Citation Nr: 21025476 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 15-03 020 DATE: April 28, 2021 ORDER Entitlement to service connection for kidney disorders, to include as due to herbicide exposure and/or as secondary to service-connected hypertension, is denied. FINDING OF FACT The Veteran has been diagnosed with nephrolithiasis (kidney stones) and a benign renal cyst, but the preponderance of the evidence is against a finding that these disorders were incurred in or otherwise related to active service, to include herbicide exposure; nor does the weight of the evidence demonstrate that the Veteran’s kidney disorders were caused or aggravated by any service-connected disease or injury, to include hypertension. CONCLUSION OF LAW The criteria for service connection for kidney disorders, to include as secondary to service-connected disease or injury, have not been met. 38 U.S.C. §§ 1110, 1116, 1131 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty for training in the United States Army Reserves from September 1965 to January 1966 and active service in the United States Army from May 1968 to December 1987. He is noted to have served in combat; his awards include the Bronze Star Medal, the Meritorious Service Medal, the Army Commendation Medal, and the Vietnam Gallantry Cross. In February 2018, the Veteran testified before the undersigned at a Board of Veterans’ Appeals (Board) videoconference hearing. A transcript of the hearing is of record. In June 2018 and again in October 2020, the Board remanded the appeal for further evidentiary development. (In October 2020, the Board also remanded the issue of entitlement to service connection for a lumbar spine disability. That claim was subsequently granted by the Agency of Original Jurisdiction (AOJ) in a February 2021 rating decision and is no longer on appeal.) Entitlement to service connection for kidney disorders, to include as secondary to service-connected disease or injury The Veteran contends that his current kidney disorders, including kidney stones and a benign renal cyst, were incurred in active service. In addition, an August 2019 VA examination report raised the possibility that elevated protein levels in the Veteran’s urine may have been attributable to his service-connected hypertension. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a link between the claimed in-service disease or injury and the present disability. Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). In addition, service connection may be granted on a secondary basis for disability which is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310. The Veteran’s service treatment records do not reflect any kidney-related diagnoses. However, these records do show genitourinary symptoms in service: in March 1976, the Veteran was seen for urinary problems; in August 1981, he reported dysuria; and at separation, in October 1987, he reported a history of frequent or painful urination. Post-service VA and private medical records reflect that the Veteran has been treated for kidney stones and increased urinary frequency during the appeal period. In addition, a renal cyst was identified in 2013 following an abdominal CT scan; the cyst was noted to be benign. (The Veteran testified at his Board hearing that he had been diagnosed with benign neoplasms of the kidney.) Accordingly, the Board finds that the “current disability” element of the Veteran’s service connection claim has been met. See 38 C.F.R. § 3.303(a). The crucial question is whether his current disorder was incurred in or otherwise related to service or to a service-connected disease or injury. To that end, the Veteran has asserted that his kidney problems may be related to various in-service genitourinary symptoms, including those noted in his service treatment records. He also indicated on his initial claim form and at his Board hearing that his kidney problems (specifically the benign neoplasm, or cyst, identified in 2013) may be attributable to exposure to herbicide agents in Vietnam. The Veteran was afforded a VA examination for his kidney conditions in August 2019. The report notes diagnoses of stable superior pole left renal cyst (diagnosed in June 2013) and kidney stone (diagnosed in 2000). The examiner acknowledged the Veteran’s reports of in-service symptoms which the Veteran asserted had persisted to the present, including “pressure in lower stomach and bladder pain,” as well as current symptoms of difficulty urinating. Nonetheless, the examiner opined that it was less likely than not that the Veteran’s current kidney disorders were related to service. The examiner reasoned that the renal cyst was an incidental finding during an abdomen CT scar; that the cyst was stable and benign; and that the Veteran’s kidney stones were not a chronic condition. The examiner further noted that labs performed in July 2019 showed a presence of proteinuria “which can be caused by uncontrolled hypertension.” In October 2020, the Board found the above VA examiner’s opinion to be inadequate, as it did not address the Veteran’s in-service genitourinary symptoms nor explain whether his service-connected hypertension caused or aggravated his kidney disorders. In January 2021, another VA examination was performed; the examiner again provided negative nexus opinions. First addressing direct service connection, the examiner listed the service treatment records identified by the Board in its remand instructions and noted that these records reflected acute conditions, namely urinary tract infections (UTIs). The examiner observed that while UTIs can be chronic, chronic infections are generally managed with chronic antibiotic therapy, and there was no record of the Veteran being prescribed such therapy (or reporting being treated in this way). The examiner noted the incidental finding of a stable kidney cyst in 2013; however, this was unlikely to cause his symptoms. Moreover, the Veteran’s increased urinary frequency was not due to kidney problems but rather most consistent with his diagnosis of benign prostatic hyperplasia (BPH), which in turn was separate from the in-service UTIs. As for secondary service connection, the examiner opined that while the Veteran did have a prior note indicating persistent proteinuria, his current laboratory findings were normal and “there were no findings consistent with decreased kidney function.” The examiner continued, “While the kidneys [do] play an important role in blood pressure control, there is not evidence on day of exam of kidney dysfunction.” Moreover, there was no evidence that the Veteran’s kidney stones were worsened by his hypertension, and increased urinary frequency was, again, related to the Veteran’s BPH and was separate from his hypertension. As a result, the examiner concluded that the Veteran’s kidney disorders were less likely as not caused or aggravated by the Veteran’s service-connected