Kidney Disease Secondary to Hypertension

If your hypertension is service connected and your lab results now show chronic kidney disease, you can claim the kidney disease as secondary to the hypertension. Long-term high blood pressure damages the kidneys, but failing kidneys also raise blood pressure. So this claim turns on which condition showed up first in your records and on your lab results over time. The rating has its own wrinkle: the schedule limits when kidney and cardiovascular conditions are rated separately.

Can hypertension cause chronic kidney disease?

Yes. Large studies show that higher blood pressure carries a higher risk of kidney failure.

• Among 332,544 men aged 35 to 57 screened for the Multiple Risk Factor Intervention Trial and followed for an average of 16 years (Klag and colleagues, New England Journal of Medicine, 1996), systolic and diastolic pressure had a strong, graded relationship with end-stage kidney disease, independent of other risk factors studied. Men with systolic pressure of 210 or more or diastolic of 120 or more had 22.1 times the risk of men below 120/80.
• Among 316,675 Kaiser Permanente members who started with an estimated GFR of 60 or higher and no protein or blood on a urine dipstick (Hsu and colleagues, Archives of Internal Medicine, 2005), the risk of end-stage kidney disease rose with each blood pressure level. Compared with pressure below 120/80, the adjusted relative risk was 1.62 at 120 to 129/80 to 84, 2.59 at 140 to 159/90 to 99, and 4.25 at 210/120 or higher.
• A 2019 teaching review for kidney specialists (Ku and colleagues, American Journal of Kidney Diseases) states that sustained hypertension can lead to worsening kidney function, and that uncontrolled hypertension can speed progression to end-stage kidney disease.

The link also runs the other way

The same review states that declining kidney function can worsen blood pressure control, as damaged kidneys retain sodium and fluid and the systems that raise pressure become more active. Among 3,612 adults with an estimated GFR of 20 to 70 in the Chronic Renal Insufficiency Cohort (Muntner and colleagues, American Journal of Kidney Diseases, 2010), 85.7% had hypertension. So the diagnoses alone do not show the direction. The Hsu study addressed that objection by excluding people with evident kidney disease at the start.

A "hypertensive nephrosclerosis" label in your records helps, but it is not proof. A 2016 review (Freedman and Cohen, Nature Reviews Nephrology) argues that kidney doctors often apply it to kidney disease with other causes, including disease tied to APOL1 gene variants in people with recent African ancestry, which often raises blood pressure rather than being caused by it. In the African American Study of Kidney Disease and Hypertension (Lipkowitz and colleagues, Kidney International, 2013), APOL1 risk variants were strongly tied to kidney disease and its progression.

Does high blood pressure make kidney disease worse?

The research behind an aggravation theory is mixed. A meta-analysis of 11 trials with 9,287 patients with chronic kidney disease (Lv and colleagues, CMAJ, 2013) found that intensive blood pressure lowering reduced end-stage kidney disease (hazard ratio 0.79), but in patients without protein in the urine at the start there was no clear reduction in kidney failure (hazard ratio 1.12). A pooled analysis of 1,860 patients with nondiabetic kidney disease (Jafar and colleagues, Annals of Internal Medicine, 2003) found the lowest risk of progression at systolic pressure of 110 to 129, with the added risk at higher pressures greater when urine protein was above 1.0 gram a day; the authors noted that reverse causation could not be ruled out. The 2019 review, by contrast, states that intensive control has not been shown in clinical trials to slow kidney disease. The research gives aggravation the most support when you have protein in your urine and a history of poorly controlled pressure.

How VA decides kidney disease secondary to hypertension

Secondary service connection is in 38 CFR § 3.310. VA grants it in two ways.

• Caused by. Your service-connected hypertension caused the kidney disease, at least as likely as not.
• Aggravated by. Your kidney disease is aggravated by your service-connected hypertension, meaning it would be less severe but for the hypertension (M21-1 V.ii.2.D). VA rates only the part above the baseline level of the kidney disease before the aggravation, so the opinion should describe that baseline.

The claim needs three things in the file: a chronic kidney disease diagnosis with lab results, service-connected hypertension, and a medical opinion linking the two with reasoning.

Why the order of your diagnoses matters

If your records show years of high blood pressure before the first abnormal kidney result, causation fits the research above. If the kidney disease appears first, or at the same time, an examiner may say it caused the hypertension, which defeats a causation claim.

Aggravation can still apply when kidney disease came first or has another cause: the question becomes whether your service-connected hypertension made it worse. Under § 3.310(b), the baseline must be shown by medical evidence created before the worsening began, or by the earliest medical evidence after it. For kidney disease, that is usually your earlier GFR and urine albumin results, so gather every lab result you have.

The rating schedule has separate codes for other causes, such as renal involvement in diabetes (DC 7541), cystic diseases of the kidneys (DC 7533) and toxic nephropathy from agents such as nonsteroidal anti-inflammatory drugs (DC 7535), and an examiner may point to one of them. If service-connected diabetes is part of your picture, see diabetes secondary conditions.

VA rating for kidney disease secondary to hypertension

Chronic kidney disease is rated as renal dysfunction under 38 CFR § 4.115a. The current levels follow.

• 100%: "Chronic kidney disease with glomerular filtration rate (GFR) less than 15 mL/min/1.73 m2 for at least 3 consecutive months during the past 12 months; or requiring regular routine dialysis; or eligible kidney transplant recipient"
• 80%: "Chronic kidney disease with GFR from 15 to 29 mL/min/1.73 m2 for at least 3 consecutive months during the past 12 months"
• 60%: "Chronic kidney disease with GFR from 30 to 44 mL/min/1.73 m2 for at least 3 consecutive months during the past 12 months"
• 30%: "Chronic kidney disease with GFR from 45 to 59 mL/min/1.73 m2 for at least 3 consecutive months during the past 12 months"
• 0%: GFR from 60 to 89 with recurrent red blood cell, white blood cell or granular casts, or structural kidney abnormalities (cystic, obstructive, or glomerular), or an albumin/creatinine ratio of 30 mg/g or more, each "for at least 3 consecutive months during the past 12 months"

A note to the table accepts GFR, estimated GFR and creatinine-based approximations calculated by a medical professional. Because every level needs three consecutive months, a series of results matters more than one draw. The kidney disease VA rating page explains the labs in more detail.

Can hypertension be rated separately from the kidney disease?

Four passages of the regulation apply.

• § 4.115 describes "the nephrosclerotic type" of nephritis as "originating in hypertension or arteriosclerosis." It then says: "Separate ratings are not to be assigned for disability from disease of the heart and any form of nephritis, on account of the close interrelationships of cardiovascular disabilities." It gives two exceptions. When absence of a kidney is the sole renal disability, "the absent kidney and any hypertension or heart disease will be separately rated." And when chronic renal disease "has progressed to the point where regular dialysis is required, any coexisting hypertension or heart disease will be separately rated."
• Diagnostic Code 7507, arteriolar nephrosclerosis, says: "Rate according to predominant symptoms as renal dysfunction, hypertension or heart disease. If rated under the cardiovascular schedule, however, the percentage rating which would otherwise be assigned will be elevated to the next higher evaluation."
• § 4.115a says: "Distinct disabilities may be evaluated separately under this section, pursuant to § 4.14, if the symptoms do not overlap." Section 4.14 says evaluating the same manifestation under different diagnoses is to be avoided.
• Before November 14, 2021, the renal dysfunction levels themselves counted blood pressure. The 30 percent level, for example, included "hypertension at least 10 percent disabling under diagnostic code 7101." The current levels are based on GFR and do not mention blood pressure.

In plain terms, the bar in § 4.115 names heart disease and nephritis, not hypertension, but its two exceptions say hypertension "will be separately rated" in those cases, which implies it is not rated separately outside them. Under DC 7507, VA rates by whichever problem is predominant. The schedule does not say in plain words whether a DC 7101 hypertension rating can stand beside a renal dysfunction rating for kidney disease caused by that same hypertension. Check the diagnostic code in your rating decision, and if VA folded your hypertension into the kidney rating, have an accredited representative review it.

Combined-rating examples

Ratings combine under 38 CFR § 4.25, larger rating first.

• Rated separately. Kidney disease at 30 percent (GFR 45 to 59) and hypertension at 10 percent combine to 37, because the 10 percent takes its share of the remaining 70. VA rounds 37 to 40 percent.
• Rated under DC 7507. If renal dysfunction is predominant, the kidney disease is rated 30 percent, and if VA treats that rating as covering the hypertension, your total from the two is 30 percent, not 40. If hypertension is predominant and VA rates it under the cardiovascular schedule at 10 percent, DC 7507 raises it to the next higher evaluation, 20 percent.

The C&P exam for kidney disease secondary to hypertension

The examiner is asked whether your kidney disease is at least as likely as not caused by your hypertension and, separately, whether the hypertension aggravated it. An opinion that answers only the first question is inadequate under El-Amin v. Shinseki (2013).

The examiner looks at these records.

• Your hypertension diagnosis date against your first abnormal GFR or urine albumin result
• Your GFR results over time, which also set the rating level
• Your urine albumin/creatinine ratio and urinalysis
• How well your blood pressure has been controlled
• Other causes, such as diabetes, cystic kidney disease and medicines that can harm the kidneys

Unfavorable opinions usually go wrong in one of three ways: they say the kidney disease caused the hypertension without checking which came first, they call the cause unknown despite years of documented high blood pressure, or they skip aggravation when uncontrolled pressure and protein in the urine are in the file. The Board section below shows how the Board ruled on these appeals. C&P exam prep can help you get ready.

Why kidney disease secondary to hypertension claims get denied

These gaps lead to denials.

• The kidney disease shows up in the records before the hypertension, and no opinion addresses aggravation.
• Another cause in the file, such as diabetes, is never addressed.
• The labs do not show abnormal results for three consecutive months, so there is no ratable level.
• An opinion answers causation but not aggravation.
• An aggravation opinion has no baseline, such as earlier GFR results.

