Citation Nr: 1615669 Decision Date: 04/18/16 Archive Date: 04/26/16 DOCKET NO. 11-15 998 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for hypertensive vascular disease, including as due to service-connected disability. 2. Entitlement to service connection for hepatomegaly (chronic liver disease), including as due to service-connected disability. 3. Entitlement to service connection for a kidney disorder, including proteinuria, and including as due to service-connected disability REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD D. J. Drucker, Counsel INTRODUCTION The Veteran had active military service from August 1970 to May 1972. This case initially came to the Board of Veterans' Appeals (Board) on appeal from an April 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In June 2011, the Veteran testified during a hearing before RO personnel. A transcript of the hearing is of record. In an April 2015 decision, the Board granted the Veteran's claims for service connection for peripheral neuropathy of the bilateral upper and lower extremities. At that time, and in January 2016, the Board remanded his claims for service connection for hypertension, hepatomegaly, and a kidney disorder, to the Agency of Original Jurisdiction (AOJ) for further development. FINDINGS OF FACT 1. The Veteran's hypertensive vascular disease is unrelated to his period of active military service nor was hypertension manifest to a compensable degree within one year of his discharge from active service, and hypertension is not due to or aggravated by service-connected disability. 2. The Veteran's chronic liver disease did not have its onset in service, nor is it otherwise related to a disease or injury during his military and chronic liver disease is not due to or aggravated by or service-connected disability. 3. The Veteran's kidney disorder, including proteinuria, did not have its onset in service, nor is it otherwise related to a disease or injury during his military service and a kidney disorder, including proteinuria is not due to or aggravated by service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertensive vascular disease have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2015). 2. The criteria for service connection for chronic liver disease have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310. 3. The criteria for service connection for a kidney disorder, including proteinuria have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). In January and March 2010 letters, the AOJ notified the Veteran of information and evidence necessary to substantiate his claims. He was notified of the information and evidence that VA would seek to provide and the information and evidence that he was expected to provide. In the letters, the Veteran was informed of how VA determines disability ratings and effective dates, as required by Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The AOJ satisfied its duty to notify the appellant under 38 U.S.C.A. § 5103(a) (West 2014) and 38 C.F.R. § 3.159(b). VA has done everything reasonably possible to assist the Veteran with respect to his claims for benefits in accordance with 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c). His service treatment and personnel records and VA and private records have been associated with the claims file, to the extent available. All reasonably identified and available medical records have been secured. The Veteran was afforded a VA examination in March 2010 and in May 2010 the examiner provided an addendum. The Veteran also underwent VA examination in August 2010 and the examination reports are of record. The Board's April 2015 remand was to afford the Veteran a VA examination regarding his claims for service connection for hypertension, chronic liver disease, and a kidney disorder including proteinuria and obtain VA medical records of his treatment since October 2014. There has been substantial compliance with this remand, as he was scheduled for VA examination in July 2015 and VA medical records, dated to March 2015, were obtained. The purpose of the Board's January 2016 remand was to obtain a clarifying medical opinion that reflected a review of the record and full explanation of any conclusions regarding the Veteran's claims for service connection for hypertension, chronic liver disease, and a kidney disorder including proteinuria. There has been substantial compliance with this remand, as a VA medical opinion was obtained in February 2016. The July 2015 VA examination report, with the February 2016 opinion, is adequate, because the examiner reviewed the accurate history, provided clinical findings and diagnoses, and offered a definitive opinion with rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The records satisfy 38 C.F.R. § 3.326 (2015). The VA opinion cured the deficiencies in the earlier opinions; hence, the Board insured that its remand instructions were complied with. The February 2016 opinion makes up for any deficiencies in the March, May, and August 2010 and July 2015 VA examination reports. The Board finds the duties to notify and assist have been met. II. Factual Background and Analysis Contentions The Veteran contends that he has hypertension, hepatomegaly, and a kidney disorder, due to his service-connected diabetes mellitus, type II. See June 2011 hearing transcript at page 2. (Service connection for diabetes mellitus, type II, was granted in an April 2010 rating decision.) He did not recall the exact date he was diagnosed with hepatomegaly but thought it was within four years or less. Id. The Veteran assumed his liver disease was due to his after hours activities in Vietnam that included liquor consumption, but had no medical evidence to support that assumption. Id. at 4. The Veteran's proteinuria was diagnosed in 2005 or 2006. Id. at 5. VA was his only medical provider for his kidney disorder and treatment involved a new diet. Id. at 7. A physician advised him that his kidneys were affected by his diabetes. Id. The Veteran stated that his hypertension was first diagnosed by VA in 2010 and that he never went to see doctors much. Id. at 8-9. He was first seen by VA in December 2009. Id. at 10. Thus, he maintains that service connection is warranted for chronic liver disease, hypertension, and a kidney disorder including proteinuria. Legal Criteria A veteran is entitled to compensation for disability resulting from personal injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b); but see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (the theory of continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a)). To establish service connection, evidence must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service" - the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain chronic diseases, such as cardiovascular renal disease (including hypertension), may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from active service. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. In addition, disability that is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. Secondary service connection on the basis of aggravation is permitted under 38 C.F.R. § 3.310, and compensation is payable for that degree of aggravation of a non-service- connected disability caused by a service- connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). By regulation, VA has placed additional limitations on grants of service connection based on the basis of aggravation. 38 C.F.R. § 3.310(b). Service incurrence for certain diseases, but not hypertension, chronic liver disease, or a kidney disorder, will be presumed on the basis of an association with certain herbicide agents (e.g., Agent Orange). 38 U.S.C.A. § 1116; 38 C.F.R. §§ 3.307(a)(6), 3.309(e). Such a presumption, however, requires evidence of actual or presumed exposure to herbicides. Id. Veterans who, during active service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed to an herbicide agent, unless there is affirmative evidence of non-exposure. 38 U.S.C.A. §§ 1116; 38 C.F.R. § 3.307. A veteran who served on land in Vietnam is presumed to have had such exposure. VA has extended this presumption to veterans who served in other areas where Agent Orange is known to have been used. Id. Notwithstanding the foregoing presumption provisions, a claimant is not precluded from establishing service connection with proof of direct causation. See Stefl v. Nicholson, 21 Vet. App. 120 (2007) (holding that the availability of presumptive service connection for some conditions based on exposure to Agent Orange does not preclude direct service connection for other conditions based on exposure to Agent Orange); Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); Brock v. Brown, 10 Vet. App. 155, 160 (1998). Thus, presumption is not the sole method for showing causation. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence."). The Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). Although the Veteran is competent to provide a diagnosis of an observable condition such as a headache, varicose veins, or tinnitus, the Veteran is not competent to provide evidence as to more complex medical questions, such as the etiology of hypertensive, hepatic, or renal pathology. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Analysis The service department has verified that the Veteran served in the Republic of Vietnam and, thus, may have been exposed to herbicides (VBMS 4/29/10, Rating Decision Narrative, p.3); VBMS 12/10/09, Certificate of Release or Discharge from Active Duty (DD 214), p.1) . His service in Vietnam and in-service exposure to herbicides are conceded. Service connection for hypertension, chronic liver disease and a kidney disorder, as due to exposure to herbicides, is not warranted on a presumptive basis. Hypertension, chronic liver disease, and a kidney disorder, are not among the diseases listed under 38 C.F.R. § 3.309(e). Therefore, presumptive service connection under this section is not warranted. Moreover, as there is no showing of hypertension within the first post-service year, the chronic disease presumption of 38 C.F.R. § 3.309(a) is likewise unavailable. The above notwithstanding, the Veteran is not precluded from otherwise establishing service connection with proof of direct causation. See Stefl v. Nicholson, 21 Vet. App. 120. Service treatment records do not discuss treatment for hypertension, chronic liver disease, or a kidney disorder. The post service medical evidence shows proteinuria was reportedly noted in approximately the 1990s and in 2006; hypertension was diagnosed in approximately 2001; and hepatic dysfunction of unknown etiology was diagnosed in 2008, when diabetes mellitus diagnosed. See February 23, 2016 VA medical opinion (VBMS 3/1/06, C&P Exam, pps. 6, 8, 9; VBMS 2/3/10, Medical Treatment Record-Non Government Facility, p. 1, 54; VBMS 2/16/10 Medical Treatment Record -Non Government Facility, p. 13, 21, 27). July 2006 private urology records indicate that the Veteran was referred regarding nocturia and was currently being evaluated for proteinuria (VBMS 2/16/10, Medical Treatment Record-Non Government Facility, p. 13). The Veteran had a family history significant for diabetes, type 2, myocardial infarction and hypertension, and stroke. Id. at 