In a patient with high +SSA antibodies and distal renal tubular acidosis (RTA), but without sicca symptoms or other systemic features of Sjogren's, should immunomodulatory therapy with hydroxychloroquine or azathioprine be considered in an effort to reduce subclinical tubular inflammation and prevent progression of renal disease?

1. Renal disease can occur as an initial manifestation in the absence of sicca in SjÓ§gren’s disease (SjD) patients (Goules et al., PMID 31464673). This is important to realize for other systemic manifestations of SjD (e.g., cystic lung disease, tubulointerstitial nephritis, radiographic nephrocalcinosis, etc) as well. Patients with these problems should undergo ANA, RF, anti-SSA, and anti-centromere antibody testing to help identify SjD as early as possible.
2. In this patient, I would assess for the possibility of SjD, as its presence could change management decisions (especially with our first SjD biologics hopefully on the near horizon!). If anti-SSA is highly positive, I would strongly consider proceeding to a minor salivary gland biopsy (m...

The absence of sicca symptoms would not affect my assessment of immune-mediated kidney disease in SjD. However, I still assess objective measures for ocular dryness. The patient can have an Ocular Staining Score >5, but without symptoms (still at risk for corneal damage). I do assess the likelihood of a reversible component and weigh the risk-benefit of a therapeutic trial. I start with low-dose prednisone (short course), and decide about azathioprine, MMF, or calcineurin inhibitor.

A high titer SSA, especially Ro 52 Ab, would factor into my decision-making. Don't think I would rely on HC in this setting.