Nexus letter for kidney disease secondary to hypertension

A strong nexus letter for this claim does six things.

1. States that the doctor reviewed your blood pressure history, GFR and urine albumin results over time, and medication list.
2. Lays out the timeline: when the hypertension began, how well it was controlled, and when the kidney results turned abnormal.
3. Gives an opinion on causation: your chronic kidney disease is at least as likely as not caused by your service-connected hypertension.
4. Gives a separate opinion on aggravation: your kidney disease is aggravated by your service-connected hypertension, meaning it would be less severe but for the hypertension, and describes the baseline, such as your earlier GFR.
5. Explains the reasoning and cites the research, including the two-way link.
6. Deals with the other causes in your file, such as diabetes or a genetic kidney disease, directly.

Where these opinions break down is predictable: a conclusion with no reasoning, no timeline, a diagnosis label used as proof, or silence on aggravation. Raven Nexus can organize your records and the research into a draft for your doctor to review.

Questions veterans ask about kidney disease secondary to hypertension

Can chronic kidney disease be secondary to hypertension for VA disability?

Yes, under 38 CFR § 3.310, when your service-connected hypertension caused the kidney disease or made it worse, and large studies tie higher blood pressure to kidney failure.

What is the VA rating for chronic kidney disease secondary to hypertension?

It is rated as renal dysfunction under 38 CFR § 4.115a: 0, 30, 60, 80 or 100 percent, based mainly on GFR held for at least three consecutive months during the past 12 months.

Will VA rate my hypertension separately from my kidney disease?

It depends on how VA codes the kidney disease. Section 4.115 says hypertension is rated separately on dialysis or with a missing kidney, and DC 7507 rates by whichever problem is predominant, so check the code in your rating decision.

What if my kidney disease was diagnosed before my high blood pressure?

Then an examiner may say the kidney disease caused the hypertension. Aggravation can still work if your service-connected hypertension made the kidney disease worse than its baseline.

What labs should I have for this claim?

GFR results covering at least three consecutive months in the past year, a urine albumin/creatinine ratio, and your dated blood pressure history. Earlier results set the timeline and the baseline.

Sources

• 38 CFR § 3.310, secondary service connection, including § 3.310(b) on the baseline; M21-1 V.ii.2.D, aggravation of a nonservice-connected disability by a service-connected one.
• 38 CFR § 4.115, nephritis; 38 CFR § 4.115a, renal dysfunction; 38 CFR § 4.115b, Diagnostic Codes 7507, 7533, 7535 and 7541; 38 CFR § 4.14, avoidance of pyramiding; 38 CFR § 4.25, combined ratings table.
• Prior text of 38 CFR § 4.115a (eCFR, version in effect before November 14, 2021), and the final rule that replaced it, Schedule for Rating Disabilities; The Genitourinary Diseases and Conditions, 86 FR 54081 (September 30, 2021).
• El-Amin v. Shinseki, 26 Vet. App. 136 (2013), an opinion must address aggravation.
• Klag MJ, Whelton PK, Randall BL, et al. Blood pressure and end-stage renal disease in men. New England Journal of Medicine. 1996;334(1):13-18. PMID 7494564.
• Hsu CY, McCulloch CE, Darbinian J, Go AS, Iribarren C. Elevated blood pressure and risk of end-stage renal disease in subjects without baseline kidney disease. Archives of Internal Medicine. 2005;165(8):923-928. PMID 15851645.
• Ku E, Lee BJ, Wei J, Weir MR. Hypertension in CKD: Core Curriculum 2019. American Journal of Kidney Diseases. 2019;74(1):120-131. PMID 30898362.
• Muntner P, Anderson A, Charleston J, et al. Hypertension awareness, treatment, and control in adults with CKD: results from the Chronic Renal Insufficiency Cohort (CRIC) Study. American Journal of Kidney Diseases. 2010;55(3):441-451. PMID 19962808.
• Freedman BI, Cohen AH. Hypertension-attributed nephropathy: what's in a name? Nature Reviews Nephrology. 2016;12(1):27-36. PMID 26553514.
• Lipkowitz MS, Freedman BI, Langefeld CD, et al. Apolipoprotein L1 gene variants associate with hypertension-attributed nephropathy and the rate of kidney function decline in African Americans. Kidney International. 2013;83(1):114-120. PMID 22832513.
• Lv J, Ehteshami P, Sarnak MJ, et al. Effects of intensive blood pressure lowering on the progression of chronic kidney disease: a systematic review and meta-analysis. CMAJ. 2013;185(11):949-957. PMID 23798459.
• Jafar TH, Stark PC, Schmid CH, et al. Progression of chronic kidney disease: the role of blood pressure control, proteinuria, and angiotensin-converting enzyme inhibition: a patient-level meta-analysis. Annals of Internal Medicine. 2003;139(4):244-252. PMID 12965979.
• Board figures on this page: Claim Raven's read of every Board decision from 2021 to 2026 that it holds, and of every decision since 1992 for the longer view.