11. Assessments included benign prostate hypertrophy (BPH) and hypertrophy with urinary obstruction. Id. at 15. A January 2008 private treatment record notes that the Veteran had significant proteinuria and saw a nephrologist but test results were unclear (VBMS 2/3/10, Medical Record Non-Government Facility, p. 54). A family history of hypertension and diabetes was reported. The assessments were hepatic dysfunction and diabetes mellitus, type II. Id. at 1. According to a January 2010 VA primary care note, the Veteran had proteinuria, an impaired fasting glucose, and hypertension remote and current (VBMS 8/5/10, Medical Record-Government Facility, p. 44; VBMS 3/17/10, Medical Record-Government Facility, p. 8). An abdominal ultrasound performed at the time showed an echogenic liver, consistent with fatty changes (VBMS 2/3/10, Medical Record Non-Government Facility, p. 5-6). In March 2010, the VA examiner noted the Veteran's history of hypertension diagnosed in January 2010, and proteinuria for the last 2 or 3 years for which he was evaluated by a nephrologist (VBMS 3/5/10, VA Examination, p. 5). There was no etiology found so far. The Veteran also had elevated liver function tests (AST and ALT) on his recent lab work. The examiner diagnosed hypertension, assessed when diabetes mellitus was diagnosed and not due to diabetes mellitus, hepatomegaly with elevated transaminase that was more likely than not fatty liver and not due to diabetes mellitus, and proteinuria that preceded diabetes, and was not due to his service-connected diabetes mellitus. The examiner did not provide any reasons for his opinion. In the May 2010 addendum, the examiner stated that hypertension and hepatomegaly were not due to or aggravated by service-connected diabetes mellitus (VBMS 5/13/10 VA Examination, p.1). Reasons were not provided for the examiner's opinion. The examiner also opined that proteinuria was less likely than not due to diabetes mellitus as the disability was recently diagnosed. In August 2010, the Veteran told a VA examiner that he was unsure when his diabetes began, that high sugar was found in his blood 6 or 7 years ago and that, prior to that time, he had not seen a doctor in over 30 years (VBMS 8/26/10, VA Examination, p.1). The first time he saw a physician was at VA in December 2009. The examiner indicated that the Veteran's hypertension was not related diabetes mellitus as there was no renal involvement and further found that no conditions were aggravated by diabetes mellitus. There is no indication that the examiner reviewed the Veteran's medical records, nor did the examiner provide a rationale for his opinion. The July 2015 VA examination, with a February 2016 addendum, contained the opinion that the Veteran's hypertension, chronic liver disease, and kidney disorder/proteinuria were not due to exposure to herbicides as the bulk of the medical literature did not support such an association. While hypertension is among the listed chronic diseases, and a continuity of symptomatology could establish a link between that disease and service, the first documented evidence of hypertension is from 2001, nearly 20 years after the Veteran's discharge. See Walker v. Shinseki, 708 F.3d at 1331. Chronic liver disease and a kidney disorder including proteinuria are not among the listed chronic diseases, but a continuity of symptomatology could not establish a link between the diseases and service, as the first documented evidence of chronic liver disease is from 2008 and of kidney disorder/proteinuria is from approximately 1990, 36 and 20 years, respectively after the Veteran's discharge. Walker. Absent a continuity of symptoms, the Veteran would not be competent to say that hypertension, chronic liver disease, or a kidney disorder/proteinuria, first demonstrated decades after service was caused by a disease or injury in service or service-connected disability. See Buchanan v. Nicholson, 451 F.3d at 1331. Lay testimony is competent if it is limited to matters that the lay person actually observed and is within the realm of the witness's personal knowledge. See 38 C.F.R. § 3.159(a)(2) (Competent lay evidence means any evidence not requiring that the proponent have specialized education, training or experience. Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a lay person). The July 2015 and February 2016 opinions from the VA examiner are the most probative evidence of record on the question of a nexus to service. They show that the claims file was extensively reviewed and the Veteran's reports considered. In July 2015, the examiner opined that the Veteran's hypertension, hepatomegaly, and kidney disorder, including proteinuria, did not have their clinical onset in service and were not otherwise related to service, including his presumed herbicide exposure. In February 2016, the examiner provided a well-reasoned opinion that the Veteran's hypertension, hepatomegaly, and kidney disorder, including proteinuria, were not caused by his service-connected diabetes mellitus. The examiner noted that the Veteran's nephrology treatment records showed that proteinuria was noted in 1991, borderline hypertension was demonstrated in 2001 and initially treated with medications that were discontinued by him. Also in 2001, hyperlipidemia, high triglycerides, high cholesterol, and LDL were reported. In 2008, diabetes mellitus and a fatty liver were diagnosed. In 2010, hypertension medications were restarted and the Veteran was diagnosed with hypothyroidism. In 2016, he had normal GFR (glomerular filtration rate?). The examiner explained that the Veteran's proteinuria/kidney disorder was not caused by his