Citation Nr: 18143529 Decision Date: 10/19/18 Archive Date: 10/19/18 DOCKET NO. 16-32 287 DATE: October 19, 2018 ORDER Entitlement to service connection for renal failure, as secondary to Veteran’s service connected cirrhosis of the liver, status post liver transplant, associated with hepatitis C, is granted. FINDING OF FACT Resolving all reasonable doubt in favor of the Veteran, the evidence demonstrates that the Veteran’s renal failure was either caused by or aggravated beyond its normal progression by his service connected cirrhosis of the liver, status post liver transplant, associated with hepatitis C. CONCLUSION OF LAW The criteria for service connection for renal failure, as secondary to service connected cirrhosis of the liver, status post liver transplant, associated with hepatitis C, have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.310(a) (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from December 1967 to December 1969. The Veteran was awarded with a National Defense Service Medal as well as a Vietnam Service Medal with two Bronze Stars. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a October 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Baltimore, Maryland. After the statement of the case was issued in May 2016, the Veteran submitted a private medical opinion in support of his appeal. In a June 2017 brief, the representative, on behalf of the Veteran, waived consideration of the private medical opinion by the Agency of Original Jurisdiction (AOJ). See 38 C.F.R. §§ 19.37, 20.1304. The Veteran is seeking service connection for renal failure as secondary to his service connected cirrhosis of the liver, status post liver transplant, associated with hepatitis C. The Veteran contends that his renal failure is connected to his March 2003 liver transplant and hepatitis C diagnosis. Service connection may be established on a secondary basis for a disability which is shown to be proximately due to or the result of a service connected disability. 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 caused by or aggravated by a service connected disability. 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran has a solitary right kidney. He was diagnosed with hepatitis C and cirrhosis of the liver at least as early as March 2002. In November 2002, he was treated for bilateral lower extremity swelling and was placed on Lasix. The Veteran’s treatment records reflect that he had renal insufficiency in March 2003. A private provider noted that that he suspected the renal dysfunction to be secondary to over diuresis (increased or excessive production of urine) and that he anticipated the Veteran’s condition to improve as the Lasix dosage decreased. In April 2004, the Veteran was diagnosed with renal insufficiency developed post-transplant. The Veteran’s continued to have renal insufficiency and in 2005 he was diagnosed with kidney failure. In October 2009, the Veteran was diagnosed with chronic stage 3 kidney disease. In November 2010, a VA examiner stated that he was unable to provide an opinion as to the etiology of the Veteran’s renal failure without resort to mere speculation. The examination report noted that while the Veteran was diagnosed with kidney disease in 2005 a note in the medical records from one of the Veteran’s treating physicians stated the that Veteran’s creatinine level was 2.7 mg/dl prior to the transplantation, which indicates that renal failure started prior to the liver transplant. A November 2013 report from the VAMC Washington Hepatology Service, who had been treating the Veteran since April 2004, indicates that the Veteran’s kidney insufficiency was associated with the tacrolimus and immunosuppression medications. According to the report, the Veteran’s tacrolimus dosage had been adjusted in hopes that tapering the dosage would improve his kidney dysfunction. In May 2016, a VA examiner concluded that the Veteran’s renal failure was less likely than not proximately due to or the result of his liver transplantation and that his renal condition was not aggravated beyond its natural progression by the liver transplantation or medications used for immunosuppression. The examiner reasoned that the Veteran’s medical records noted that his creatinine levels were 2.7 mg/dl pre-transplantation and that since the transplant his creatinine levels have been between 1.6–2.0 mg/dl. Thus, the medical records indicate that his renal disease preceded his liver transplantation. Lastly, the VA examiner noted that because a renal biopsy was not conducted when the Veteran’s renal disease was first discovered it is impossible to state the underlying cause of the renal dysfunction. In June 2017, a private examiner opined that the Veteran’s renal failure was more likely than not caused by and permanently aggravated by his service connected hepatitis C and that his renal condition has been further aggravated by his liver transplant and medications used for immunosuppression and diuretics. The examiner noted that hepatitis C can take anywhere from six months to 10 years before an individual with the virus becomes aware of any symptoms and in some cases individuals with chronic hepatitis C do not have any symptoms until liver problems have developed. Additionally, any chronic liver disease that leads to cirrhosis can affect the kidneys and lead to kidney failure. The private physician reasoned that the Veteran’s treatment records prior to the liver transplant note that he was having renal insufficiencies and that his renal dysfunction progressed to renal failure post-transplant. Thus, in his opinion the Veteran’s kidney disease has clearly been permanently aggravated by the use of medications to treat his immunosuppression. The private examiner submitted academic medical research to support his opinion. The record includes conflicting medical opinions as to whether or not the Veteran’s renal failure is proximately due to or the result of his liver transplant and whether or not his renal condition was aggravated beyond its natural progression by the liver transplant or medications used for immunosuppression. When the evidence of record contains conflicting medical opinions, it is the responsibility of the Board to assess the credibility and weight to be given to the evidence. Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192–93 (1992)). The Board may favor the opinion of one competent medical expert over another if his or her statement of reasons and bases is adequate to support that decision. Owens v. Brown, 7 Vet. App. 429, 433 (1995). The Board finds that the competing medical opinions, the May 2016 VA opinion and the June 2017 private opinion, are both based on a review of the claims file and medical records, consideration of the Veteran’s lay statements, and are supported by a detailed rationale. Additionally, both physicians possess the necessary education, training, and expertise. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Under these circumstances the Board cannot find a basis for which competing medical opinion is more probative over the other. Therefore, based upon a careful review of the subjective and clinical evidence, and resolving all reasonable doubt in favor of the Veteran, the Board finds that the evidence is at least in equipoise that the Veteran’s renal failure has been caused by and/or permanently aggravated by his service connected hepatitis C and cirrhosis of the liver, status post liver transplant. See 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990) (holding that when a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails). Additionally, the Board finds that the submitted academic medical research has probative value. A medical article “can provide important support when combined with an opinion of a medical professional” if it discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least “plausible causality.” Sacks v. West, 11 Vet. App. 314 (1998); Wallin v. West, 11 Vet. App. 509 (1998); Mattern v. West, 12 Vet. App. 222 (1999). According to the American Association for the Study of Liver Diseases, hepatitis C is independently associated with the development of chronic kidney disease and recent meta-analysis indicated that chronic hepatitis C was associated with a 43% increase in the incidence of chronic kidney disease. Additionally, there is a higher risk of progression to end-stage renal disease in persons with chronic hepatitis C and chronic kidney disease. The private examiner also cited an article that states that there is an increase in evidence for the association between hepatitis C infection and kidney disease. For example, recent epidemiological studies strongly suggest that hepatitis C is a risk factor for proteinuria and/or impaired renal function. Lastly, the private examiner cited an article to support his conclusion that an important cause of chronic kidney disease among liver transplant recipients is calcineurin inhibitor based immunosuppression. (CONTINUED ON NEXT PAGE) In summary, resolving all reasonable doubt in favor of the Veteran, the Board finds that a grant of service connection for renal failure, as secondary to his cirrhosis of the liver, status post liver transplant, associated with hepatitis C, is warranted. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Robinson, Associate Counsel