hypertension. The Veteran has not questioned the VA examiner’s January 2021 findings. In April 2021, his representative submitted an Informal Hearing Presentation with no substantive arguments or evidence. In this case, the positive evidence of record consists primarily of the Veteran’s reports of genitourinary symptoms beginning in service and persisting until the present day, as well as a VA examiner’s indication that laboratory findings indicating proteinuria could be causally related to the Veteran’s service-connected hypertension. As to the Veteran’s lay statements, the Board accepts his descriptions of his in-service symptoms as competent and credible evidence, particularly given the corroborating service treatment records discussed above; there is no reason to doubt that he experienced urinary symptoms and abdominal pain in service. See Layno v. Brown, 6 Vet. App. 465, 469-70 (1994); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, the Veteran is not competent to offer opinions on complex medical questions requiring specialized knowledge, such as the physiological causes of his current kidney disorders. Moreover, as noted above, none of his private care providers or VA examiners have specifically linked his kidney disorders to his in-service symptoms. The Veteran has never reported being told by any medical professional that his kidney disorders were incurred in service or are secondary to any service-connected disease or injury. See id. at 1377. Conversely, a VA medical professional has reviewed the record and opined that the Veteran’s current kidney disorders, namely a benign renal cyst and history of kidney stones, are less likely than not causally related to any of the documented in-service symptoms or to the Veteran’s service-connected hypertension. The examiner thoroughly addressed the Veteran’s medical history, the most likely causes of his current symptoms, and his lay contentions regarding the onset of his kidney disorders. In light of the detailed, fact-specific, and logical nature of the January 2021 VA medical opinion discussed above, the Board finds that it is entitled to significant probative weight. See, e.g., Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). For the reasons discussed above, the Board concludes that the preponderance of the evidence is against a finding that the Veteran’s current kidney disorders are related to service. Likewise, the weight of the evidence is against a finding that his kidney disorders were caused or aggravated by his service-connected hypertension. In so finding, the Board notes that the January 2021 VA examiner’s opinion substantially complied with the matters raised in the Board’s October 2020 remand, to include discussing the specifics of the Veteran’s medical history (including his reports of in-service genitourinary symptoms) and whether his kidney disorders are secondary to his hypertension. The examiner also addressed the Veteran’s complaints of increased urinary frequency, concluding this symptom was the result of an unrelated condition. The examiner thoroughly addressed each pertinent contention, and determined that the Veteran’s kidney disorders, for a variety of reasons, could not be said to have been incurred in service or caused or aggravated by his service-connected hypertension. There is no competent evidence of record calling these findings into question. The Board finds that the January 2021 VA examiner’s opinion outweighs the positive evidence of record. Accordingly, the claim for service connection for kidney disorders must be denied. As a final matter, the Board acknowledges that the Veteran served in Vietnam and is thus presumed to have been exposed to herbicide agents. The Veteran, moreover, raised the possibility that his benign neoplasm, or renal cyst, was related to herbicide exposure. Although none of the Veteran’s kidney disorders are listed under 38 C.F.R. § 3.309(e) as being among the conditions known to be associated with herbicide exposure, the Veteran may still be service connected upon proof of direct causation, or on any other recognized basis. See Stefl v. Nicholson, 21 Vet. App. 120 (2007); see also Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). As discussed in detail above, VA afforded the Veteran an examination in January 2021 to evaluate whether his specific in-service symptoms were indicative of kidney problems or were in any way related to his current kidney disorders. That examination report does not include an opinion regarding a possible nexus to herbicide exposure. Rather, the report identified the Veteran’s renal cyst as an incidental finding with no known etiology; his history of kidney stones as being unrelated to any in-service symptoms; and his increased urinary frequency as being related to a non-service-connected condition. The Board notes that a medical examination or medical opinion is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but: (1) contains competent evidence of a current diagnosed disability or persistent or recurrent symptoms of a disability; (2) establishes that an event, injury, or disease occurred in service or certain diseases manifested during an applicable presumptive period for which the claimant qualifies; and (3) indicates that the disability or symptoms may be associated with the established event, injury or disease in service or with another service-connected disability. McClendon v. Nicholson, 20 Vet. App. 79 (2006). The third prong, which requires that the evidence of record “indicate” that the claimed disability or symptoms “may be” associated with the established event, is a low threshold. Id. (Continued on the next page)   In this case, the Board finds that the Veteran has not submitted any competent evidence linking his current kidney disorders, including the benign neoplasm identified in 2013, to herbicide exposure. The Board regrets that the Veteran was placed in harm’s way in Vietnam, to include being exposed to herbicide agents. However, his lay statements alone are not sufficient to establish a causal link between such exposure and his current kidney disorders. Moreover, the Board has ensured that a VA medical professional analyzed the Veteran’s specific in-service symptoms in conjunction with his claims; the resulting opinion reflects that examiner’s finding that the Veteran’s current kidney disorders are not related to his service. As such, the Board finds that the lack of a medical opinion on the question of nexus to herbicide exposure does not prejudice the Veteran in this case. The Board is grateful for the Veteran’s honorable service, and this decision in no way is meant to detract from that service. The Board is constrained by law, however, and unfortunately there is no basis on which to award the benefits sought. A. S. CARACCIOLO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Minot, 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.