service-connected diabetes mellitus as it presented prior to the diagnosis of diabetes. She noted that a July 2006 record indicates the Veteran had proteinuria/microalbumin prior to July 2006 (onset 1991). At that time, he also had benign prostatic hypertrophy (BPH) with obstruction. An August 2006 renal ultrasound showed right upper pole renal calculus, and was otherwise was normal. The Veteran was 56 years old, obese, with a family history of renal failure and current BPH with obstruction. He did not have diabetes or hypertension at the time of proteinuria (diabetes was diagnosed in 2008). Thus, the examiner concluded that the Veteran's proteinuria (renal disease) was likely due to etiology other than diabetes mellitus or hypertension.. The examiner observed that, according to WebMD Medical Online research, other types of kidney disease unrelated to diabetes or high blood pressure can also cause protein to leak into the urine. Increased production of proteins in the body can lead to proteinuria. Other risk factors included obesity, age over 65, and a family history of kidney disease. Additionally, the examiner pointed to a July 10, 2006 nephrology note, showing that the Veteran had a history of what he called borderline hypertension. His blood pressure could be in the 150/90-95 range. He was started on medications but was intolerant to them and stopped taking them five years earlier. The nephrologist noted that the Veteran reported having mild proteinuria for 14 to 15 years, and that was most likely due to borderline hypertension that was not treated, as well as the herbs he took. The examiner also called attention to a July 31, 2006, a nephrology note recounting the Veteran's history of borderline hypertension for 4 to 5 years, chronic back problems, and proteinuria for the past 14 to 15 years. He presented to his primary care physician and was referred to the nephrology clinic for evaluation. The Veteran reported that he was not on any medications and did take a lot of herbal medications for his back and cholesterol issues. His blood pressure was 168/110. The examiner reasoned that the Veteran's hypertension was not due to his service-connected diabetes mellitus, as he had likely had hypertension as early as 2001, that was prior to the onset of diabetes mellitus. The July 10, 2006 nephrology note reflects a diagnosis of hypertension as early as 2001. The Veteran was started on medications but stopped and had persistent high blood pressure readings until 2010 was he re-started prescribed medications. The examiner noted that the Veteran's diabetes was confirmed in January 2008. Thus, his hypertension was diagnosed years before he was diagnosed with diabetes mellitus. The examiner stated that the Veteran's hepatomegaly/fatty liver disease was not due to his service-connected diabetes mellitus, and noted that liver function tests in 2001 were essentially normal. A liver ultrasound in January 2008 revealed an echogenic liver consistent with fatty changes that was the likely cause of elevated liver function tests (ALT and AST). Between 2008 and 2010, the Veteran's liver function tests were elevated but returned to the normal range between 2010 and 2015. His ALT labs were normal on all tests and his AST labs were all normal, aside from one test in February 2012. According to the examiner, the Veteran's risk factors for fatty liver disease at the time of diagnosis were middle age, obesity, and hyperlipidemia (metabolic syndrome). Non-alcoholic fatty liver disease was associated with obesity, insulin resistance states (i.e. diabetes), and metabolic conditions. The examiner explained that the Veteran had metabolic syndrome prior to the diagnosis of diabetes mellitus (the Veteran had a long history of obesity, hypercholesterolemia/hypertriglyceridemia and hypertension prior to his diabetes diagnosis in 2010 (2008?). High cholesterol was documented in 2001 and 2006, when seen by the nephrologist). The examiner further pointed to medical literature from the Mayo Clinic indicating that metabolic syndrome is a cluster of conditions - increased blood pressure, a high blood sugar level, excess body fat around the waist and abnormal cholesterol levels - that occur together, and increased one's risk of heart disease, stroke, and diabetes. The examiner noted the Veteran's January 2010 laboratory tests results, that reflected high AST, ALG, cholesterol, and triglyceride findings. The examiner also noted that, according to WebMD Online Medical Reference, it was unclear what caused nonalcoholic fatty liver disease (NAFLD). It tended to run in families and was more likely to happen in those who were middle-aged and overweight or obese. People like that often had high cholesterol and diabetes as well. The examiner opined that the hypertension, hepatomegaly, and kidney disorder, including proteinuria, were not worsened beyond their natural progression by the service-connected diabetes mellitus, type II. According to the VA examiner, the onset of the Veteran's hypertension was prior to 2001 and he was started on prescribed medication that he quit taking for approximately nine years. He restarted taking one medication that he discontinued soon after. Another physician prescribed a combination of two medications with additional medication for BPH and hypertension. A fourth medication was added. The examiner noted the Veteran's elevated blood pressure readings in July 2006, January 2008, and January 2010, after which Lisinopril was prescribed but discontinued soon after due to adverse effects. Other medication was prescribed by his private physician that improved his blood pressure for a