Citation Nr: 20026718 Decision Date: 04/17/20 Archive Date: 04/17/20 DOCKET NO. 13-03 299 DATE: April 17, 2020 ORDER Entitlement to service connection for hepatitis C is denied. Entitlement to service connection for cirrhosis of the liver is granted. Entitlement to service connection for liver transplant is granted. Entitlement to service connection for a kidney disorder associated with diabetes mellitus, type II is granted. Entitlement to service connection for right knee disorder is denied. REMANDED Entitlement to service connection for hepatopulmonary syndrome is remanded. Entitlement to service connection for hepatic encephalopathy is remanded. FINDINGS OF FACT 1. Hepatitis C is not currently shown at any time during the rating period on appeal. 2. The evidence is in equipoise whether cirrhosis of the liver is the result of sarcoidosis that as likely as not began in service. 3. The evidence is in equipoise whether liver transplant caused by cirrhosis of the liver is the result of sarcoidosis that as likely as not began in service. 4. The evidence supports a finding that a kidney disorder diagnosed as chronic kidney disease and diabetic nephropathy is the result of his service-connected disability, including diabetes mellitus. 5. The preponderance of the evidence is against finding that a right knee disability began during active service, or is otherwise related to an in-service injury or disease CONCLUSIONS OF LAW 1. The criteria for an award of service connection for hepatitis C, including on a secondary basis, have not been met. 38 U.S.C. §§ 1131, 5103, 5107 (West 2014); 38 C.F.R. § 38 U.S.C. §§ 3.303, 3.304, 3.307, 3.309, 3.310. 2. The criteria for service connection for cirrhosis of the liver as secondary to an inservice incurrence of sarcoidosis have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 3. The criteria for service connection for liver transplant as the result of cirrhosis as secondary to an inservice incurrence of sarcoidosis have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 4. The criteria for service connection for a kidney disorder as secondary to a service-connected diabetes mellitus have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 5. The criteria for service connection for a right knee disability have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1967 to February 1969. This matter comes before the Board from a June 2010 rating that in part denied service connection for nephrolithiasis, status post-surgery, claimed as kidney disease. The Veteran filed a notice of disagreement (NOD) in July 2010, a statement of the case (SOC) was issued in November 2012 and a VA Form I-9 was received in January 2013. This matter also comes before the Board from a January 2013 rating decision, which in part denied service connection for hepatitis C; cirrhosis; liver damage; liver transplant residuals of liver damage-liver; hepatopulmonary syndrome; hepatic encephalopathy and a right knee disability. The Veteran filed a notice of disagreement (NOD) in February 2013, a statement of the case (SOC) was issued in January 2015 and a VA Form I-9 was received in February 2015. He testified at a hearing held before the undersigned in March 2016. In an August 2016 decision, the Board reopened the service-connection claim for cirrhosis and remanded this matter and all remaining enumerated claims for further development. Such has been completed and this matter is returned to the Board for further consideration. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Service connection may be also established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a) (2015). 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) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a) (2015); Allen v. Brown, 7 Vet. App. 439 (1995). Certain diseases associated with exposure to herbicide agents will be presumed to have been incurred in service even though there is no evidence of that disease during the period of service at issue. 38 U.S.C. § 1116 (a) (West 2014); 38 C.F.R. §§ 3.307 (a)(6), 3.309(e). 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. §§ 1116; 38 C.F.R. § 3.307. The Veteran, who served on land in Vietnam is presumed to have had such exposure. 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. A service connection claim must be accompanied by evidence establishing that the claimant currently has the claimed disability. See Degmetich v. Brown, 104 F. 3d 1328 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The current disability requirement is satisfied when a claimant has a disability at the time of filing the claim or during the pendency of that claim, even if the disability has since resolved. McLain v. Nicholson, 21 Vet. App. 319 (2007). See also Romanowsky v. Shinseki, 26 Vet. App. 303 (2013) (to the effect that where a disease or disability is diagnosed proximate to the current appeal period, but not currently, the Board is required to determine whether the earlier diagnosis was inaccurate, or the previously diagnosed condition had gone into remission. The Veteran is competent to report symptoms and experiences observable by his senses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159 (a). Factual Background for liver and kidney disabilities The Veteran contends that service connection is warranted for various disabilities of the kidney and liver, to include as secondary to Agent Orange exposure; he also contends that his kidney problems are associated with Type II diabetes mellitus. Additionally, it has been alleged that the Veteran’s liver disabilities are related to sarcoidosis, which in turn has been claimed to have resulted from Agent Orange exposure. The Board shall address the factual background of these claimed disabilities of the liver and kidney together. Service treatment records (STRs) are negative for any issues involving the liver or kidney. Nor did they show any diagnosis of a sarcoidosis. The records did show that he was assigned to duties involving nuclear weapons systems. Thus, possible exposure to radiation has been among the theories of entitlement under consideration. The Veteran alleged that he was treated for a pulmonary disability believed to be sarcoidosis in the 1970s, shortly after service. At his March 2016 hearing he testified to a history of sarcoidosis diagnosed in the 1970s and treated with Prednisone. In a February 2008 treatment report he gave a history of sarcoidosis treated in the 1970s about 5 years after service. A March 2011 record