Bio fluid exosomes: promises, challenges, and future directions in translational medicine

Soltanmohammadi et al. Journal of Translational Medicine https://doi.org/10.1186/s12967-025-06886-5 (2025) 23:993 Journal of Translational Medicine Open Access REVIEW Bio fluid exosomes: promises, challenges, and future directions in translational medicine Fatemeh Soltanmohammadi1,2, Maryam Maghsoodi2, Effat Alizadeh3*, Khosro Adibkia2, Yadollah Azarmi4, Adel Mahmoudi Gharehbaba1,2 and Yousef Javadzadeh2,5* Abstract Exosomes, a subset of extracellular vesicles (EVs) secreted by virtually all cell types, have emerged as pivotal nanocarriers of bioactive molecules, including proteins, nucleic acids, and lipids, facilitating intercellular communication and modulating physiological and pathological processes. Initially discovered in reticulocytes, exosomes have since been recognized for their diverse roles in immune regulation, antigen presentation, and disease progression, paving the way for their application in diagnostics, therapeutics, and personalized medicine. This review comprehensively examines biofluid-derived exosomes, focusing on their biogenesis, molecular composition, and innovative isolation techniques from various biological fluids. We highlight their diagnostic potential as non-invasive biomarkers for diseases such as cancer, neurodegenerative disorders, and infectious diseases, as well as their therapeutic applications in drug delivery, regenerative medicine, and immunotherapy. Additionally, we discuss ongoing and completed clinical trials leveraging exosomes for precision medicine, while addressing the technical challenges and limitations in exosome isolation, characterization, and clinical translation. By integrating the latest advancements and future perspectives, this review underscores the transformative potential of biofluid exosomes in revolutionizing modern medicine. *Correspondence: Effat Alizadeh Yousef Javadzadeh Full list of author information is available at the end of the article © The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creati vecommons.org/licenses/by-nc-nd/4.0/. Soltanmohammadi et al. Journal of Translational Medicine (2025) 23:993 Page 2 of 39 Graphical Abstract Keywords Exosome, Biofluids, Drug delivery, Treatment, Diagnosis Background Extracellular vesicles (EVs), which are secreted by all types of body cells, are small vesicles with phospholipid bilayers [1]. EVs, including micro vesicles and exosomes, are biological nanocarriers that transport proteins, DNA, RNA, lipids, and other biological molecules. These types of EVS are different in size, morphology, biologic content, surface markers, and origin [2]. As shown in Fig. 1, in the endosomal–lysosomal system, early endosomes (EE) develop into late endosomes (LEs) which are intracellular organelles called multivesicular bodies (MVBs) [3]. During MVB maturation, intraluminal vesicles (ILVs) are formed inside MVBs by inward invagination of the EE membrane. In other words, MVBs contain ILVs, and ILVs contain lipids, proteins, DNA, RNA, etc. MVBs can have three destinations: (1) they can fuse with lysosomes (leading to degradation of ILVs content); (2) they can participate in signal generation; and (3) they can fuse with the plasma membrane to release ILVs in the form of exosomes [1]. It is worth mentioning that the two membranes should contain soluble N-ethylmaleimide-sensitive factor adhesion protein receptors, which are vital for fusion occurrence [4, 5]. Furthermore, Ras-associated GTP-binding protein 27a (Rab27a) and Rab27b control the release of exosomes [6]. For the first time, exosomeswere discovered in the sheep reticulocytes in 1970, but a new horizon was opened up when G.Raposo found that B lymphocytes can secrete exosomes in 1996 [8, 9]. Between 1996 and 2001, other cell types that could secrete exosomes, such as dendritic cells and intestinal epithelial cells, were identified [10, 11]. In 2000, scientists understood that exosomes released during reticulocyte maturation, bind to fibronectin via integrin [12]. Exosome-based immune therapy was introduced in 2001 [13]. The role of exosomes in apoptosis, along with immune modulation and cell-to-cell interaction, was understood in 2002 and 2004, respectively [14, 15]. In 2005, exosomes were introduced as nanovesicular vaccines according to their ability to carry major histocompatibility complex (MHC) molecules, costimulatory molecules, heat shock proteins, and native tumor antigen [16]. Numerous studies have revealed that immune cells such as B cells and natural killer cells (NKs) can secrete exosomes that have similar characteristics to the cells of origin [17]. Even macrophages release exosomes carrying pathogen-related antigens after exposure to a specific antigen [18]. Nowadays, exosomes are obtained from a variety of sources, like different cell types, stem cells, cancer cell lines, biofluids, etc. They have broad applications in cargo delivery, Soltanmohammadi et al. Journal of Translational Medicine (2025) 23:993 Page 3 of 39 Fig. 1 The biogenesis and secretion of exosomes by the endosomal sorting complex required for transport (ESCRT) pathway. EEs (early endosomes), MVBs (multivesicular bodies), LEs (late endosomes), SNREs (soluble N-ethylmaleimide-sensitive factor adhesion protein adhesion protein receptor), Rab (Ras-associated GTP-binding protein) [7] regenerative medicine, cosmetics, dermatology, cancer therapy, and personalized medicine. This review, focuses on different kinds of biofluids that can be a source for exosome isolation. Moreover, the characteristics, isolation methods, and applications of these exosomes will be clarified based on recent reports. Afterwards, the clinical trials involving exosomes derived from biofluids will be described, whether they are ongoing or completed. Finally, the challenges and limitations that researchers face in isolating and using exosomes will be explained. Properties and functions of exosomes Properties The exosomes are biological nanovesicles ranging between 30 and 200 nm in size [19]. These endogenous nanoplatfo (...truncated)