Citation Nr: 22017495 Decision Date: 03/25/22 Archive Date: 03/25/22 DOCKET NO. 17-17 768 DATE: March 25, 2022 ORDER 1. Entitlement to service connection for hypertension, to include as due to exposure to contaminated water at Camp Lejeune, is denied. 2. Entitlement to service connection for chronic kidney disease (CKD), to include as due to exposure to contaminated water at Camp Lejeune, is denied. FINDINGS OF FACT 1. The Veteran served at Camp Lejeune, North Carolina, during the period of potential exposure to contaminated drinking water and is presumed to have been exposed to contaminated water during service. 2. The Veteran's hypertension did not have an onset during active duty service, was not manifested within one year following service discharge, and is not otherwise related to active duty, to include contaminated water during service. 3. The Veteran's chronic kidney disease did not have an onset during active duty service, was not manifested within one year following service discharge, and is not otherwise related to active duty, to include contaminated water during service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for hypertension, to include as due to exposure to contaminated water at Camp Lejeune, have not been met. 38 U.S.C. §§ 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 2. The criteria for entitlement to service connection for chronic kidney disease, to include as due to exposure to contaminated water at Camp Lejeune, have not been met. 38 U.S.C. §§ 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1977 to March 1987. In July 2021, the Veteran provided testimony in a Virtual Board hearing before the undersigned Veterans Law Judge (VLJ). Unfortunately, the Veteran died during the pendency of this appeal, in October 2020. In November 2021, the Board dismissed the appeal due to the death of the Veteran. The appellant has since been properly substituted for the purposes of the appeal. The Board will continue with adjudication of the appeal. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present 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. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be established on a presumptive basis for chronic diseases listed under 38 C.F.R. § 3.309(a) if chronic symptoms of the disease were shown in service; the disease was manifested to a compensable degree with a presumptive period, usually one year after service separation; or continuous symptoms of the disease were manifested since service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.33(b), 3.307, 3.309(a); see also Walker v. Shinseki, 708 F. 3d 1131 (Fed. Cir. 2013). The diagnoses of chronic kidney disease (i.e., as a renal disease) and hypertension are listed as chronic diseases under 38 C.F.R. § 3.303(b), thus, the presumptive service connection provisions are applicable to the diagnoses. A veteran, or former reservist or member of the National Guard, who had no less than 30 days (consecutive or nonconsecutive) of service at Camp Lejeune during the period beginning on August 1, 1953, and ending on December 31, 1987, shall be presumed to have been exposed during such service to the contaminants in the water supply, unless there is affirmative evidence to establish that the individual was not exposed to contaminants in the water supply during that service. 38 C.F.R. § 3.307(a)(7). Contaminants in the water supply means the volatile organic compounds trichloroethylene (TCE), perchloroethylene (PCE), benzene and vinyl chloride, that were in the on-base water-supply systems located at United States Marine Corps Base Camp Lejeune during the period beginning on August 1, 1953 and ending on December 31, 1987. 38 C.F.R. § 3.307(a)(7). If a veteran, or former reservist or member of the National Guard, was exposed to contaminants in the water supply at Camp Lejeune during military service and the exposure meets the requirements of § 3.307(a)(7), certain diseases shall be service-connected when manifested to a degree of 10 percent or more at any time after service, even though there is no record of such disease during service, subject to the rebuttable presumption provisions of § 3.307(d). However, chronic kidney disease and hypertension are not among the diseases presumed to be associated with exposure to contaminated water at Camp Lejeune. 38 C.F.R. § 3.309(f). 1. Entitlement to service connection for hypertension, to include as due to exposure to contaminated water at Camp Lejeune. The Veteran contended that his hypertension was related to service as being due to water contamination at Camp Lejeune during service. During the July 2021 Board hearing, the Veteran testified that he was diagnosed as possible hypertension prior to his diagnosis of kidney disease in January 2012, but for a period of time he had lost weight and was did not have hypertension at that point. The Veteran confirmed that he was not alleging that the disability had its onset while in service but rather that he believed it was due to the contaminated water at Camp Lejeune. The appellant seeks service connection on this basis. Service personnel records reflect service at Camp Lejeune, North Carolina, from periods between January 1978 to August 1982, therefore, exposure to contaminants in the water supply at Camp Lejeune is presumed. After a careful review of the evidence of record, the Board finds that the evidence persuasively weighs against a finding that service connection for hypertension is warranted. The reasons follow. "Hypertension" refers to persistently high arterial blood pressure. Medical authorities have suggested various thresholds ranging from 140 mm Hg systolic and from 90 mm Hg diastolic to as high as 200 mm Hg systolic and 110 mm Hg diastolic as reflective of hypertension. See Dorland's Illustrated Medical Dictionary 909 (31st ed. 2007). Similarly, for VA rating purposes, the term hypertension means that the diastolic blood pressure is predominantly 90 mm or greater. The term "isolated systolic hypertension" means that the systolic blood pressure is predominantly 160 mm or greater with a diastolic blood pressure of less than 90 mm. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1. As to evidence of a current disability, VA medical records prior to the Veteran's death show an assessment of hypertension, blood pressure stable on medication, as recent as May 2019. Accordingly, the Board finds there is evidence of a current disability of hypertension. While the claim is based upon contaminated water at Camp Lejeune and the Veteran did not contend that his hypertension had its onset in service, after review of all the lay and medical evidence of record, the Board finds that the weight of the evidence also demonstrates that no vascular injury, disease, or chronic symptoms of hypertension occurred during service. Review of the service treatment records show that the blood pressure readings were consistently within normal limits during service, to include close to the Veteran's separation from service with readings of 108/68 in June 1986 and 100/70 in January 1987. The Board finds that hypertension is a condition that would have ordinarily been recorded during service, including at the service separation examination, had it been present during service; therefore, the lay and medical evidence generated contemporaneous to service, which showed no in-service vascular injury or disease and no chronic symptoms of hypertension, is likely to reflect accurately the Veteran's physical condition, so is of significant probative value and provides evidence against a finding of hypertension or chronic symptoms of hypertension during service. The Veteran has also indicated that he was not alleging that the disability had its onset in service. The Board next finds that the weight of the lay and medical evidence shows that symptoms of hypertension were not continuous since service, including not within one year of service separation. See 38 C.F.R. § 4.104, Diagnostic Code 7101. The evidence shows the earliest onset of hypertension symptoms occurred approximately in June 2000, which is 13 years after service separation. For example, a June 2000 VA medical record reflects that the Veteran was educated on a low sodium diet for hypertension and low-fat diet for weight reduction. A March 2001 VA medical record indicates an assessment of hypertension and that the Veteran's blood pressure was not a goal of less than 140/90. The Veteran was taking verapamil at the time. The Veteran presented for hypertension in April 2001, he reported that he had another "incident" of supraventricular tachycardia (SVT). Hypertension is noted in VA medical records in the problem list with a date of February 2000 and essential hypertension, resolved March 2004. An August 2012 private medical record shows a history of hypertension for at least five years, thus, since 2007. This history presented for treatment purposes has high probative value because one would be expected to present an accurate medical history in order to receive efficacious treatment. Considered together with the absence of in-service vascular injury or disease or symptoms of hypertension during service, and the vascular system clinically evaluated as normal at service separation, the 13-year gap between service and the onset of hypertension is one more factor that tends to weigh against a finding of continuous symptoms of hypertension after service separation or hypertension manifested to a compensable degree within one year of service separation. The Board further finds that the weight of the evidence demonstrates that hypertension, which was first manifested many years after service, was not caused by or etiologically related to service. Treating VA medical providers have diagnosed essential hypertension, which is defined as hypertension occurring without a discoverable organic cause. Essential hypertension is noted with a date of September 2016 in the problem list. See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 909 (31st ed. 2007) (defining essential hypertension). Thus, the diagnosis of essential hypertension reflected in post-service treatment records indicates that the Veteran's hypertension has an unknown etiology in this case. See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 909 (31st ed. 2007) (defining "essential hypertension" as "hypertension occurring without discoverable organic cause"). Although the Veteran had asserted that his hypertension was causally or etiologically related to service, to include exposure to contaminated water at Camp Lejeune, he is a lay person and, under the facts of this case, does not have the requisite medical expertise to render a competent opinion regarding the etiology of hypertension when the evidence shows no in-service vascular injury or disease, no chronic symptoms of hypertension during service, no continuous symptoms of hypertension since service, and no hypertension manifested to a compensable degree within one year of service. Such diagnoses and opinions as to relationship involve unseen systems processes and disease processes that are largely unobservable by the five senses of a lay person, involve an understanding of the cardiovascular system, and involve making findings based on medical knowledge and clinical testing results. Consequently, the Veteran's assertion of relationship between hypertension and service is of no probative value. Hypertension is not presumed to be associated with exposure to contaminated water at Camp Lejeune. 38 C.F.R. § 3.309(f). The Veteran and the appellant have not offered other probative and competent medical evidence to support the assertions on medical etiology. In addition, there is no competent medical opinion of record linking hypertension to service. There are numerous post-service medical records reflecting complaints and treatment for hypertension; however, these records do not provide a positive nexus regarding the onset, etiology, or relationship of hypertension to military service, specifically due to exposure to contaminated water at Camp Lejeune. Accordingly, direct and presumptive service connection for hypertension may not be established. 38 C.F.R. §§ 3.303, 3.307, 3.309. Moreover, to the extent that the claim for entitlement to service connection for hypertension is based as secondary to the Veteran's CKD, as the claim for service connection for CKD is denied herein, the claimed hypertension cannot be granted on a secondary basis as CKD is not a service-connected disability. The Board has reviewed and considered a May 2015 opinion from Dr. M. J. C. She indicated that it was her belief that there is a high likelihood that exposure to trichloroethylene and perchloroethylene at Camp Lejeune have caused his chronic renal disease, which in turn likely caused his hypertension, however, the Board finds that this opinion has no probative value, as there is no supporting rationale and the evidence of record supports a finding that the Veteran's hypertension predated his CKD, which is discussed in further detail below in the Board's analysis of the claim for service connection for CKD. Additionally, Dr. M.J.C. did not attribute the hypertension diagnosis to contaminated water, versus alleging that hypertension was caused by the CKD. VA did not provide the Veteran with an examination or opinion in connection with the claim of service connection for hypertension. VA must provide a medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). As stated above, while the Board acknowledges that the Veteran was exposed to contaminated water at Camp Lejeune, neither the Veteran nor the appellant have proffered credible and probative evidence establishing that the Veteran's hypertension may be related to service, to include exposure to contaminated water at Camp Lejeune. For a VA examination to be warranted, all the McLendon criteria must be met, and at least one criterion is not met for the claim for service connection. Therefore, entitlement to a VA examination and/or medical opinion is not warranted. For the above reasons, the evidence is neither evenly balanced nor approximately so with regard to whether entitlement to service connection for hypertension is warranted. Rather, the evidence persuasively weighs against a finding that his hypertension had its onset during service or within one year of separation, or is etiologically related to the Veteran's active duty military service, to include exposure to contaminated water at Camp Lejeune. The benefit of the doubt doctrine, see 38 U.S.C. § 5107(b), is therefore not for application, and the claim is denied. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application). 2. Entitlement to service connection for chronic kidney disease, to include as due to exposure to contaminated water at Camp Lejeune. The Veteran contended that his chronic kidney disease (CKD) was related to service as being due to water contamination at Camp Lejeune during service. During the July 2021 Board hearing, the Veteran testified that he was diagnosed in total renal failure in January 2012, his kidneys had shut down and that he had since had a transplant. The Veteran confirmed that he was not alleging that the disability had its onset while in service but rather that he believed it was due to the contaminated water at Camp Lejeune. The appellant seeks service connection on this basis. After a careful review of the evidence of record, the Board finds that the evidence persuasively weighs against a finding that service connection for chronic kidney disease is warranted. The reasons follow. As to evidence of a current disability, a VA review in December 2016 confirmed a diagnosis of hypertensive nephrosclerosis and underlying chronic glomerulonephritis resulting in CKD stage V undergoing dialysis. VA medical records reflect that the Veteran had a kidney transplant in June 2018. Accordingly, the Board finds there is evidence of a current disability of CKD. Service personnel records reflect service at Camp Lejeune, North Carolina, from periods between January 1978 to August 1982, therefore, exposure to contaminants in the water supply at Camp Lejeune is presumed. After review of all the lay and medical evidence of record, the Board finds that the lay and medical evidence demonstrates that no kidney injury or disease was manifested during service and no chronic symptoms of kidney disease were manifested during service. The Veteran's service treatment records show no report, complaint, findings, diagnosis, or treatment for kidney problems. In March 1982 and October 1982 Reports of Medical Examination, shortly before and after he left Camp Lejeune, respectfully, the genitourinary system was clinically evaluated as normal, and the urinalysis for albumin and sugar was negative. The Board finds that a kidney injury or disease and chronic kidney disease are conditions that would have ordinarily been recorded during service, particularly around the time of the Veteran's departure from Camp Lejeune, had they occurred during service; therefore, the lay and medical evidence generated contemporaneous to service, which showed no in-service kidney injury or disease and no chronic symptoms of chronic kidney disease, is likely to reflect accurately the Veteran's physical condition, so is of significant probative value and provides evidence against a finding of a kidney injury or disease or chronic symptoms of chronic kidney disease during service. The Veteran has also indicated that he was not alleging that the disability had its onset in service. The Board next finds that the lay and medical evidence shows that symptoms of chronic kidney disease were not continuous since service, including within one year of service separation. During the July 2021 Board hearing, the Veteran stated that he was not diagnosed with end-stage renal disease, total kidney failure, until 2012, but there were indications previously, as he was denied life insurance in 1997 because there was an extra protein in the urine. February 2012 private medical records reflect CKD stage IV, chronic as evidenced by elevated creatinine in 2009 and likely representative of chronic glomerulonephritis (GN), possibly membranous or focal segmental glomerulosclerosis (FSGS) with super imposed hypertensive nephropathy as hypertension has been poorly controlled. Thus, the evidence indicates that chronic kidney disease had a post-service onset approximately in 2009, which is more than 20 years after service discharge. The Veteran reported an extra protein in the urine in 1997, however, he has not provided medical evidence to support a finding that this was the start of symptoms of his CKD. Regardless, this is almost a decade after his service discharge. Considered together with the absence of in-service kidney injury or disease or symptoms of chronic kidney disease during service, the 20-plus-year gap between service and the onset of chronic kidney disease is one factor that tends to weigh against a finding of continuous symptoms of chronic kidney disease after service separation and chronic kidney disease manifested to a compensable degree in the first post-service year. The Board further finds that the weight of the evidence demonstrates that the kidney disability, which was first manifested many years after service, was not caused by or otherwise related to service, to include presumed exposure to contaminated water during service at Camp Lejeune. After review of the record, in March 2014, a VA physician opined that the condition claimed was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. She provided the opinion that the Veteran suffered from end stage renal disease and was stationed at Camp Lejeune, NC., from January 1978 to August 1982. She referenced an August 2012 note from Dr. S. S. that mentioned the most likely etiology of the Veteran's condition was as follows, "per renal specialist most likely secondary to hypertensive nephrosclerosis with underlying glomerulonephritis," and that the Veteran was on renal transplant active list. The physician stated, in addition to hypertension, the Veteran suffered from multiple co-morbidities, which she wrote are considered additional risk factors for the development of renal disease. For example, gout (purine deposits inability to excrete protein by-products causing further renal damage) was a risk factor, as records show recurrent "gout attacks" treated with colchicine and maintenance Allopurinol. An August 2012 clinical note from Dr. S. S. states, "gout involving the toes." The physician also wrote that records show a G6PD deficiency "from blood test done in 1975," and explained that this type of genetic condition further increased the risk of renal damage via hemolytic reactions. She added that the Veteran also suffered from cardiac disease with congestive heart failure and atrial fibrillation, referencing an October 2013 note from Dr. L. T. W. The physician noted the Veteran had a positive smoking history prior to service with discontinuance of smoking in 1977. She directly addressed an October 2013 medical opinion from Dr. L. T. W. In the October 2013 opinion, Dr. L. T. W. indicated that the Veteran was under her care for CKD stage 5, and she had been asked to provide a statement regarding the effects of hydrocarbon exposure as it may related to the Veteran's renal disease. She indicated that the following information was available, "hydrocarbon exposure may cause glomerulonephritis and worsen renal function: evidence based on Hill's criteria for causality." She indicated that the cause of the Veteran's renal disease is unknown (no renal biopsy was performed); however, she wrote it is possible to have been related to prior hydrocarbon exposure at Camp Lejeune. The March 2014 physician stated that the October 2013 opinion mentions only general exposure to hydrocarbons with an opinion being rendered without considering the multiple other risk factors and co-morbidities that most likely caused the Veteran's renal disease. The physician explained that although TCE and PCE and Benzene have been implicated in aggravating renal disease, the Veteran's other co-morbidities definitely represented a more likely putative cause than potential exposures at Camp Lejeune. She stated based on the evidence of record, the strongest causative agents to the Veteran's end stage renal disease are 1) hypertension, 2) long standing frequent gout attacks leading to renal damage, 3) G6PD deficiency, 4) ex-smoker, 5) positive family history (the physician noted that records mention one uncle on dialysis), and 6) parathyroid condition PTH. The physician provided additional discussion on the epidemiologic evidence and recent studies of TCE PCE and Benzene and risk or aggravation of renal disease. She indicated that difficulties in separating the mode of