indicated a history of sarcoidosis treated with Prednisone in the 1970s, which included pulmonary and probable liver involvement. Most recently in May 2019 and October 2019 he was noted to have been initially diagnosed with sarcoidosis in the 1970’s when he presented with shortness of breath and fevers. These and other medical records repeatedly linked a diagnosis of sarcoidosis with liver involvement. Of note, records from September 2007 and October 2007 noted a history of cirrhosis of the liver after having first been seen by GI in 2005 with elevated liver test and biopsy showing granulomatous hepatitis and steatosis, along with the history of sarcoidosis and a non-drinking history. Regarding the onset of kidney issues, the Veteran gave a history in his March 2016 hearing of having kidney stones beginning in the 1970s, with subsequent surgeries for removal of stones in the 1980s and 1990s. Likewise, VA records showed a history of recurrent kidney stones treated in the 1980s, including a September 2007 record describing surgeries to remove kidney stones in the 1970s and 1980s and a February 2008 record noting a history of recurrent kidney stones “throughout adulthood.” A March 2008 Agent Orange program note disclosed complaints of liver disease, diabetes and a past medical history of chronic kidney disease (CKD), cirrhosis of liver/granulomatous hepatitis and kidney stone disease, with a last stone passed 2005 and two surgeries for kidney stones in the 1970s-80s. Records leading up to the Veteran’s June 2011 liver transplant showed that he was referred to the VA transplant program and evaluated in February 2008 for such purposes, where a possible diagnosis of hepatic sarcoidosis was said to have been evaluated in October 2005. There was evidence of cirrhosis and moderate lobular hepatitis noted on a January 2006 liver biopsy and a history of treatment in the 1970s for a diagnosis of pulmonary sarcoidosis that was later refuted. The overall assessment was granulomatous hepatitis and cirrhosis with some synthetic dysfunction. He was deemed to be a good candidate for transplant. In February 2011 and again in May 2016, the Veteran submitted an August 2010 pre-transplant medical opinion from the Veteran’s treating VA physician, Dr. D. H., Chief of Hepatology and Medical Director of Liver Transplantation. Dr. D. H. opined that the Veteran has liver cirrhosis of unknown cause, possibly related to sarcoidosis. He was also noted to be a Vietnam combat Veteran with a history of Agent Orange exposure and the possibility of Agent Orange related liver damage must be considered. This note indicated that he had been initially referred for consideration of transplantation in 2008 but he had not experienced complications other than poor liver function, so it was deferred at that time. Over the past 6 months prior to August 2010 the Veteran had developed edema of the legs, a common sign of worsening cirrhosis, increasing shortness of breath on exertion, and frequent symptoms of forgetfulness and inattention, cognitive symptoms seen in cirrhosis when patients develop hepatic encephalopathy. He also had findings consistent with hepatopulmonary syndrome which likely explained his dyspnea. Because of his liver failure, plans were made to get him prepared for liver transplantation. In June 2011 the Veteran underwent orthotopic liver transplant for cirrhosis possibly secondary to sarcoidosis verus NAS. He received intensive care post-operatively. He also underwent tracheas-omyandre-exploration and evacuation of hematoma. His postoperative course was complicated by bleeding infection ventilator support, and an acute kidney injury requiring hemodialysis. Surgical pathology disclosed a history of cryptogenic cirrhosis, with histologic findings suggesting a combination of non-alcoholic steatohepatitis and hepatic sarcoidosis. He was discharged from the hospital following the transplant in August 2011. Thereafter, post-transplant records continued to suggest that his liver failure was related to sarcoidosis, including a January 2012 etiology note and a September 2012 gastroenterology diagnosing sarcoidosis with granulomatous liver disease and cholestatic cirrhosis status post liver transplant in June 2011. The records also showed that his renal function had improved, and he was no longer on hemodialysis (HD). Subsequent records continued to suggest a relationship between the Veteran’s liver disease and a sarcoidosis. VA examinations prior to October 2012, including an Agent Orange protocol examination of March 2008, do not contain an opinion as to the etiology of the Veteran’s liver disorders noted in these examinations. The kidney portion of a June 2012 VA general examination diagnosed nephrolithiasis and CKD, with a history of kidney stones that he passed when hospitalized s/p transplant. He had no current symptoms of kidney stones. He also had a history of acute renal failure requiring 2 months dialysis status post liver transplant in 2011. Kidney function recovered and no further dialysis needed. The examiner’s opinion on CKD was that it is less likely as not due to SC diabetes and more likely due to residuals of perioperative liver failure s/p transplant and immune suppression medications. The report of an October 2012 VA examination noted no evidence of hepatitis C with a history of cryptogenic cirrhosis diagnosed in 2006 per liver biopsy and transplant in June 2011. The examiner stated that cirrhosis is not due to or the result of Type 2 diabetes mellitus because the cirrhosis predates diabetes mellitus Type 2. Later, a December 2012 VA examination addendum further addressed multiple theories of entitlement regarding his liver disorder. These included entitlement to hepatitis C (Hep C) with secondary liver cirrhosis & hepatitis encephalopathy due to military service blood exposure, encephalopathy secondary to Hep C hepatopulmonary syndrome secondary to liver, varices secondary to a liver condition, liver damage, and liver transplant. The examiner reviewed records with a diagnosis of sarcoidosis, a 2006 diagnosis of cryptogenic cirrhosis, noting that STRs did not show anything related to this diagnosis. STRs showed duties involving nuclear systems and the claimed conditions were not presumptive for radiation exposure. Thus, the examiner was asked to provide an opinion per direct link per Combee. The examiner reviewed multiple records of treatment for his liver disorders. Following such review, the examiner noted that STRs are silent