Citation Nr: 21042184 Decision Date: 07/12/21 Archive Date: 07/12/21 DOCKET NO. 16-55 644 DATE: July 12, 2021 ORDER Service connection for left radical nephrectomy is denied. FINDING OF FACT The Veteran's left radical nephrectomy is not secondary to Gabapentin or Tramadol prescribed for service-connected disabilities, and is not otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for left radical nephrectomy due to service or Gabapentin or Tramadol prescribed for service-connected disabilities are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served honorably on active duty in the United States Marine Corps from February 1986 to February 1990. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2016 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran attended a videoconference hearing before the undersigned in June 2019. In June 2019 and November 2020, the Board remanded this matter for further development. Service connection for left radical nephrectomy Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. To establish service connection for a disability, a Veteran must show: (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 or aggravated during service. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection may also be granted for a disability that is proximately due to or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310. The Veteran contends that his left radical nephrectomy was due renal cell carcinoma (RCC) caused by prescribed medication for his service-connected disabilities, specifically, Tramadol and Gabapentin. For the following reasons, the Board disagrees and finds that service-connection is not warranted. In December 2015, the Veteran underwent a left radical nephrectomy. VA treatment records indicate that he was prescribed Tramadol and Gabapentin for his service-connected disabilities. As such, the Board finds that the Veteran meets the first two elements for secondary service-connection. Turning to the element of medical nexus, the evidence consists of VA examinations and the Veteran's statements. The Veteran's first examination was in March 2016. Though, the examiner found it was less likely than not that the Veteran's left radical nephrectomy was due to Gabapentin and Tramadol, the examiner stated they could not provide a rationale without resorting to speculation. Accordingly, the Board affords this opinion little probative weight. After the first remand, an opinion was obtained in November 2019. The VA examiner provided multiple opinions that it was less likely than not that the Veteran's left radical nephrectomy was due to his service-connected disabilities. The examiner discussed evidence about analgesics as a risk-factor for RCC, but did not discuss specifically the effects of Gabapentin or Tramadol on RCC. The opinions are inadequate, and the Board affords them little probative weight. After the most recent remand, a December 2020 addendum opinion was obtained. The VA physician found that it was less likely than not that the Veteran's RCC, which resulted in a left nephrectomy was caused by Gabapentin or Tramadol or aggravated beyond its natural progression by Gabapentin or Tramadol. The physician provided an extensive rationale in support of their opinion. The physician first explained that the Veteran misinterpreted the progression and cause of his RCC. The physician found that the Veteran did not exhibit significant deterioration in kidney function until September 2015 when obstructing right kidney stone and left kidney mass identifiable as contributing factors. The Veteran contended that his kidney function was not properly monitored, leading to his RCC, but the physician explained that one-time yearly care is appropriate unless kidney function is considered impaired and kidney function is not considered impaired unless estimated glomerular filtration rate (eGFR) is less than 60 for at least three months. The physician addressed the Veteran's contention that since he showed an eGFR less than 60 in May 2014 he should have been more closely monitored. The physician explained that first, the lab information tables the Veteran was referring to stated that chronic kidney disease (CKD) is defined as eGFR less than 60 for three months or more. Second, though the Veteran did exhibit an eGFR less than 60 in May 2014, this was noted to be due to dehydration and after the Veteran was advised to rehydrate, labs taken 10 days later showed eGFR above 60. The physician found this to support their finding that the May 2014 lab results with eGFR less than 60 were not indicative of CKD and instead was acute kidney dysfunction due to dehydration. The physician then continued to explain the relationship between RCC and pain medication. The physician explained that the relationship has been studied with mixed results and no clear causality and that studies have not looked at Gabapentin and/or Tramadol. They noted that while Gabapentin and Tramadol can have effects on renal function, there is no quality, reproducible evidence to support a relationship specifically between Gabapentin and/or Tramadol and RCC. The physician addressed the study submitted by the Veteran noting that it is a review study that identified an increased incidence of RCC in those taking Gabapentin, but it did not establish a causality. Furthermore, the physician stated that no study has been able to reproduce the results of the review study to support any relationship between Gabapentin and RCC. The physician also addressed an article regarding Gabapentin and toxicity in renal failure that discussed a single case in which an elderly patient already with compromised renal function and taking other medications in addition to Gabapentin that compromise renal function, specifically Diclofenac and Irbesartan, developed acute renal failure. The case study addressed the effects of Gabapentin on rapidly deteriorating kidney function over chronically compromised kidney function, not associated with RCC. The physician explained this case study is not relevant to the Veteran's kidney function history which was normal prior to RCC diagnosis. The physician noted that the Veteran discontinued Gabapentin in June 2015, three months prior to his RCC diagnosis and he had taken Gabapentin for more than five years without any acute or rapid deterioration of kidney function sustained. The physician found that there were no articles in the record in support of Tramadol as related to RCC and medical literature in general fails to establish any relationship between Tramadol and RCC. The physician then addressed the drug information summaries submitted by the Veteran. They noted that the summaries included side effects of Gabapentin and that no cancer was included as a side effect related to Gabapentin. The physician also addressed "The Poison Review" printout explaining that it is not a peer reviewed journal or any other clinically respected source and is not considered a reliable source of information regarding any medication. The physician noted that Gabapentin and Tramadol can have adverse effects on kidney function, though not invariably so and that Gabapentin dosage adjustment for kidney function is not recommended until eGFR is less than 60 and Tramadol dosage adjustment for kidney function is not necessary until eGFR less than 30. The physician explained that the Veteran's eGFR was never persistently below 60 until September 2015, months after Gabapentin was already discontinued. The physician then addressed the Veteran's contention that his urology doctor, Dr. N., suggested that either Gabapentin or Tramadol caused his RCC. The physician found that Dr. N.'s suggestion was either in error or they did not fully understand the Veteran's question over whether Gabapentin or Tramadol caused RCC as there is a complete lack of evidence in medical literature supporting a relationship between the medications and RCC. Accordingly, the physician found that it was less likely than not that the Veteran's RCC was caused by Gabapentin and/or Tramadol. Turning to aggravation, the physician opined that it was less likely than not that the Veteran's RCC was aggravated beyond its natural progression by Gabapentin and/or Tramadol. The physician referred to their rationale explaining that Gabapentin and/or Tramadol do not have an established relationship to RCC. As such, the medications do not affect the development of RCC and do not affect the progression of same. Accordingly, the physician found that it was less likely than not that the Veteran's RCC was aggravated beyond its natural progression by Gabapentin and/or Tramadol. The VA physician is competent to provide these opinions, the Board finds them to be credible, and affords the opinions great probative weight. The Board acknowledges the Veteran's contention that Gabapentin and/or Tramadol caused him to develop RCC which led to his left radical nephrectomy, including his statement that Dr. N. told him that Gabapentin and/or Tramadol caused him to develop the tumor that led to the diagnosis of RCC. Though the Veteran is competent to report a diagnosis from a physician, no rationale for Dr. N.'s opinion has been provided and the Veteran has acknowledged that when he asked Dr. N. to provide their opinion in writing, Dr. N. denied that they had ever told the Veteran that his tumor was due to Gabapentin and/or Tramadol. As such, the Board finds the positive opinion from Dr. N. that the Veteran reports to not be credible and affords it little probative weight. The Veteran also contends that his urinalysis lab reports indicate that he had chronic kidney disease citing to the May 2014 findings when his eGFR was less than 60. The Veteran has not shown that he has the requisite medical knowledge to interpret medical results and provide a medical nexus opinion for his current disability. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Furthermore, the December 2020 physician explained that the results the Veteran cites in support of his claim were due to dehydration and that ten days later the Veteran had normal eGFR. Accordingly, the Board affords the Veteran's lay statement less probative weight and affords more probative weight to the December 2020 addendum opinion. Accordingly, the preponderance of the evidence is against a finding that the Veteran's left radical nephrectomy was caused or aggravated beyond its natural progression by Gabapentin and/or Tramadol prescribed for his service-connected disabilities. Because the preponderance of the evidence weighs against this claim, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. As such, service connection for left radical nephrectomy is denied. JOHN Z. JONES Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Michael Chandeck, 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.