action and synergistic effects between multiple chemicals to which populations are exposed create study limitations, which, at this point, preclude the establishment of a clear causal nexus. She found that the Veteran's medical records contain sufficient information to conclude that his personal medical risk factors/medical co-morbidities are most likely to far outweigh the risk incurred during his time at Camp Lejeune. In conclusion, the physician concluded that the Veteran's renal condition is less likely as not (less than 50/50 probability) caused by or a result of the Veteran's potential exposure to contaminated water at Camp Lejeune. The March 2014 VA physician provided another opinion in November 2016. She noted the Veteran's diagnosis of hypertensive nephrosclerosis and underlying chronic glomerulonephritis resulting in CKD stage V undergoing dialysis. The physician opined that the diagnosis above was less likely than not (less than 50/50 probability) caused by or the result of the Veteran's exposure to Camp Lejeune contaminated water (CLCW). She wrote that the Veteran appeared to have developed CKD in 2009 per private medical records, approximately 27 years after service at Camp Lejeune. She noted service treatment records document multiple normal urinalyses and blood pressure readings, to include re-enlistment in 1982 and at separation examination in 1987 and that the VA examination in October 1990 also revealed normotensive blood pressure reading. The physician noted the risk factors she had documented in the March 2014 opinion. She explained that hypertension is the second leading cause of CKD in the United States, studies have shown that uncontrolled hypertension is a strong risk factor for progression to end stage renal disease (ESRD), and long-term uncontrolled high blood pressure leads to damage of the glomeruli. The physician also stated that smoking increased the risk of developing renal disease, citing to several sources, including a large study in the New England Journal of Medicine. The physician noted the Veteran's 2013 congestive heart failure with ejection fraction of 45 percent can lead to pre-renal acute kidney injury and acute on chronic renal failure. The physician noted that obesity was reported with a body mass index (BMI) greater than 30 in the records as of 1999, which could also contribute to the development of renal disease, specifically, the Framingham Offspring study indicated those with a BMI greater than 26.6 had a 1.45 odds ratio of developing CKD. The physician directly addressed a May 2015 opinion from Dr. M. J. C., who indicated that it was her belief that there is a high likelihood that exposure to trichloroethylene and perchloroethylene at Camp Lejeune have caused the Veteran's chronic renal disease, which, in turn, likely caused his hypertension. The physician indicated that Dr. M. J. C., is a primary care physician and not a nephrologist/OEM, did not provide a discussion of exposure duration, latency, established risk factors, or references or citations in support of her opinion. Moreover, the physician pointed out that the Veteran's private nephrology and renal transplant specialty records note CKD is attributable to longstanding hypertension and likely underlying chronic glomerulosclerosis (FSGS versus membranous GN) and primary or isopathic FSGS occurs in the absence of a known etiology. She wrote that secondary FSGS is multifactorial and can be a result of drug toxicity, viruses, caused by reduced renal mass, obesity, sickle cell disease, congenital heart disease, malignancies, hypertension A1port syndrome, sarcoidosis or from radiation, etc. She stated that kidney biopsy is the only definitive method for diagnosis, however, one has not been performed in the Veteran's case. The physician explained that although there are some studies that suggest evidence of a relationship between occupational exposures to organic solvents and the development of nephropathies, these studies suggest an increase related only to high-level, long-term exposure. The studies also indicate that the renal disease would start at the time of exposure and would likely improve with cessation of exposure. She noted that the Veteran developed CKD several decades after service at Camp Lejeune and had other prominent risk factors, as listed above. The physician concluded in her medical opinion that the Veteran's renal contention is due to the direct result of his multiple risk factors and that the combined effect of all main putative factors in this case resulted in the development of the Veteran's renal disease on a more likely than not basis (greater than 50 percent probability). Thus, the examiner found that the Veteran's renal condition is less likely than not (less than 50 percent probability) due to his time assigned at Camp Lejeune. The physician provided references and citations to the Veteran's specific medical records, which were relevant to and supported her opinion. She also provided references to medical studies and literature review regarding the relevant risk factors for kidney disease and occupational exposure, including TCE. She indicated that despite the limitations of industrial studies, the estimate of occupational exposures in these studies are significantly higher than the estimates of CLCW exposure. She stated that it is therefore likely that even the lower levels of workplace exposures exceed CLCW exposures. In summary, she found based on her literature review that there is no statistically significant data that supports exposure to the CLCW solvents, at the measured levels, as being causative of CKD. The examiner wrote that although the studies might suggest evidence of a relationship