for any form of hepatitis. Chest X ray was negative at separation in February 1969 and STRs were silent for sarcoidosis or any early symptoms that could have been but were not diagnosed as sarcoidosis. Medical records within 2 years of active duty were silent for hepatitis or sarcoidosis The December 2012 VA examiner stated that no opinion could be reached regarding hepatitis C (Hep C), as the Veteran did not/did not have Hep C and there was no objective evidence of Hep C. The examiner opined that encephalopathy is due to cirrhosis, as a well-known cause of encephalopathy, but the Veteran did not have hep C as a cause of cirrhosis. Regarding hepatopulmonary syndrome secondary to liver, the examiner found it speculative to state that the Vet has this disorder of lung compromise due to liver failure. This was because his private transplant team said he has pulmonary fibrosis on oxygen due to sarcoidosis, not hepatis. Regarding varices secondary to liver condition, cirrhosis is a known cause. Liver damage and transplant were deemed due to sarcoidosis, again with no objective evidence of hepatitis C. The examiner reviewed Dr. D. H’s opinion speculating a possible link between Agent Orange and liver disease and noted that Dr. H provides no rationale for this opinion. The examiner opined that sarcoidosis is not related to service due to STRs and medical records from within 2 yrs of service are silent for sarcoidosis. As for duties working in nuclear weapons systems, medical literature review does not find a known relationship between his clinical disabilities, including hepatitis and sarcoidosis, and his duties working with nuclear weapons system. A June 2012 VA kidney examination noted the history of liver transplant due to cirrhosis of unknown etiology, chronic kidney disease (CKD) and sarcoidosis, but indicated that these were non-service connected. A May 2014 VA examination which noted diagnoses of cirrhosis, liver transplant and sarcoidosis also noted a history of Agent Orange exposure, with the possibility of Agent Orange related liver damage. The Veteran also had exposure to blood in Vietnam due to his activities in moving dead soldiers from choppers. He was a lifelong non-drinker and was first seen in 2005 for elevated LFT and splenomegaly, and was found to have cirrhosis. A history of liver transplant in 6/11 with renal failure, hemodialysis and prolonged ventilator dependence postoperatively was also noted. However, the examiner failed to provide an etiologic opinion regarding any claimed disorder and his exposure to Agent Orange and/or blood. The report of an October 2016 (completed November 2016) VA pulmonary disorders examination conducted to address the etiology of sarcoidosis included a detailed review of the records and examination of the Veteran. This yielded a diagnosis of pulmonary sarcoidosis, per his history, with date of diagnosis said to be in the 1970s. However, records of the initial diagnosis were unavailable. The Veteran gave a history of being hospitalized for severe illness. He underwent multiple tests to determine the etiology of the pulmonary condition and he recalled being told he had sarcoidosis. He reported that it had resolved and that he had occasional respiratory illnesses since then but he did not describe any recurrence of symptomatic sarcoidosis lung condition. He was told that CT studies show streaks that might have been infection. The examiner’s review of the records noted that STRs were negative for pulmonary issues, with a September 2005 primary care record noting the history of a questionable diagnosis of sarcoidosis in the 1970s treated with prednisone and a history of “spots on the liver” told to possibly be sarcoid involvement. The examiner noted that other subsequent records included evidence suggestive of sarcoidosis, such as a September 2016 record noting a diagnosis of pulmonary sarcoidosis with liver involvement in the past with the same history of initial diagnosis in the 1970s and CT findings of interstitial coarsening in the lungs corroborated with recent pulmonary function tests of May 2016 showing an intrinsic restrictive ventilatory defect. His history included in-service exposure to Agent Orange and post service exposure to asbestos. He alleged no exposure to TB. The September 2016 record assessed a past medical history of sarcoidosis s/p liver transplant (06/2011, currently on cyclosporine), in addition to hypertension, diabetes mellitus, and allergic rhinitis. He presented the day of the September 2016 visit as a follow-up concerning pulmonary sarcoidosis, which was asymptomatic. Following examination of the Veteran and review of the records, the examiner diagnosed pulmonary sarcoidosis per Veteran’s description/clinical history. This diagnosis was based upon clinical description, and mild intrinsic restrictive ventilatory disorder, consistent with this diagnosis. The VA examiner referred to the liver examination DBQ for further opinion and rationale. However, the examiner stated that the Veteran had signs and symptoms attributable to this diagnosis of sarcoidosis, including stable lung infiltrates, with imaging studies having shown evidence of fairly stable interstitial disease. Although medical treatment records were without histopathologic confirmation of sarcoidosis, his clinical history as a whole was consistent with an underlying sarcoidosis. The report of an October 2016 (completed November 2016) VA liver and kidney disorders examination to address the etiology of his claimed liver and kidney disorders included detailed review of the records and examination of the Veteran. This yielded a diagnosis of the following: 1. Post liver transplant for cirrhosis attributed to a possible combination of non-alcoholic steatohepatitis and hepatic sarcoidosis (based upon final report of histologic findings for the removed liver). He had normal liver function since transplant. 2. No history of a viral hepatitis condition (to include hepatitis C); the examiner referred to medical history/ records review for this finding. 3. History of hepatic encephalopathy and hepatopulmonary syndrome prior to Veteran’s successful liver transplantation, resolved after transplantation; no residuals. 4. Pulmonary sarcoidosis, per Veteran description/clinical history. The examiner referred to the respiratory DBQ for support of this diagnosis. 5. History of recurrent nephrolithiasis, at least as likely as not due to sarcoidosis. 6. Chronic kidney disease deemed at least as likely as not due to diagnosis #1 with lesser contribution of diagnosis #5, in Veteran who also has underlying diabetes mellitus, type II (DM II). Medical treatment records (MTR) supported post-transplant complications/medications as the major (greater than 50%) cause for Veteran’s current level CKD. The examiner referenced the kidney DBQ for further support of the kidney diagnoses. The examiner commented that the Veteran has a complex medical history. The examiner opined that the Veteran’s post liver transplant for cirrhosis attributed to a possible combination of non-alcoholic steatohepatitis and hepatic sarcoidosis is at least as likely as not result of or otherwise connected to sarcoidosis. The rationale was based upon medical literature review, clinical experience, medical record review, and evaluation of the veteran. His remote (1/2006) liver biopsy showed granulomata. Histopathology of the native liver (removed at 6/2011 transplant) showed signs c/w hepatic sarcoidosis. Signs of non-alcoholic steatohepatitis (NASH) were also noted. A precise percentage contribution is not given by the pathologist; however, Veteran was a known diabetic (SC DMII); NASH is known to be associated with DM II. The Veteran was noted to give a clinical history consistent with a diagnosis of pulmonary sarcoidosis in the 1970s, shortly after return from Vietnam. The examiner noted that although these records are not available, subsequent pulmonary studies are consistent with the history of pulmonary sarcoidosis. Initial illness and pulmonary imaging abnormalities were noted commonly subside with time. The Veteran reported that his doctors have been equivocal at times, with regards to the role of sarcoidosis in his conditions, due to the rarity of sarcoidosis as a cause for cirrhosis. Despite this rarity, review of the case as a whole was deemed to find sarcoidosis to be at least as likely as not to be the underlying condition for his lung, liver, and kidney conditions. The examiner also cited to excerpts from review of medical literature. The Veteran described an extensive history of kidney stones--initial surgery in early 1970s. Sarcoidosis is a known cause for alteration of calcium metabolism, with resultant kidney stones. The examiner noted that treatment records show that Veteran has had prior calcium elevations, and there is reference to his stones having been calcium based. In light of the described onset of significant clinical signs/symptoms consistent with a condition of sarcoidosis, in close proximity to Veteran’s active duty service, the examiner stated that it is at least as likely as not that the sarcoidosis condition onset during or proximate to active duty service. The examiner cited to medical literature and letters from the Veteran’s medical specialists were noted. The examiner did not locate evidence that sarcoidosis or other non-malignant conditions of the gastrointestinal/hepatobiliary, respiratory, or genitourinary tract (such as Veteran’s diagnoses listed above) were included among the conditions specifically reviewed by the Institute of Medicine (IOM). Medical literature was found to not support an etiologic relationship (with 50% probability) between Veteran’s diagnosed disorders (listed above) and exposure to herbicides such as Agent Orange, exposure to nuclear weapons material, or to exposure to blood products in service as a result of air gun injectors or as helping to care for wounded servicemen being unloaded by the Veteran from helicopters. However, this examiner found that it is at least as likely as not that the Veteran’s sarcoidosis condition onset was during or proximate to active duty service, with the reasons stated as above. The kidney DBQ portion of an October 2016 (completed November 2016) VA examination diagnosed the following kidney disorders: Chronic Kidney Disease--mixed etiology. His medical history was of kidney problems prior to liver problems with multiple stones (about 38) described and 2 surgeries in 1973 and 1980. He also described kidney failure while hospitalized in 2011 post-liver transplant, which required dialysis post-operatively. He also reported having passed a stone during a post-transplant stay. A May 2016 renal consult noted his history of CKD, with his 2011 liver transplant complicated by the need for kidney dialysis for 11 weeks and subsequent stable kidney function findings for several years afterwards with creatinine ranging between 1.6 mg/dl and 1.9 mg/dl for several years, but now with recent worsening of renal function with a baseline creatinine ranges between 1.8 mg/dl and 2.1 mg/dl.” The kidney symptoms noted during the October 2016 VA examination including signs and symptoms of renal dysfunction, but does not require regular dialysis, with recurring proteinuria, reduced eGFR. He had a past history of treatment for recurrent stone formation in kidney, ureter or bladder. He had a history of treatment for recurrent stone formation in the kidney (urolithiasis) with most recent procedure in 1980s per vet, no records available, with occasional attacks of colic. As to etiology, the examiner deferred to the opinion in the liver DBQ portion of the examination. Such found that CKD is at least as likely as not due to his diagnosis of post-liver transplant for cirrhosis attributed to a possible combination of non-alcoholic steatohepatitis and hepatic sarcoidosis, and to a lesser extent, to a history of recurrent nephrolithiasis that itself was deemed at least as likely as not due to sarcoidosis. More recently, records dated late 2016 through January 2020 continued to note the residuals of liver transplant as a result of sarcoidosis, most notably with progressive decline in kidney function to the extent that kidney transplantation was planned. Of note, in December 2016 the Veteran was described as having stage III early stage IV CKD thought to be mainly from calcineurin inhibitor toxicity although there could also be superimposed hypertensive renal disease or diabetic nephropathy. In February 2017 he had stage IV CKD, with the same likely causation as given in December 2016 and a mild decline in kidney function. Similar findings of stage IV CKD with relatively stable renal function were noted in May 2017. By May 2018 the Veteran was noted to be evaluated for a kidney transplant with a history of liver transplant for end stage liver disease (ESLD) secondary to Sarcoidosis(pulmonary) w/granulomatous liver disease, cholestatic cirrhosis. He also had CKD not on hemodialysis (HD). See 498 pg. CAPRI received 3/30/19 at pg. 4, 262, 421, 453. In June 2018, he was highly motivated to obtain a kidney transplant. The June 2018 records also noted his CKD stage IV was likely multifactorial, with contributions from diabetes, hypertension, and calcineurin inhibitor toxicity, as evidenced by kidney biopsy from May 2017. Per an August 2018 transplant introduction letter, he was now described as having Stage V Chronic Kidney Disease with biopsy proven hyaline arteriosclerosis deemed secondary to hypertension and calcineurin inhibitor toxicity from his liver transplant. He had a long history of kidney stones. He was not yet on dialysis and wished to have a kidney transplant for a better lifestyle and did not want to be tied down to dialysis; he has several potential donors. Records from September 2018 describe his kidney function as stage IV and worsening, with the Veteran remaining undecided about undergoing dialysis. Records from March 2019 followed up on plans for kidney transplant and to start dialysis due to his kidney dysfunction continuing to progress. The remainder of the records from 2019 through January 2020 primarily addressed the Veteran’s CKD, classified as either stage IV or stage V, with the Veteran continuing to seek a transplant, but now on dialysis. The CKD continued to be described as likely multifactorial in origin per an October 2019 record, with contributions from diabetes, hypertension, and calcineurin inhibitor toxicity, as evidenced by kidney biopsy from May 2017 showing a predominant finding of marked hyaline arteriosclerosis and having started dialysis in September 2019. The records also included a May 2019 pulmonary consult for history that included stage V CKD and presumed hepatic sarcoidosis, status post liver transplant on cyclosporine for immunosuppression with complaints of chest pain, increased shortness of breath and clear productive cough for 2 weeks. A history of sarcoidosis dating back to the 1970s was again given. Following examination and comprehensive review of the records, he was assessed with hypertension, hypothyroidism, CAD, gout, diabetes mellitus, CKD stage V, cirrhosis with presumed hepatic sarcoidosis s/p liver transplant 6/2011 on cyclosporine for immunosuppression who presented for persistent chest pain, increasing shortness of breath, and clear productive cough x 2 weeks. The etiology of chest pain was unclear, and the etiology of his progressive dyspnea on exertion was broad, and included fluid overload/heart failure, symptoms of swelling, weight gain, orthopnea, and chest X-ray showing new effusions that have improved since yesterday with diuresis. Sarcoid could not be ruled out at this time. Records from December 2019 and January 2020 disclosed that he was still on kidney dialysis, awaiting transplant. The report of a January 2020 VA kidney examination included review of the claims file and examination of the Veteran. Following this examination, the examiner diagnosed the Veteran with diabetic nephropathy with date of diagnosis May 10, 2017, nephrolithiasis with date of diagnosis 1970 and ureterolithiasis with date of diagnosis 1980. The examiner commented on the evidence, which included exposure to Agent Orange in Vietnam, kidney stones requiring surgery in 1970 and 1980s; new onset diabetes diagnosed in March 2008; kidney failure requiring 11 weeks dialysis following liver transplant surgery in 2011; CKD evaluated as multifactorial in June 2012 and a stage IV CKD diagnosis made in April 2017. Following evaluation, the examiner gave the following opinions regarding the etiologies of his claimed disabilities. 1. Diabetic Nephropathy. The claimed condition was opined to be at least as likely as not proximately due to or the result of the Veteran’s service-connected disability of diabetes. The examiner noted the history of Agent Orange exposure in service with resulting service connected Diabetes Mellitus II and findings from an April 2017 evaluation by Nephrology which assessed: “Stage IV chronic kidney disease mainly from calcineurin inhibitor toxicity, although there could also be superimposed hypertensive renal disease or diabetic nephropathy” and a May 2017 kidney biopsy which showed Hyaline arteriolosclerosis which is universally medically recognized as associated with aging, hypertension, diabetes mellitus and may be seen in response to certain drugs (calcineurin inhibitors). Therefore, the examiner considered the Diabetes Mellitus type II linked with the Diabetic Nephropathy, which was confirmed on the kidney biopsy, and the claimed condition is at least as likely as not (50 percent or greater probability) proximately due to or the result of the Veteran’s service-connected condition. 2. Renal Disease. The claimed condition was opined to be at least as likely as not proximately due to or the result of the Veteran’s service-connected disability of diabetes. The rationale was the same as that used in the opinion addressing diabetic nephropathy. 3. Kidney stones and ureterolithiasis. The claimed conditions were opined to be less likely than not proximately due to or the result of the Veteran’s service-connected disability of diabetes. Although his history of Agent Orange exposure with resulting service-connected diabetes mellitus was noted, the examiner noted that kidney stones pre-existed service and were less likely than not proximately due to or the result of his service-connected diabetes and not linked with the diabetes. 1. Entitlement to service connection for Hepatitis C is denied The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have a current diagnosis of Hepatitis C and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). As noted above, the preponderance of the evidence shows that the Veteran does not have a diagnosis of Hepatitis C as disclosed in the treatment records diagnosing other liver disorders of cirrhosis resulting in liver transplant, the etiology of which shall be addressed later. The VA examiners in October 2012, December 2012 and October 2016 all concluded that the Veteran does not have a diagnosis of hepatitis C, and adequate rationale was provided in support of these conclusions. The file lacks medical evidence that directly contradicts these findings. Rather, the record supports the finding that hepatitis C was not among his liver diagnoses. Thus, the preponderance of the evidence is against a grant of service connection for hepatitis C. This denial is limited to the specific diagnosis of hepatitis C. Other liver disabilities besides hepatitis are present, which shall be addressed in the following grants of service-connection. 