Secondary claim guide

Nexus Letter for Kidney Disease Secondary to Hypertension

Medically reviewed by the Patriot Path Medical Team

Licensed MD reviewers • Last updated: November 7, 2026

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VA can service connect kidney disease secondary to service-connected hypertension under 38 CFR 3.310. Its manual directs the grant when nephrosclerosis with impaired kidney function is diagnosed, though a claim is still required. Before dialysis, VA rules can fold kidney disease and hypertension into one evaluation, which may or may not exceed the hypertension rating alone.

Three things belong up front. First, you may not need to buy a letter. Where your hypertension is service connected and your records already diagnose nephrosclerosis of the kidneys with impairment of renal function, VA's manual tells raters to grant service connection on a secondary basis (M21-1 Part V, Subpart iii, Chapter 5, Block 3.g). You still have to file a claim, and the same block cautions that arteriosclerosis occurs with advancing age without preexisting hypertension. Where the records leave the cause unclear, the manual tells VA to request a medical opinion. A physician's own opinion does its real work when there is something to answer: a VA decision or examiner against the link, another cause in your records that VA has not service connected, or an aggravation claim that needs a baseline under 38 CFR 3.310(b). Second, we make no promise that a kidney grant raises what you are paid: before dialysis the rules can give one evaluation for the kidney disease and the hypertension together, and that evaluation can stay where it is or come out higher. Third, studies tie higher blood pressure to later kidney disease, and the tie runs both ways; a chart label of hypertensive nephrosclerosis is a clinical judgement, not proof of what caused yours.

An illustrative example

A veteran has been service connected for hypertension at 10 percent since 2014. He takes daily blood pressure medication and has a documented history of diastolic readings predominantly 100 or more. Over the past two years his eGFR results have run between 48 and 56, and his primary care notes say chronic kidney disease stage 3a, with no cause written down. He files a claim for the kidney disease as secondary to his hypertension.

Because his records do not say what caused it, VA's manual tells the rater to request a medical opinion on whether it is a type of nephrosclerosis. Suppose the VA examiner says age is the more likely cause. That is where a physician's opinion can do real work: setting his blood pressure history against when the kidney results fell, his findings against what is expected at his age, and the other causes his records do or do not show.

Suppose VA then grants it as nephrosclerosis. His results sit in the band of the 30 percent renal row, but before dialysis the rules point to one evaluation for nephrosclerosis and hypertension, not a 30 percent kidney rating beside his 10 percent hypertension rating: DC 7507 rates nephrosclerosis by its predominant symptoms, and VA's manual practice bars a separate hypertension evaluation where the kidney disease is a form of nephritis, a question this page leaves open. By DC 7507's text, that one evaluation follows the 30 percent row if it is rated as renal dysfunction, and if it is rated as hypertension, under the cardiovascular schedule, the 10 percent that would otherwise be assigned is elevated to the next higher evaluation. Which route applies is the rater's decision, and we found no decision applying DC 7507 beside an existing DC 7101 evaluation, so this page does not predict the figure.

We built this example from the rules on this page to show how they fit together. It is not a client or a case result, and it predicts nothing about any claim.

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Does VA Automatically Connect Kidney Disease to Service-Connected Hypertension?

Not automatically, since a claim is still required, but in one fact pattern VA's manual tells raters to grant. M21-1 is VA's internal procedures manual, not a regulation; SC in its text means service connection.

If additional arteriosclerotic manifestations are subsequently diagnosed in a Veteran with SC hypertension, grant SC on a secondary basis through the relationship to hypertension for any of the following:
cerebral arteriosclerosis or thrombosis with hemiplegia
nephrosclerosis of the kidneys with impairment of renal function, or
myocardial damage or coronary occlusion of the heart.
M21-1 Part V, Subpart iii, Chapter 5, Block 3.g

Important: A claim for benefits is required to adjudicate a secondary SC claim for any of the arteriosclerotic manifestations.
M21-1 Part V, Subpart iii, Chapter 5, Block 3.g

Notes:
Address SC for the above-listed cardiovascular conditions through the relationship to the hypertension when a sympathetic reading of the Veteran’s claim reasonably implies a claim for SC for those conditions.
Arteriosclerosis occurs with advancing age without preexisting hypertension, and may occur in some younger individuals who are predisposed to arterial changes.
The existence of arteriosclerosis does not imply/indicate prior hypertension.
M21-1 Part V, Subpart iii, Chapter 5, Block 3.g, all three Notes

The block's topic carries a change date of February 5, 2024; the version in force from November 15, 2021 differed only in a narrower sympathetic-reading Note. We could not verify earlier text, so nothing here says the manual read this way when the 2018 decisions below were made.

