• MSC-EVs show therapeutic potential in T2D by modulating inflammation, promoting tissue regeneration, and improving insulin resistance.
• Engineering strategies such as optimizing culture conditions, modifying EV contents, and using bioactive material-based delivery systems can enhance MSC-EV yield and efficacy.
• Challenges including limited yield, heterogeneity, long-term safety, immunocompatibility, and large-scale production must be addressed for clinical translation.
• Artificial intelligence is highlighted as a promising tool to guide future research and overcome current limitations in MSC-EV-based therapies.