2. Entitlement to service connection for cirrhosis of the liver is granted. The Veteran contends that service connection is warranted for cirrhosis of the liver. Following review of the record as set forth above, the Board finds that service connection for this liver disability is warranted. The evidence, when taken as a whole, supports a finding that cirrhosis is the result of sarcoidosis, which as likely as not began in service. Repeatedly, the medical evidence addressing the liver disability prior to and after transplantation, gave a diagnosis of cirrhosis, which the evidence indicated was likely as not caused by sarcoidosis. The August 2010 opinion from the VA hepatologist prior to his liver transplant opined that the Veteran’s cirrhosis was possibly related to sarcoidosis, and raised the possibility that Agent Orange exposure was a factor as well. Finally, the October 2016 VA examiner gave an opinion, discussed at length above, that determined the cirrhosis was as likely as not related to sarcoidosis. Regarding the etiology of the sarcoidosis, this is problematic because there were no medical records from the 1970s, the time at which the Veteran repeatedly gave a history of first being treated for pulmonary sarcoidosis. However, the October 2016 VA examiner gave an opinion that sarcoidosis as likely as not began in service, based in part on the lay history provided by the history of being treated for a pulmonary disorder that he was told was sarcoidosis. This opinion was supported by other evidence noted to be in the medical records, to include a medical history of kidney stones, for which a surgical history for these dating back to the 1970s. The examiner noted that treatment records showing prior calcium elevations, and there is reference to his stones having been calcium based. The examiner also cited to other medical evidence suggestive of long-term sarcoidosis, including from findings of other diagnostic studies such as CT scans. Additionally, the examiner cited to medical literature to support the conclusion that the onset of significant clinical signs/symptoms consistent with a condition of sarcoidosis, in close proximity to Veteran’s active duty service, made it at least as likely as not that the sarcoidosis condition onset during or proximate to active duty service. The Board lends the greatest weight to the findings and opinions of the October 2016 VA examiner in granting this claim. The October 2016 VA examiner’s opinion is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). The opinions from the October 2016 VA examiner that the Veteran’s cirrhosis is due to sarcoidosis, which as likely as not began in service, is not directly contradicted by other medical evidence, and is supported by medical evidence and literature. In sum, the Board finds the evidence to at least be in equipoise as to whether the Veteran’s current cirrhosis is proximately due to sarcoidosis, which as likely as not began in service. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for cirrhosis is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102.” In so finding, the Board acknowledges that service connection is not presently in effect for sarcoidosis. However, it is important to note that the instant decision does not award secondary service connection. Rather, this is an award of direct service connection for a disorder attributed by the weight of the competent evidence to an in-service cause. The claim is granted. 3. Entitlement to service connection for liver transplant is granted. Having found that service connection for cirrhosis is warranted, the Board further finds that service connection is warranted for residuals of a liver transplant. The evidence shows that need for the transplant was due to cirrhosis of the liver, for which service connection is now established. This was shown in the records addressing the June 2011 liver transplant. Further the June 2016 VA examination opinion diagnosed the Veteran with post liver transplant for cirrhosis. There is no medical evidence that directly contradicts the evidence showing that the transplant was due to cirrhosis. Accordingly, and based on the reasons given in the grant of service connection for cirrhosis, the Board finds that service connection for residuals of a liver transplant is warranted. 4. Entitlement to service connection for a kidney disorder associated with diabetes mellitus, type II is granted. The Veteran contends that service connection is warranted for a kidney disorder to include as secondary to service-connected diabetes mellitus as a result of Agent Orange exposure. Following review of the record as set forth above, the Board finds that service connection for a kidney disability is warranted. The evidence is in equipoise as to whether kidney disorder is related to his type II diabetes. Additionally, the evidence discussed at length in the factual background above also suggests that the Veteran’s kidney disorder is being caused or aggravated by immunosuppressive drugs used to treat his residuals of liver transplant. In addition to the records showing of chronic kidney disease (CKD) to be related to his immunosuppressive drugs taken in association with his liver transplant, the October 2016 VA examiner gave an opinion that CKD is at least as likely as not due to his diagnosis of post liver transplant for cirrhosis. Later, a more detailed examination of the kidneys obtained in January 2020 diagnosed diabetic nephropathy and renal disease, with opinions that these diseases are at least as likely as not proximately due to or the result of the Veteran’s service-connected disability of diabetes. The January 2020 VA examiner’s opinion is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). This opinion is supported by other medical evidence of record suggesting that diabetes played a factor in the development of his kidney disease. Additionally, even if other evidence, including the opinion from the October 2016 VA examiner, suggests that his kidney disease is due to immunosuppressive drugs taken for his liver transplant residuals, this too would warrant service-connection on a secondary basis. In sum, the Board finds the evidence to at least be in equipoise as to whether the Veteran’s kidney disease is secondary to service-connected disability to include diabetes mellitus. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for kidney disease is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102, 3.310. 5. Entitlement to service connection for right knee disorder is denied. The Veteran contends that service connection is warranted for a right knee disorder. He has alleged both in written statements such as his February 2013 NOD and his and his March 2016 hearing testimony that he injured the right knee while jumping out a truck to avoid a collision with a tank. In his hearing testimony he described receiving brief treatment of the knee after the accident, with the knee wrapped and stitched but indicated the medical staff was shorthanded so he actually helped them unload wounded from choppers. He described post service symptoms including the knee sometimes popping on turning or stepping “wrong” and swelling up especially in cold weather. He indicated that he first noticed these symptoms three years after service. He indicated that there were no X-rays taken and the doctor he saw retired in the 1980s. The current symptoms were of occasional swelling and sharp pain. Transcript pg. 18-23. Service treatment records (STRs) show no evidence of any knee issues or complaints, including on pre-induction in March 1966 and separation in February 1969. He is noted to have had an abrasion in an unknown location treated with bacitracin in August 1967 and dressing changes and stitch removal of an unknown area in January and February 1969. See 34 pg. STRs at pg. 3, 7, 11, 15, 19, 34. Post-service treatment records show very few findings regarding the right knee, and mostly focus on his other major medical issues. Records addressing his evaluations for possible liver transplant in March 2008 and August 2010 are noted to show a history of laceration of the right knee in the military but these disclosed no residual issues of the knee. Among the records referencing the right knee is an April 2012 report documenting complaints of pain in the right knee and shoulder. Records from February 2016 and August 2016 disclosed complaints of right foot pain described as cramping, starting in the great toe radiating up to the knee. Other records showed full range of motion of the knees in June 2016 and March 2017. In September 2019 the Veteran was seen for chronic kidney disease with 3+ edema of the knee noted. None of these post-service records showing knee findings contained an opinion regarding the cause of the knee problems. An August 17, 2010 private opinion from a chiropractor, P. J. Y., D.C. noted the history of right knee injury in a truck from which he jumped from to avoid collision, injuring his right knee in a twisting injury. Since the injury he has reported having swelling and pain in the right knee. He also injured his knee moving bodies in Vietnam. He currently had pain, swelling, clicking and popping in the right knee. Examination disclosed a full range of motion but with crepitus and grinding of the joint. He was diagnosed with post traumatic residuals degenerative joint disease (DJD) and osteoarthritis (OA) of the right knee. The chiropractor gave an opinion that this is more likely than not that this was causally related to injuries sustained, as discussed. It was also recommended that he consult with a Board-Certified orthopedist to address the possibility of joint replacement. An October 2016 (completed November 2016) VA examination of the knee diagnosed enthesopathic changes along right patella, with the date of diagnosis in 2016. A history of in-service injury from jumping out of a vehicle was noted. He described the knee as requiring stitches and being wrapped up, but no X-rays were taken. He was separated from service shortly after the incident. Since the injury the knee would pop when he turned left or right. Then the knee would swell and become stiff for a couple days after that. Occasionally, when duck hunting and when stepping up with the right leg, he would have to lift the leg up due to weakness. He has not been treated for the right knee condition. He indicated that his post-service job as a dealership manager where he worked for 37 years required standing, walking, and sitting. Prolonged walking occasionally caused knee pain. The VA examiner reviewed X-rays from July 2009, November 2010 and October 2016, which were noted to be unremarkable for any evidence of fracture or other significant findings. The October 2016 VA examiner gave an opinion that the enthesopathic changes along the patella of the right knee are less likely as not incurred in military service, to include when he jumped from a moving vehicle to avoid an oncoming tank. In the discussion and rationale, the examiner cited to review of records and current medical literature to support the opinion. The October 2016 examiner’s review of records noted that the STRs showed normal examinations of the knee and no complaints of trick/locked knee on examinations/reports of medical history on pre-induction in November 1966 and separation in February 1969. The examiner did note that a July 17, 1967 record showed treatment for abrasions with bacitracin, but noted the location was not given and there were no records of knee problems in the STRs. It was noted that the Veteran did not receive treatment for decades after service, with there being no VA records showing right knee issues prior to September 2003 and then not again until May 2016. The October 2016 VA examiner also reviewed the favorable August 2010 opinion from P. J. Y., D.C. who diagnosed post traumatic residual degenerative joint disease and osteoarthritis of the right knee and found that it is more likely than not that the aforementioned is directly and causally related to injuries sustained in service when he jumped from a truck to avoid a collision. The VA examiner found that the August 2010 diagnosis and statements made by P.J.Y., D.C. to be inconsistent and seemingly inaccurate. It was pointed out that the diagnosis of traumatic DJD/osteoarthritis (OA) of the right knee was not confirmed by the X-ray report for this November 2016 VA examination. Further the findings from P.J.Y., D.C.’s examination of full range of motion with crepitus and grinding were deemed not consistent with his DJD/OA diagnosis. Medical literature was noted to suggest that a severely arthritic knee joint would not have full range of motion and further ‘crepitus and grinding’ can also be found in a normal, nonarthritic knee and is not indicative of degeneration of the joint. Further although the enthesopathic changes along the patella of the right knee. These can be considered degenerative in nature however these changes are not considered a severe degeneration of the knee joint, and can either be from an inflammatory disorder such as psoriatic arthritis versus a degenerative one. The examiner further stated that pain and swelling can be associated with an inflammatory process at the site known as “enthesopathy.” Again, the October 2016 VA examiner pointed to the literature showing that these changes are not usually associated with acute traumatic injury such as that noted by the Veteran after he jumped from the truck in active duty. The examiner further stated that when considering the absence of objective evidence for a chronic right knee ailment for over 40 years after separation from active duty and the objective evidence provided by current medical literature, a nexus is not supported for the claimed right knee condition, defined as enthesopathic changes along right patella. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a current diagnosis of enthesopathic changes along right patella, and evidence shows that an in-service injury to the right knee occurred, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis of enthesopathic changes along right patella began during service or is otherwise related to an in-service injury, event, or disease. The record contains conflicting medical opinions regarding whether the Veteran’s right knee enthesopathic changes is at least as likely as not related to an in-service injury from the incident in Vietnam jumping off the truck. Although the August 2010 private medical opinion from chiropractor, P. J. Y., D.C. gave an opinion that the Veteran’s right knee disorder, which was diagnosed by this provider as DJD/OA, was related to the in-service injury, this opinion was not supported by rationale, or by the evidence which did not disclose that DJD/OA was an appropriate diagnosis. This opinion is outweighed by the opinion from the October 2016 VA examiner who opined that the knee disability was not shown by X-ray evidence to even be OA/DJD much less of such severity for the Veteran to consider a knee replacement as suggested by P.J.Y., D.C. The rationale as discussed above pointed out that the Veteran’s enthesopathic changes were less likely than not the result of the in-service trauma to the knee, pointing to medical literature to support this opinion, as well as the medical evidence available. This opinion is more probative than the private chiropractor’s opinion for the reasons discussed above. The VA examiner’s opinion is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). While the Veteran is competent to report having experienced symptoms of his right knee symptoms since service, he is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of residuals of an inservice injury to his right knee. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the October 2016 VA examiner’s opinion. As there is also no evidence of arthritis manifested within the first year of his discharge from service in 1969, the presumptions under 38 C.F.R. § 3.307, 3.309 are not applicable. Thus, the preponderance of the evidence is against this claim. REASONS FOR REMAND 1. Entitlement to service connection for hepatopulmonary syndrome is remanded. Now that service connection for a liver disability has been granted, the question of whether service connection for hepatopulmonary syndrome is warranted is dependent on whether a current hepatopulmonary syndrome exists. The Board notes that the requirement that there be a current disability is satisfied when the disability is shown at the time of the claim or during the pendency of the claim, even though the disability subsequently resolves. McClain v. Nicholson, 21 Vet. App. 319 (2007). The October 2016 VA examiner in the liver disorders examination diagnosed a history of hepatopulmonary syndrome prior to Veteran’s successful liver transplantation in June 2011, resolved after transplantation, with no residuals. Thus, although there are presently no residuals, further clarification is needed to address whether hepatopulmonary syndrome was present at any time during the pendency of this claim, beginning on July 12, 2011, and if so, the length of time it was present prior to the total resolution of such disability following the June 2011 transplant. 2. Entitlement to service connection for hepatic encephalopathy is remanded. Now that service connection for a liver disability has been granted, the question of whether service connection for hepatic encephalopathy is warranted is dependent on whether a current hepatic encephalopathy exists. The Board notes that the requirement that there be a current disability is satisfied when the disability is shown at the time of the claim or during the pendency of the claim, even though the disability subsequently resolves. McClain, supra. The October 2016 VA examiner in the liver disorders examination diagnosed a history of hepatic encephalopathy prior to Veteran’s successful liver transplantation in June 2011, resolved after transplantation, with no residuals. Thus, although there are presently no residuals, further clarification is needed to address whether hepatic encephalopathy was present at any time during the pendency of this claim, beginning on November 3, 2010, and if so, the length of time it was present prior to the total resolution of such disability following the June 2011 transplant. The matters are REMANDED for the following action: Obtain an addendum medical opinion from the October 2016 VA liver disorders examiner (or, if unavailable, from a medical professional with appropriate expertise) to determine: (a) whether there was a current disability of hepatopulmonary syndrome due to his service-connected cirrhosis resulting in liver transplant that was present during the pendency of this claim, beginning on July 12, 2011, and if so, the length of time it was present prior to the total resolution of such disability following the June 2011 transplant. (Continued on the next page)   (b) Whether there was a current disability of hepatic encephalopathy due to his service-connected cirrhosis resulting in liver transplant that was present at any time during the pendency of this claim, beginning on November 3, 2010, and if so, the length of time it was present prior to the total resolution of such disability following the June 2011 transplant. Eric S. Leboff Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Eckart The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.