A Note added to the genitourinary chapter on March 19, 2026, after every Board decision on this page, covers records that name no cause:

As noted in M21-1, Part V, Subpart iii, 5.3.g, nephrosclerosis is a recognized arteriosclerotic manifestation of hypertension. Chronic kidney disease is not always a form of nephrosclerosis. When the clinical evidence is unclear, request a medical opinion to determine whether the disability in question is a type of nephrosclerosis.
M21-1 Part V, Subpart iii, Chapter 7, Block 2.f, second Note (added March 19, 2026)

A diagnosis on file did not by itself settle the link in 18160181 (2018). The Board found current diagnoses of hypertensive nephrosclerosis and chronic kidney disease, drawing on a June 2015 VA examination report and the treating provider's August 2015 letter together, without saying which recorded which, and still weighed the cause, setting the VA examiner's negative opinion, which blamed past kidney cancer, the nephrectomy and age, against the letter. It granted because the evidence was "at least evenly balanced" (binding only with regard to the specific case decided, 38 CFR 20.1303).

Where a physician's opinion does real work

An opinion earns its place when the file holds something to answer: a VA decision or opinion against the link, including one that answered a different question (A25024415) or leaned on a competing cause (18160181; 22003375); another cause in the record, such as diabetes (18146719), a renal tumor and nephrectomy (22003375, 18160181) or an inherited kidney disease (25001040); or an aggravation claim, which needs a baseline under 38 CFR 3.310(b). A cause VA already service connects is a route of its own under 38 CFR 3.310(a). Each decision is binding only with regard to the specific case decided (38 CFR 20.1303).

A record naming no cause is different: there the manual itself has VA request a medical opinion, which is not by itself a dispute.

How VA Decides Kidney Disease Secondary to Hypertension

One regulation gives two routes, and one standard of proof governs both.

Route one: the hypertension caused the kidney disease

Under 38 CFR 3.310(a), "disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition." VA's manual asks whether the secondary disability is "shown to be the result of, or would not have occurred but for, an SC disability", and says "the primary disability need not be SC, or even diagnosed, at the time the secondary disability is incurred" (M21-1 Part V, Subpart ii, Chapter 2, Section D, Block 1.b).

Route two: the hypertension made it worse

Aggravation is 38 CFR 3.310(b), in full: "Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities (38 CFR part 4) and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level."

On its face the regulation names only medical evidence for the baseline and recites natural progress twice, and 4.115 calls the nephrosclerotic type "associated with natural progress." VA's manual, as its own practice, reads the rule more broadly: Block 1.a's Notes (May 1, 2026) say "Permanent worsening of an NSC disability by an SC disability is not required" and, in a Note the manual ties to Spicer v. McDonough, that VA "will apply the broader but-for standard and will no longer consider natural progress of the NSC disability when deciding a claim based on aggravation of an NSC disability by an SC disability" (NSC: not service connected).

The baseline survives. Block 1.c accepts "any other credible evidence, including lay evidence, that supports establishment of the baseline", though lay evidence "on its own, may not be sufficient"; Block 1.g keeps the deduction: "The evaluation assigned will reflect the difference between the current and baseline levels of severity." Block 1.f runs against the veteran: "if no baseline can be established, no aggravation can be demonstrated", and "Do not assume a baseline of 0 percent", though VA must first develop for one. Block 1.h allows a 0 percent grant. All of this is VA manual practice.

The standard: approximate balance, not proof

Under 38 CFR 3.102, "By reasonable doubt is meant one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim." Such doubt "will be resolved in favor of the claimant." The phrase "at least as likely as not" is not in 3.102; it is the conventional form of an opinion's conclusion, as in a VA examiner's opinion, as the Board recorded it in 25000604 (2025), that the kidney disease was "at least as likely as not proximately due to or a result of service-connected hypertension" (binding only with regard to the specific case decided, 38 CFR 20.1303).

What a VA examiner has to answer

For aggravation, the examiner must separately address "the current level of severity of the NSC disability"; whether "there has been any increase in severity of the NSC disability that would not have occurred but for an SC disability, or" "the NSC disability would have been less severe but for an SC disability, including where the SC disability has interfered with or impeded treatment for the NSC disability"; and "an adequate analysis with medical considerations supporting the opinion" (Block 1.e).

In A25024415 (2025) a VA opinion "only opined as to the issue of a TERA and not as secondary to hypertension" (a toxic exposure risk activity), and the Board remanded with but-for questions; in 23061641 (2023), also a remand, the examiner had skipped the kidney questionnaire the hypertension form called for. Both are binding only with regard to the specific case decided (38 CFR 20.1303).

Does High Blood Pressure Cause Kidney Disease? What the Research Shows

In large studies, higher blood pressure goes with a higher later risk of kidney disease. The association runs both ways, and no study can say what caused one veteran's kidney disease.

