Citation Nr: 1754710 Decision Date: 11/29/17 Archive Date: 12/07/17 DOCKET NO. 16-46 769 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUE Entitlement to service connection for kidney failure, status post transplant, to include as secondary to service-connected pulmonary sarcoidosis. ATTORNEY FOR THE BOARD Patricia Kingery, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, had active service from March 1981 to February 1983. This appeal comes to the Board of Veterans' Appeals (Board) from a February 2016 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon, which, in pertinent part, denied service connection for kidney failure, status post transplant. A claim for service connection for kidney failure secondary to sarcoidosis was received in September 2015. In July 2017, the Board, in pertinent part, remanded the issue on appeal for additional development. The Board is granting service connection for end stage renal disease (i.e., kidney failure), status post transplant, constituting a full grant of the benefit sought on appeal; therefore, any discussion with regard to compliance with the Board's remand instructions is rendered moot. While previously represented by a veterans service organization (VSO), the Veteran subsequently revoked representation. See October 2017 written statement ("From this date on, I will represent myself."). This appeal has been advanced on the Board's docket pursuant to 38 U.S.C. § 7107(a)(2) (2012) and 38 C.F.R. § 20.900(c) (2017). FINDING OF FACT The currently diagnosed end stage renal disease, status post transplant is causally related to the service-connected pulmonary sarcoidosis. CONCLUSION OF LAW Resolving reasonable doubt in favor of the Veteran, the criteria for service connection for end stage renal disease, status post transplant, as secondary to the service-connected pulmonary sarcoidosis, have been met. 38 U.S.C. §§ 1101, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.310 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159 (2017). The Board grants service connection for end stage renal disease, status post transplant, constituting a full grant of the benefit sought on appeal; therefore, no discussion of VA's duty to notify and to assist is necessary. Service Connection for Kidney Failure Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a) (2017). Generally, service connection for a disability requires evidence of: (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 in or aggravated by service. See Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995). As adjudicated below, the Board is granting secondary service connection for end stage renal disease, status post transplant, under 38 C.F.R. § 3.310; therefore, the additional service connection theories of presumptive service connection based on chronic symptoms in service or continuous symptoms since service of a "chronic" disease (38 C.F.R. § 3.303(b) (2017)), a "chronic" disease manifesting within one year of service separation (38 C.F.R. § 3.307 (2017)), and direct service connection pursuant to the same benefit (38 C.F.R. § 3.303) are rendered moot because there remain no questions of law or fact as to the fully granted service connection issue. For this reason, these presumptive and direct service connection theories will not be further discussed. See 38 U.S.C. § 7104 (2012) (stating that the Board decides actual case questions of law or fact). The contention liberally construed for the Veteran is that the current kidney failure is a result of the service-connected pulmonary sarcoidosis. See generally September 2015 service connection claim. In a September 2016 written statement, the Veteran contended that he has hypercalcemia related to the service-connected sarcoidosis that caused significant renal disease. The evidence of record reflects that the Veteran has currently diagnosed end stage renal disease, status post transplant. VA treatment records dated throughout the appeal period note diagnoses of end stage renal disease (i.e., kidney failure). See e.g., June 2008 VA treatment record. A January 2016 VA examination report notes a diagnosis of chronic renal disease. The Board finds that the evidence is at least in equipoise as to whether the currently diagnosed end stage renal disease, status post transplant, is causally related to the service-connected pulmonary sarcoidosis. VA treatment records note that the Veteran has end stage renal disease, status post renal transplant, due to (non-service-connected) hypertension or (service-connected) sarcoidosis. The treatment records note that, because the Veteran presented to VA in 1998 with small kidneys and end stage renal disease, a biopsy was never performed. See e.g., February 2016 VA treatment record. A June 2008 VA treatment record shows that a VA nephrologist opined that sarcoidosis can cause end-stage renal disease. The VA nephrologist noted that, because the Veteran presented to VA for treatment in 1998 already with end stage renal disease, the cause of the renal disease was never established. While it was presumed that the end stage renal disease was secondary to (non-service-connected) hypertension, the VA nephrologist opined that it could also have been from (service-connected) sarcoidosis. In a June 2017 written statement, a VA nephrologist who had treated the Veteran since 2001 indicated that the cause of the kidney failure was unknown when the Veteran initially presented for VA care. Because the Veteran already had advanced kidney disease, a kidney biopsy was not performed. The VA nephrologist opined that it is highly likely that the cause of the Veteran's kidney failure was the (service-connected) sarcoidosis, a systemic disease that was diagnosed during service. The VA nephrologist opined that the Veteran was diagnosed with a sarcoid during service, and there is a highly probability that the cause of the end stage renal disease is sarcoidosis. Weighing against the claim are October 2001, January 2016, and August 2017 VA examination reports. The October 2001 VA examiner noted that VA treatment records indicated that the renal disease was believed to be from (non-service-connected) hypertension. The January 2016 VA examiner opined that the kidney failure is less likely than not proximately due to or the result of the service-connected sarcoidosis because, although sarcoidosis can cause renal failure, it is far less common than renal insufficiency due to uncontrolled hypertension. The August 2017 VA examiner opined that the kidney failure is less likely as not caused or aggravated by the service-connected sarcoidosis because, while it is true that sarcoidosis can cause renal complications, the bulk of medical literature indicates that such causal relationship is uncommon. The August 2017 VA examiner noted that the Veteran had multiple potential reasons for end stage renal disease, including poorly controlled hypertension, gouty nephropathy, and possibly sarcoidosis. The January 2016 and August 2017 VA examiners' rationales are insufficient because the examiners were tasked with providing an expert nexus opinion in this specific case, instead of relying on medical literature about the statistical probability of such a relationship. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Further the October 2001 VA examiner's opinion does not address the lack of biopsy performed on the Veteran's kidneys and how this may prevent a more definitive etiology as discussed by the VA nephrologist in the June 2017 medical opinion. The Board finds that the evidence is at least in equipoise as to whether the kidney failure was caused by pulmonary sarcoidosis; therefore, resolving reasonable doubt in favor of the Veteran, service connection for end stage renal disease, status post transplant, as secondary to the service-connected pulmonary sarcoidosis, is warranted. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.310. The grant of secondary service connection renders moot other theories of service connection. ORDER Service connection for end stage renal disease, status post transplant, as secondary to the service-connected pulmonary sarcoidosis, is granted. ____________________________________________ J. Parker Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs