• First systematic analysis of serum exosomal miRNA expression in TB-DILI patients identifies 128 differentially expressed miRNAs, with miR-122-5p as a potential early biomarker.
• miR-122-5p is upregulated within 24 hours of isoniazid exposure, earlier than traditional ALT/AST markers, offering a window for early diagnosis.
• Differentially expressed miRNAs target genes involved in PI3K/Akt, calcium, and Wnt signaling pathways, implicating these pathways in TB-DILI pathogenesis.
• A six-miRNA diagnostic profile was proposed for TB-DILI, potentially enabling early intervention and reducing severe liver injury risk.