Long-running cohorts: higher pressure, higher later risk

Klag (1996) followed 332,544 men aged 35 to 57, screened from 1973 to 1975 for entry into the Multiple Risk Factor Intervention Trial, for end-stage renal disease through 1990: against below 120/80, systolic 210 or more or diastolic 120 or more carried a relative risk of 22.1 (the abstract gives no confidence interval), not explained by kidney failure soon after screening or, in 12,866 trial entrants, by baseline creatinine and urine protein (PMID 7494564). Hsu (2005) studied 316,675 Kaiser Permanente Northern California members with eGFR 60 or more and dipsticks negative for proteinuria or hematuria: against below 120/80, adjusted relative risks of end-stage renal disease ran from 1.62 (95 percent confidence interval 1.27 to 2.07) at 120 to 129 over 80 to 84 to 4.25 (2.63 to 6.86) at 210/120 or more. That screen only partly answers reverse causation; the conclusion reaches only "clinically evident baseline kidney disease" (PMID 15851645). In 10.5 million Korean adults, each 10 mm Hg higher systolic went with a 35 percent higher risk of new CKD at G3 to G5 (1.35 to 1.36), residual confounding not excluded (Chang, 2020, PMID 32305207); six pooled cohorts of 2,382,712 people gave relative risks for new CKD or end-stage renal disease of 1.56 (1.39 to 1.75) in women and 2.06 (1.64 to 2.60) in men at systolic 140 or more against below 120 (Weldegiorgis, 2020, PMID 33238919). All are observational.

Veterans

Lohr (2015) followed 15,221 veterans aged 70 or older with eGFR above 60 in VA primary care in upstate New York: new CKD occurred in 16 percent over a median of 19 quarters, with a higher hazard at systolic 140 to 149 or more than at 130 to 139; the abstract gives no hazard ratios (PMID 25537459). In the Million Veteran Program, Akwo (2021) followed 139,685 veterans who all had hypertension: where pressure stayed at 140/90 or above on three drugs including a thiazide, or four or more drugs were used, end-stage kidney disease ran 4.7 per 1,000 person-years against 1.6 otherwise, and among African American veterans the APOL1-adjusted incidence rate ratio was 1.98 (95 percent confidence interval 1.66 to 2.35, from the results text) (PMID 34148359; figures from the full text in PubMed Central). That compares hypertensive veterans with each other, not with normal blood pressure. The cohort also took in veterans who entered with an eGFR of 30 to 59, its adjusted models accounted for baseline eGFR, and the authors cite earlier studies reporting a higher risk of treatment-resistant hypertension in people with CKD (from the full text).

The link runs both ways

Hsu's background states the problem: "because renal disease itself can raise blood pressure, some investigators argue that ESRD seen in patients with hypertension is due to underlying primary renal disease" (ESRD: end-stage renal disease). Staplin (2022) begins: "It is well established that decreased kidney function can increase blood pressure (BP), but it is unproven whether moderately elevated BP causes chronic kidney disease (CKD) or glomerular hyperfiltration." The genetic studies split: Yu (2020) found genetic support for higher kidney function lowering blood pressure, that is, for reduced kidney function raising it, and no significant effect of blood pressure on kidney function (PMID 32454124); Staplin, in 311,119 White British UK Biobank participants, found 37 percent higher odds of CKD per genetically predicted 10 mm Hg higher systolic (1.29 to 1.45; PMID 36082669); Zheng (2022) found a causal signal in Europeans and none in East Asians (PMID 34999880); and Nierenberg (2021) found no association with progression in 3,074 people who already had CKD (PMID 35369652).

Treatment trials

SPRINT (2021) randomly assigned 9,361 people at raised cardiovascular risk, without diabetes or prior stroke, to a systolic target below 120 or below 140. Among those without CKD at entry, an eGFR fall of 30 percent or more to below 60 was more likely with the lower target (hazard ratio 3.67, 2.62 to 5.26), which the investigators read as "consistent with a hemodynamic reduction in glomerular pressure"; among those with CKD at entry, the kidney composite did not differ significantly, with few events (PMID 34010531; kidney results and the quotation from the full text in PubMed Central). In 3,041 participants followed through health records, post-trial eGFR slopes did not differ (Drawz, 2024, PMID 37883184). Kidney benefit from the lower target was not demonstrated.

What this means for a claim

The research supports an association and does not settle how much of it is cause, or in which direction; no source we found measures what share of veterans' kidney disease began with hypertension. That makes the question fair for a physician to weigh in one file, against that veteran's own dates, results and other risks, but not enough to answer it for him. An opinion that says the science settles it overstates the science.

Hypertensive Nephrosclerosis: What the Label Can and Cannot Show

A chart can say hypertensive nephrosclerosis with no biopsy behind it. Checked against stricter tests, the label has matched in some groups and missed in others.