between occupational exposures to organic solvents and the development of nephropathies, these studies suggest an increase only related to high-level, long-term exposure. She stated that the studies indicate the renal disease would start at the time of the exposure and would likely improve with cessation of exposure. The Board accords the most probative weight to the opinions of the VA physician in March 2014 and November 2016. The physician, a member of the Subject Matter Expert Panel of the Camp Lejeune Contaminated Water Project, provided medical opinions supported by well-reasoned rationale after she reviewed the claims file, including the medical opinions from Dr. L. T. W. proffered in October 2013 and Dr. M. J. C proffered in May 2015. The VA physician addressed the Veteran's specific risk factors other than the Veteran's exposure to CLCW and indicated the Veteran's renal contentions were due to the direct result of his multiple risk factors and that the combined effect of all main putative factors in this case resulted in the development of the Veteran's renal disease on a more likely than not basis. The Board finds the private opinions are of diminished probative value, as they are not supported by a well-reasoned rationale supported by medical literature and does not consider the Veteran's other risk factors listed by the VA physician. Moreover, private treating physicians have suggested that while the etiology of the Veteran's CKD is unclear, it could be related to hypertensive nephrosclerosis versus underlying chronic glomerulonephritis, including in May 2012 and August 2012 private treatment records, which is consistent with the opinions from the VA physician. A February 2012 private treatment record reflects an assessment of CKD stage IV, chronic as evidence[d] by elevated creatinine in 2009 and likely representative of chronic GN, possibly membranous or FSGS with super imposed hypertensive nephropathy as hypertension has been poorly controlled. The Board has also considered the lay statements submitted on behalf of the Veteran by his family (spouse, son, daughters), which includes statements attesting to the Veteran's smoking history. During the July 2021 Board hearing, the Veteran "objected" to the fact that VA claimed his renal toxicity was caused by smoking and reported that he did not smoke for a long duration of time and never had a "smoking issue." However, the Board finds that the VA physician's opinion was based upon an accurate depiction of the Veteran's smoking history. The VA physician, in her November 2016 opinion, specifically referenced medical records that note a "positive smoking to history prior to service discontinued smoking in 1977" and "smoking: prior to 1977." Further, while the Veteran reported during the July 2021 Board hearing that the uncle who was on dialysis was his mother's sister's husband, this is inconsistent with the Veteran's report to medical providers for purposes of treatment. For example, an August 2012 private treatment record only documents that "his uncle on his mother's side was on dialysis." Moreover, family history is only one risk factor of many thoroughly addressed by the VA physician. Although the Veteran during his lifetime had asserted the belief that the kidney disability was caused by service, he is a lay person and, under the facts of this case, does not have the requisite medical expertise to render a competent medical opinion in this case regarding the etiology of chronic kidney disease, when there was no in-service kidney injury or disease, no in-service chronic symptoms of chronic kidney disease, and symptoms of chronic kidney disease manifested many years after service. Such diagnoses and opinions as to relationship involve unseen systems processes and disease processes that are largely unobservable by the five senses of a lay person, involve an understanding of the genitourinary system and the possible causes or etiologies of chronic kidney disease, and involve making findings based on medical knowledge and clinical testing results. Consequently, the Veteran's assertions that the current kidney disability to service are of no probative value. CKD is not presumed to be associated with exposure to contaminated water at Camp Lejeune. 38 C.F.R. § 3.309(f). Neither the Veteran nor the appellant has offered other probative and competent medical evidence to support his assertions on medical etiology. The Board finds that the medical opinions from Dr. L. T. W. proffered in October 2013 and Dr. M. J. C. proffered in May 2015 are of diminished probative value as they are not supported by well-reasoned rationales, explained above. Accordingly, direct and presumptive service connection for CKD may not be established. 38 C.F.R. §§ 3.303, 3.307, 3.309. Lastly, to the extent that the claim for entitlement to service connection for CKD is based as secondary to the Veteran's hypertension, as the claim for service connection for hypertension is denied herein, the claimed CKD cannot be granted on a secondary basis as hypertension is not a service-connected disability. For these reasons, the Board finds that the evidence persuasively weighs against finding that the kidney disability was incurred in service, manifested within one year from service discharge, or was otherwise related to service, to include exposure to contaminated water at Camp Lejeune; therefore, the benefit of the doubt doctrine is not for application, and the claim of entitlement to service connection for chronic kidney disease is denied. See 38 U.S.C. § 5107(b); Lynch, 21 F.4th 776. A. P. SIMPSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Cheng, 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.