as central drivers of inflammation and vascular remodeling, while urinary exosomes offer non-invasive insights into renal sodium handling and early hypertensive injury. Conversely, mesenchymal stem cell-derived exosomes demonstrate considerable vasoprotective and immunomodulatory properties, positioning them as therapeutic candidates. We further discuss emerging engineering strategies, both endogenous and exogenous, that aim to enhance exosomal targeting, cargo delivery, and therapeutic efficacy. Despite progress, challenges related to biological heterogeneity and long-term safety remain barriers to clinical translation. This review underscores the dual potential of exosomes as diagnostic biomarkers and therapeutic platforms, while outlining directions for future research toward clinical implementation in hypertension management.