Three-panel diagram with no people, titled what the label hypertensive nephrosclerosis has matched when it was checked. Panel one is headed registry form against strict criteria, 607 people with kidney failure in a genetics study, Zarif 2000, and shows two bars: 37 percent named on the registry form, and 1.5 to 13.5 percent by strict clinical criteria, adjusted. Panel two is headed clinical criteria against biopsy, Norwegian patients referred for kidney biopsy, Øvrehus 2020, and shows three bars for patients who met the clinical criteria: 40 percent arterionephrosclerosis, 22 percent glomerulonephritis, 14 percent interstitial nephritis, with a note that other diagnoses make up the rest, and a line reading sensitivity 0.17, specificity 0.94. Panel three is headed a strictly selected group, AASK pilot, Fogo 1997, and reads: 38 of 39 biopsies showed arteriosclerosis and/or arteriolosclerosis. A band across the bottom reads: a matching lesion is consistent with the label but does not show what caused it; Hill 2008 calls correlations between hypertension and these lesions only moderate, in part because they are present to a greater or lesser degree in aging kidneys without high blood pressure. — Three checks of the label against stricter tests. In the Norwegian group the clinical criteria also missed 765 of the 918 cases that biopsy confirmed, and a matching lesion still does not show the cause.

Clinical criteria against biopsy, in Norway

Øvrehus (2020) studied 4,920 Norwegian CKD patients referred for biopsy from 1988 to 2012 whose presentation was "consistent with, but not primarily suspicious for," hypertensive nephrosclerosis. The clinical criteria tested were blood pressure above 140/90, urine protein below 0.5 g a day, no blood in the urine and no diabetes. Against biopsy they had a sensitivity of 0.17 and a specificity of 0.94, and that cuts both ways. Among patients who met them, biopsy showed arterionephrosclerosis in 40 percent, glomerulonephritis in 22 percent and interstitial nephritis in 14 percent. But the criteria picked out only 153 of the 918 patients whose biopsy showed arterionephrosclerosis; the authors write that a negative result "would not give a clinical meaningful decrease of the disease probability" and tie the low accuracy to "an atypical phenotype with proteinuria and hematuria", so in this group, failing the criteria did not rule the disease out. These figures describe a white, biopsy-referred group only: the authors say it "probably included more atypical cases than found in clinical practice", so the criteria may perform better in clinical practice, and that generalizing to other regions should be done "with caution (and for African Americans not at all)" (PMID 32154455; figures beyond the abstract from the full text in PubMed Central).

The same registry, an optimized test

Hallan (2021), from the same registry group and so not an independent check, put the current criteria at a sensitivity of 0.13 and a specificity of 0.94; an optimized algorithm reached only 0.19 and 0.96, with 40 percent of its positives having other, treatable diagnoses (PMID 32613703).

Registry forms against strict criteria

Zarif (2000) studied 607 people with kidney failure in a genetics study, 73 percent African American. The registry form named hypertensive nephrosclerosis in 37 percent; strict criteria gave an adjusted 1.5 to 13.5 percent. Of the patients who could not be phenotyped as hypertensive nephrosclerosis, 14 were misdiagnosed, 14 had a urine protein-to-creatinine ratio above 2.0, and "insufficient data were available in the remainder", so the low figure partly reflects what the records did not show. Dropping only the rule that hypertension came first moved one count from 4 of 100 to 44 of 100, so the order of onset, which records can document, carries weight. Only 4 were biopsied, 1 consistent with the label (PMID 11071968).

Gene sequencing in early-onset disease

At one French centre, exome sequencing of 128 patients labelled with hypertensive nephropathy beginning before 45 found a single-gene diagnosis in 19 (15 percent): 7 percent with African ancestry, 30 percent without. It does not carry over to veterans diagnosed older (Serre, 2024, PMID 38471460).

The counterweight: a strictly selected group

In the AASK pilot, 38 of 39 biopsies from strictly selected non-diabetic hypertensive African American patients, with GFR 25 to 70 and no marked proteinuria, showed arteriosclerosis and/or arteriolosclerosis. The lesions were "consistent with" the diagnosis; the small study did not test whether hypertension caused them (Fogo, 1997, PMID 8995739).

Age

Hill's 2008 review calls correlations between hypertension and these lesions "only moderate", in part because they are present "to a greater or lesser degree in the normotensive, aging kidney" (PMID 18408477). Asghar (2023) set age-based thresholds for scarring from normotensive living donors, 7.1-fold to 36-fold higher at 70 or older than at 18 to 29. In patients who had a kidney removed for a tumor or a native kidney biopsy for a clinical reason, the risk of progressive CKD (kidney failure or a 40 percent fall in eGFR) was higher only when the scarring was abnormal for age. The measure is scarring, not the vascular lesion (PMID 37254246).