while. Medication was also prescribed for BPH that acted as an antihypertensive agent. The Veteran's blood pressure remained elevated between 2012 and 2014. The examiner noted that in February 2016, the Veteran's blood pressure was in the normal range. He also lost approximately 60 pounds in six months and his diabetes mellitus was controlled without medication. According to the examiner, since weight loss improved the Veteran's hypertension and diabetes, it was likely a more significant risk factor affecting the progression or control of hypertension. Further, while the Veteran's hypertension was controlled with four prescribed medications, he had multiple other conditions that affected the progression of the hypertension. His other known risk factors affecting his hypertension, aside from a positive family history and age, were obesity, obstructive sleep apnea, hyperlipidemia, chronic kidney disease, hyperthyroidism, and years of uncontrolled hypertension. The examiner concluded that, while chronic kidney disease can affect control of hypertension, the Veteran's kidney disease was not caused or aggravated beyond its normal progression by his diabetes and observed that the Veteran's kidney disease was well controlled. In the examiner's opinion, the Veteran's hypertension was not as likely as not aggravated beyond normal progression by service-connected diabetes mellitus. The examiner found that the Veteran's renal disease was not aggravated beyond normal progression by service-connected diabetes mellitus. She explained that the Veteran's renal function only recently demonstrated a decrease in GFR on two occasions, but had normal GFR, BUN, and creatinine in February 2016. It was otherwise functioning well within normal limits with no significant if any progression. The examiner also observed that the Veteran's diabetes mellitus was well controlled since his diagnosis other than in 2012. His hypertension was not well controlled until approximately February 2016 when he lost 60 pounds in six months. The examiner noted that the Veteran had normal kidney function in 2014 by laboratory tests results. The examiner concluded that the Veteran's diabetes mellitus did not cause either his kidney disease (proteinuria) or his hypertension. Thus, there was no evidence that the Veteran's renal disease was aggravated beyond its normal progression. The examiner opined that the Veteran's hepatomegaly was not aggravated beyond its normal progression. The Veteran's liver function improved since 2008 when liver function tests were elevated and there was no evidence of progression to NASH (nonalcoholic steatohepatitis). This indicated that the liver disease was not aggravated. The examiner cited to varied medical literature regarding the causes of nonalcoholic fatty liver disease (NAFLD), a benign condition, that was strongly associated with obesity, and insulin resistance states, including diabetes and other features of the metabolic syndrome, such as high triglycerides and low HDL. It was more common in men, and increased with increasing age. More advanced stages of NAFLD were associated with old age, higher body mass index, diabetes, hypertension, high triglycerides, and/or insulin resistance. See e.g. Journal of Clinical Gastroenterology; 2006 Mar.;40 Suppl 1; S5-10. Since the VA examiner's opinion was based on a review of the pertinent medical history, and was supported by sound rationale, it provides compelling evidence against the appellant's claims. The Board emphasizes that the VA examiner provided a valid medical analysis to the significant facts of this case in reaching her conclusions. In other words, the VA examiner did not only provide data and conclusions, but also provided a clear and reasoned analysis that the court has held is where most of the probative value of a medical opinion comes is derived. See Nieves-Rodriguez v. Peake, 22 Vet App at 295. The Veteran believes that his claimed disabilities are related to the service-connected diabetes mellitus, but this opinion is of little probative value, because he lacks the medical expertise needed to attribute his hypertension, liver, and kidney disabilities, to the diabetes mellitus disability as opposed to the other possible causes. The VA examiner was well qualified to assess the causes of the renal, hepatic, and hypertensive disability in the Veteran's system and provided extensive reasons for her opinions. There is no competent and credible lay or medical opinion or evidence to refute the July 2015 VA examiner's opinion. The preponderance of the evidence is thus against a finding that hypertension, hepatomegaly, and kidney disorder, including proteinuria, are related to the Veteran's active service. In sum, a preponderance of the evidence is against the claims for service connection for hypertensive vascular disease, chronic liver disease, and a kidney disorder including proteinuria, including as due exposure to herbicides or service-connected diabetes mellitus, type II. Reasonable doubt does not arise, and the claims must be denied. Ortiz v. Principi, 274 F. 3d 1361, 1365 (Fed. Cir. 2001). ORDER Service connection for hypertensive vascular disease, including as due to exposure to herbicides or service-connected diabetes mellitus, type II, is denied. Service connection for chronic liver disease, including as due to exposure to herbicides or service-connected diabetes mellitus, type II, is denied. Service connection for a kidney disorder, including proteinuria, and including as due to exposure to herbicides or service-connected diabetes mellitus, type II, is denied. ____________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs