Citation Nr: 21066529 Decision Date: 11/01/21 Archive Date: 11/01/21 DOCKET NO. 17-59 189 DATE: November 1, 2021 REMANDED Entitlement to service connection for a genitourinary condition, renal disease (kidney disorder) is remanded. REASONS FOR REMAND The Veteran served on active duty from August 2001 to February 2007. This matter comes before the Board of Veterans' Appeals from a June 2017 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In November 2018, the Veteran testified before the undersigned Veterans Law Judge at a Travel Board hearing; a transcript is associated with the claims file. An August 2019 Board decision remanded this matter for further development and a VA examination. 1. Entitlement to service connection for a kidney disorder is remanded. The Veteran submitted evidence asserting that his kidney disorder manifested throughout the years with skin symptoms, diagnosed by his private physician as hyperphosphatemia. See November 2018 Board hearing transcript. The Veteran was provided VA examinations in November 2019 and May 2020. In providing a negative nexus opinion, the November 2019 examiner reasoned that Service Treatment Records (STR) are silent for any diagnosis or treatment of kidney disease, and for any reported symptoms or other indications to suggest any kind of kidney disease. The examiner stated that the Veteran had normal kidney function until 2011, well any skin complaints in 2004. See November 2019 VA Renal Conditions Disability Benefits Questionnaire (DBQ), Medical Opinion. The examiner added that the Veteran does not have cardiovascular kidney disease, but long-standing hypertension which preceded kidney failure. Regarding skin symptoms, the examiner opined it is less likely than not that his skin conditions caused his kidney disorder, as no skin condition causes kidney disease. The examiner did not address whether the Veteran's skin related problems were a sign or symptom of a kidney disorder, but instead opined whether skin disorders cause kidney disorders, which mischaracterizes the Veteran's argument. Further, the examiner did not thoroughly address inservice complaints of skin rashes, joint pain, headaches, swollen or stiff joints, fainting, light-headedness as indicators of renal malfunction. Therefore, the examination is inadequate for adjudication. In May 2020, a VA examiner opined that the Veteran's kidney disorder was less likely than not related to service. See May 2020 Medical Opinion, DBQ, pg.2. In providing a negative nexus opinion, the examiner reasoned that there were no symptoms, diagnosis, or treatment in service. The 2020 examiner noted that the Veteran was diagnosed in 2009, which the examiner stated was well after service. The examiner did not opine whether the Veteran has cardiovascular renal disease. However, the Board notes that the diagnosis is within two years of service. The examiner also stated that there were no complaints that would suggest a kidney disorder of any kind. See id. Further, the examiner did not provide a rationale as to why the symptoms described are not associated with any kind of kidney disorder. See id. at pg.3. The Board notes that a cursory review of symptoms associated with the early onset kidney disorder include headaches, tiredness, lethargy, insomnia, dry itchy skin, and muscle cramps. See Merck Manual Consumer Version, Chronic Kidney Disease, found at https://www.merckmanuals.com/home/quick-facts-kidney-and-urinary-tract-disorders/kidney-failure/chronic-kidney-disease. The Board notes that the Veteran listed similar symptoms at separation. The Board finds the rationale conclusory, and thus inadequate. Therefore, remand is necessary. Further, the Veteran submitted learned treatises regarding early symptomology of kidney failure, the affect of kidney failure on the skin, as well as blood tests that diagnose kidney failure. See September 2021 Appeal Brief. Neither examiner has commented on the learned treatises, and thus, a remand is required to obtain an opinion on them. The Veteran also argued that the VA examination is inadequate because the examiner relied on urine analysis (UA), rather than on a glomerular filtration rate (GFR). Finally, neither examiner reviewed photos submitted by the Veteran of his skin conditions. See Photos, received October and December 2018. For all these reasons, remand is required to obtain a new VA examination. The matters are REMANDED for the following action: 1. Schedule the Veteran for a new examination by an appropriate clinician to determine the nature and etiology of his kidney disorder, currently diagnosed as end-stage kidney disease and nephrosclerosis. It is the examiner's whether to reexamine the Veteran. If an in-person examination is needed, the RO should be aware that the Veteran undergoes hemodialysis on Mondays, Wednesdays, and Fridays; a copy of the notice of the scheduled examination, along with consequences for failure to report, should be included in the electronic claims file. (a) The examiner must opine whether, for each kidney disorder diagnosed, is it at least as likely as not related to an in-service injury, event, or disease. (b) The examiner must explain whether it is at least as likely as not that his skin related symptoms since service, or the other symptoms reported in a November 2004 post-deployment questionnaire (including headaches, swollen/stiff/ painful joints, chest pain/pressure, dizziness, fainting/light headedness, still feeling tired after sleeping) are manifestations of a kidney disorder. The examiner must address whether his diagnosed hyperphosphatemia that causes itching, rashes, and skin ulcers are manifestations of a kidney disorder. (c) For any diagnosed cardiovascular-renal disease, the examiner should opine whether it is at least as likely as not the disorder (1) began during active service, (2) manifested within presumptive period after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. The examiner must address: 1) a February 2009 VA treatment record (noting protein of "2000 or more +++" and blood "large +++" in urine); 2) a March 2009 VA treatment record referral for abnormal vital signs, noting abnormal blood pressures; 3) the Veteran's of his skin conditions; and 4) GFR results. H.M. WALKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. McKenzie, Associate Counsel 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.