APOL1 in veterans of African ancestry

Among 121,492 Million Veteran Program participants of African ancestry, 12.8 percent carried two high-risk APOL1 variants. In this cross-sectional analysis, among participants without diabetes, that genotype without the p.N264K variant went with higher odds of CKD (1.72, 1.60 to 1.85) and end-stage kidney disease (3.94, 3.52 to 4.41) than low-risk genotypes without p.N264K; an exploratory analysis of participants with diabetes found smaller odds ratios, 1.3 for CKD and 1.8 for end-stage kidney disease (Hung, 2023, PMID 37798822; comparison groups and the diabetes figures from the full text). An AASK case-control study sharing an author with the review below linked the variants to kidney disease (odds ratio 2.57, 95 percent confidence interval 1.85 to 3.55, from the full text, Table 4) (Lipkowitz, 2013, PMID 22832513). Freedman and Cohen's opinion review says APOL1 nephropathies "are not initiated by systemic hypertension" and can raise blood pressure secondarily, while keeping a category "potentially related to hypertension" (PMID 26553514); "only a minority" of two-variant carriers develop kidney disease (Daneshpajouhnejad, 2022, PMID 35217848). This concerns people of recent African ancestry with two variants; nothing here means a veteran needs genetic testing to file or to win, or says how a rater weighs a genetic result.

How VA's manual draws the line

The manual's terms are rating terms. Block 2.e ("Characteristics of Nephritis") lists, under "Characteristics of nephrosclerotic nephritis", first "Originating in hypertension or arteriosclerosis." Block 2.c says the 4.115 heart-and-nephritis rule "does not apply when evaluating other types of nephropathy". Block 2.h says "A nephropathy diagnosis is not dispositive for the purpose of making this distinction." and "It is impermissible to evaluate a type of nephritis specifically identified in the rating schedule, such as gouty nephropathy, by analogy in an effort to achieve a higher disability evaluation." (M21-1 Part V, Subpart iii, Chapter 7.)

Why this page will not suggest a different label

We will not suggest describing hypertensive kidney disease as nephropathy, or as anything else, to get around 38 CFR 4.115, nor the reverse; the characterization is the physician's clinical call, then the rater's. For VA's manual, diagnosed nephrosclerosis with impaired renal function, with service-connected hypertension and a claim filed, is enough to direct the grant; for medicine, the label is a judgement that can be wrong, and an examiner can dispute it. Both are true.

What Counts as Chronic Kidney Disease, Medically and for VA

Medicine and VA's rating schedule each have their own test.

Medically, KDIGO 2024 defines chronic kidney disease as abnormalities of kidney structure or function, present for at least 3 months, with implications for health. The criteria are a GFR below 60 or a marker of kidney damage: albuminuria at an albumin-to-creatinine ratio (ACR) of 30 mg/g or more, urine sediment abnormalities, persistent hematuria, electrolyte and other abnormalities due to tubular disorders, abnormalities on histology, structural abnormalities on imaging, or a history of kidney transplantation.

KDIGO 2024 GFR categories (Table 2)

KDIGO 2024 GFR categories (Table 2)
GFR category	GFR, ml/min per 1.73 m²	KDIGO description
G1	90 or more	Normal or high
G2	60 to 89	Mildly decreased
G3a	45 to 59	Mildly to moderately decreased
G3b	30 to 44	Moderately to severely decreased
G4	15 to 29	Severely decreased
G5	Below 15	Kidney failure

"In the absence of evidence of kidney damage, neither G1 nor G2 fulfills the criteria for CKD." (KDIGO 2024, Table 2.) Albuminuria has its own categories: A1 below 30 mg/g, A2 30 to 300 and A3 above 300.

KDIGO on chronicity and cause

KDIGO says not to assume chronicity from a single abnormal eGFR or ACR (Practice Point 1.1.3.2), to establish the cause from history, tests, imaging, and genetic and pathologic diagnosis (Practice Point 1.1.4.1), and suggests a biopsy "when clinically appropriate", graded 2D (Recommendation 1.1.4.1). It lists hypertension, diabetes, cardiovascular disease and prior acute kidney injury among CKD risk factors, an association rather than a finding about one person. The 2025 VA/DoD guideline reproduces these criteria and says: "These guidelines are not intended to represent VA or DOD policies."

VA's own duration test

Each renal row of 38 CFR 4.115a requires its finding "for at least 3 consecutive months during the past 12 months", apart from the 100 percent row's dialysis and transplant alternatives. VA's manual adds that an abnormal finding repeated 3 or more months later within 12 months documents chronicity, and that where clinical data are unavailable "a one-time finding may be used", with a second GFR reading scheduled three months later (Part V, Subpart iii, Chapter 7, Block 1.c). The table's Note accepts estimated GFR and creatinine-based approximations "when determined to be appropriate and calculated by a medical professional". And 4.115's "Albuminuria alone is not nephritis" is a rating statement about nephritis, not a clinical definition: a CKD diagnosis made on persistent albuminuria can meet KDIGO while no renal row above 0 percent applies.

How VA Rates a Kidney Grant Since November 14, 2021

Since November 14, 2021, renal dysfunction under 38 CFR 4.115a has been rated on GFR, dialysis and transplant status.

Renal dysfunction, 38 CFR 4.115a (rows as printed)

Renal dysfunction, 38 CFR 4.115a (rows as printed)
Row text	Rating
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	100 percent
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	80 percent
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	60 percent
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	30 percent
GFR from 60 to 89 mL/min/1.73 m² and either recurrent red blood cell (RBC) casts, white blood cell (WBC) casts, or granular casts for at least 3 consecutive months during the past 12 months; or GFR from 60 to 89 mL/min/1.73 m² and structural kidney abnormalities (cystic, obstructive, or glomerular) for at least 3 consecutive months during the past 12 months; or GFR from 60 to 89 mL/min/1.73 m² and albumin/creatinine ratio (ACR) ≥30 mg/g for at least 3 consecutive months during the past 12 months	0 percent

"Note: GFR, estimated GFR (eGFR), and creatinine-based approximations of GFR will be accepted for evaluation purposes under this section when determined to be appropriate and calculated by a medical professional." (38 CFR 4.115a.) The renal rows are 100, 80, 60, 30 and 0 percent; there is no 10 or 20 percent renal row.

In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met.
38 CFR 4.31, Zero percent evaluations

Where diagnostic codes refer the decision maker to these specific areas of dysfunction, only the predominant area of dysfunction shall be considered for rating purposes.
38 CFR 4.115a, preamble

Nephrosclerosis, arteriolar: 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.
38 CFR 4.115b, DC 7507

Apart from the 100 percent row's dialysis and transplant alternatives, no renal row above 0 percent applies at a GFR of 60 or more. DC 7502, "Nephritis, chronic", DC 7530, "Chronic renal disease requiring regular dialysis", DC 7534, "Atherosclerotic renal disease (renal artery stenosis, atheroembolic renal disease, or large vessel disease, unspecified)", and DC 7541, "Renal involvement in diabetes mellitus type I or II", each "Rate as renal dysfunction." DC 7500, "Kidney, removal of one", has a 30 percent minimum. The rater chooses the code from the whole record.

DC 7530 is for disease "requiring regular dialysis", yet A24001987 (2024) named it in its body, and DC 7534 in its conclusion, for a veteran never on dialysis, and A23032816 (2023) rated non-dialysis kidney disease under it. We build no advice on that coding (both binding only with regard to the specific case decided, 38 CFR 20.1303).

If you have read older descriptions

The eCFR's 4.115a texts for November 13 and 14, 2021 differ; the amendment, 86 FR 54085 (September 30, 2021), is cited through the eCFR because the Federal Register site was not reachable from our tools. VA's manual: "Prior to the revision of 38 CFR 4.115a effective on November 14, 2021, hypertension was included among the criteria for evaluation of renal dysfunction." (Chapter 7, Block 2.c, Note.) A Board percentage from before then is no expectation now, and we do not reprint the old criteria.

How DC 7101 rates the blood pressure itself is on our high blood pressure page.

Will a Kidney Grant Add to Your Hypertension Rating?

Before dialysis, the rules point to one evaluation, not two, for arteriolar nephrosclerosis and for kidney disease that is a form of nephritis, unless an absent kidney is the only kidney disability; VA's manual says other types of nephropathy may be evaluated separately. Where there is one evaluation, it can stay where the hypertension rating is or come out higher, and no one can promise which; under DC 7507, quoted below, it takes the renal row or a cardiovascular rating elevated to the next higher evaluation.

The nephrosclerotic type, originating in hypertension or arteriosclerosis, develops slowly, with minimum laboratory findings, and is associated with natural progress. 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. If, however, absence of a kidney is the sole renal disability, even if removal was required because of nephritis, the absent kidney and any hypertension or heart disease will be separately rated. Also, in the event that chronic renal disease has progressed to the point where regular dialysis is required, any coexisting hypertension or heart disease will be separately rated.
38 CFR 4.115, sentences three to six

38 CFR 4.115 prohibits assignment of separate evaluations for renal dysfunction from nephritis and for hypertension except where
the sole renal disability is absence of a kidney (even if that was due to nephritis), or
nephritis has progressed to the point where regular dialysis is required.
M21-1 Part V, Subpart iii, Chapter 5, Block 3.j (VA manual practice)

Nephrosclerosis, arteriolar: 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.
38 CFR 4.115b, DC 7507

4.115's bar names heart disease and nephritis; hypertension appears only in its type sentence and the exceptions. Barring a separate hypertension evaluation beside renal dysfunction from nephritis before dialysis is how VA's manual applies 4.115, so this page labels it VA manual practice. DC 7507's elevation is rule text, which VA's manual repeats (Chapter 7, Block 2.f); we found no procedure or decision applying it beside an existing DC 7101 evaluation, and compute no elevated percentage.

Diagram with no people, titled before dialysis: one evaluation for nephrosclerosis and hypertension. On the left, a box reads service-connected hypertension, Diagnostic Code 7101. Beside it, a box reads kidney disease granted secondary to it, rated as arteriolar nephrosclerosis, Diagnostic Code 7507. Lines from both boxes join into one wide box below, which reads: one evaluation, rated by the predominant symptoms as renal dysfunction, hypertension or heart disease; if rated under the cardiovascular schedule, the rule text elevates it to the next higher evaluation; which one, and under which code, is the rater's decision. Under that box, two smaller boxes sit side by side with no arrow between them and neither placed above the other: the left reads as renal dysfunction: the renal row applies; the right reads can be higher than the hypertension rating alone. A band across the bottom reads: 38 CFR 4.115, separate ratings are not to be assigned for disability from disease of the heart and any form of nephritis; for renal dysfunction from nephritis and hypertension, the same limit is VA manual practice, M21-1 Part V, Subpart iii, Chapter 5, Block 3.j. A footer reads: separate ratings apply where an absent kidney is the only kidney disability, or once regular dialysis is required; other types of nephropathy may be evaluated separately, M21-1 Part V, Subpart iii, Chapter 7, Block 2.c. — Before dialysis, one evaluation by predominant symptoms, what that leaves open, and the exceptions in 38 CFR 4.115 that allow separate ratings.

VA's manual examples, M21-1 Part V, Subpart iii, Chapter 7, Block 2.g (codes and percentages only)

VA's manual examples, M21-1 Part V, Subpart iii, Chapter 7, Block 2.g (codes and percentages only)
Manual example	Separate evaluations
Example 1: DC 7101 Hypertension 10 with DC 7502 Nephritis 60	not permitted
Example 2: DC 7500 Kidney, removal of one, history of glomerulonephritis 30 with DC 7101 Hypertension 20	allowed, because absence of the kidney is the sole renal disability
Example 3: DC 7530 Nephritis 100 with DC 7101 Hypertension 10	allowed if the 100 percent evaluation is based on the requirement for dialysis

The open question: is this kidney disease a form of nephritis?

The bar reaches "any form of nephritis". The manual lists, under the heading "Characteristics of nephrosclerotic nephritis", first "Originating in hypertension or arteriosclerosis." (Chapter 7, Block 2.e) and says "Other types of nephropathy may be assigned separate evaluations for the renal impairment and heart disease and/or hypertension." (Block 2.c). Block 2.h adds: "A nephropathy diagnosis is not dispositive for the purpose of making this distinction." and "It is impermissible to evaluate a type of nephritis specifically identified in the rating schedule, such as gouty nephropathy, by analogy in an effort to achieve a higher disability evaluation."

Whether a veteran's kidney disease is a form of nephritis, which brings in 4.115, or another type of nephropathy, which the manual says may be evaluated separately, is decided from the medical evidence. This page sets out the texts, does not answer that question, and does not suggest describing the disease either way.

4.14 is a different rule

38 CFR 4.14 ends: "the evaluation of the same manifestation under different diagnoses are to be avoided." The 4.115a preamble considers "only the predominant area of dysfunction" and says "Distinct disabilities may be evaluated separately under this section, pursuant to § 4.14, if the symptoms do not overlap." 4.25(b) makes separate ratings the default but opens "Except as otherwise provided in this schedule", the hook for 4.115's bar. Today the renal rows measure GFR and DC 7101 measures blood pressure, so the single evaluation comes from 4.115 and manual practice, not 4.14; under the pre-2021 table, which used hypertension as a renal criterion, separate evaluations "would have been in violation of 38 CFR 4.14" (Chapter 7, Block 2.c, Note).

What the decisions show, in both directions

In 1802901 (2018) one evaluation of "30 percent, but no higher, for service-connected stage 2 renal disease with hypertension", under DC 7502, replaced the hypertension evaluation and exceeded it: 10 percent at the regional office, 20 as the Board set it for the earlier period. In 25000604 (2025), A24001987 (2024) and 18144383 (2018) the renal disease and the hypertension also sat in one rating, in 18144383 on the Board's own holding citing 4.115 and 4.14. All four used the pre-2021 table; we found no decision applying DC 7507 or rating kidney disease beside hypertension under today's table. The Board and regional offices have applied 4.115 this way although its bar names heart disease. Each decision is binding only with regard to the specific case decided (38 CFR 20.1303).

What a grant does even when the number does not move

Under 38 CFR 3.310(a) a secondary condition "shall be considered a part of the original condition." A later worsening is then a claim for an increase, and 3.400(o)(2) works on its own terms: "The provisions of this paragraph apply only when such reports relate to examination or treatment of a disability for which service-connection has previously been established." At regular dialysis the bar lifts, and a kidney grant can support later claims, such as sleep apnea secondary to it, each with its own medical support.

When two ratings are allowed

"If, however, absence of a kidney is the sole renal disability, even if removal was required because of nephritis, the absent kidney and any hypertension or heart disease will be separately rated." And: "Also, in the event that chronic renal disease has progressed to the point where regular dialysis is required, any coexisting hypertension or heart disease will be separately rated." (38 CFR 4.115.) Examples 2 and 3 above show each one. VA's manual adds a third case, for kidney disease that is not a form of nephritis: other types of nephropathy may be evaluated separately (Chapter 7, Block 2.c, quoted above).

DC 7101, 38 CFR 4.104 (rows as printed, for reference)

DC 7101, 38 CFR 4.104 (rows as printed, for reference)
Row text	Rating
Diastolic pressure predominantly 130 or more	60 percent
Diastolic pressure predominantly 120 or more	40 percent
Diastolic pressure predominantly 110 or more, or; systolic pressure predominantly 200 or more	20 percent
Diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control	10 percent

DC 7101 prints no 0 percent row; under 38 CFR 4.31 a 0 percent evaluation is assigned when the requirements for a compensable evaluation are not met. The medication route at 10 percent is for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control.

Effective Dates: How Far Back a Kidney Grant Can Reach

The start date decides the back pay, so this section keeps to the rule texts.

Except as otherwise provided, the effective date of an evaluation and award of pension, compensation, or dependency and indemnity compensation based on an initial claim or supplemental claim will be the date of receipt of the claim or the date entitlement arose, whichever is later.
38 CFR 3.400, general rule

The effective date of any grant of SC for arteriosclerotic manifestations secondary to hypertension is the date of claim or date entitlement arose, whichever is later.
M21-1 Part V, Subpart iii, Chapter 5, Block 3.h

Important:
Arteriosclerotic manifestations are not considered a worsening of hypertensive vascular disease (hypertension and isolated systolic hypertension) rated under 38 CFR 4.104, DC 7101. They are separate conditions which may be secondary to hypertensive vascular disease, but which nonetheless must be evaluated under rating criteria specific to their symptomology and the functions and anatomical localities they affect. Therefore, do not apply 38 CFR 3.400(o)(2) to allow an effective date prior to the date of claim, as this only applies to increases.
If awarding SC for a disability as within scope of the hypertension claim, apply an effective date based on the date of claim for hypertension.
M21-1 Part V, Subpart iii, Chapter 5, Block 3.h

The within-scope sentence came with the February 5, 2024 change, so it is current practice, not a rule for older decisions; the 3.400(o)(2) instruction is also in the November 15, 2021 version. That route is a records question first: dated kidney findings while the hypertension claim was pending, and an opinion that dates the onset where the record allows. The kidney claim is not an increase of the hypertension rating. Once the kidney disease is service connected, a later claim that it worsened is an increase, and 3.400(o)(2) applies to that claim on its own terms.

What the Board did with the dates

In 25000604 (2025) the Board granted November 1, 2009, holding that entitlement "was reasonably raised by the record during the pending claim for an increased rating for hypertension" (Bailey v. Wilkie) and that "the evidence is at least in approximate balance regarding whether the Veteran's chronic renal disease began in 2009". In 23061641 (2023), the same veteran's earlier remand, renal disease had been assessed in August 2012 while the hypertension claim was pending. Both are binding only with regard to the specific case decided (38 CFR 20.1303).

In A25035038 (2025) the Board granted August 10, 2022. It put the earliest possible date at "June 29, 2022, the date VA received the Veteran's intent to file form. 38 C.F.R. § 3.155(b)" (the Board's words; we did not read 3.155), but held that a secondary grant "can be no earlier than the effective date of service connection for the primary disability", and the hypertension dated from August 10, 2022. It adopted the date the veteran's representative argued. The decision is binding only with regard to the specific case decided (38 CFR 20.1303).

Agent Orange, Other Presumptions and Chained Claims

However the hypertension was won, a secondary kidney claim rests on it.

Through the Agent Orange presumption for hypertension

The statute, 38 U.S.C. 1116(a)(2)(M), lists "Hypertension." for veterans with "covered service", which 1116(d) defines as service in the Republic of Vietnam from January 9, 1962 to May 7, 1975; at a United States or Royal Thai base in Thailand from January 9, 1962 to June 30, 1976; and in Laos, in Cambodia at Mimot or Krek, on Guam or American Samoa or in their waters, or on Johnston Atoll or a ship that called there, each for its stated period. Two companion sections extend the same list of diseases, hypertension included: 38 U.S.C. 1116A to service offshore of the Republic of Vietnam from January 9, 1962 to May 7, 1975, not more than 12 nautical miles seaward of a line the statute sets, and 38 U.S.C. 1116B to service in or near the Korean Demilitarized Zone from September 1, 1967 to August 31, 1971.

The PACT Act's section 404(d)(2), printed as a note to the statute, says the amendment took effect on enactment, August 10, 2022, and applies "On the date of the enactment" to claimants for dependency and indemnity compensation and to veterans VA determines are "terminally ill", "homeless", "under extreme financial hardship", "more than 85 years old" or "capable of demonstrating other sufficient cause", and "On October 1, 2026, for everyone not described in subparagraph (A)." Its retroactivity clause reads: "Notwithstanding any Federal court decisions or settlements in effect on the day before the date of the enactment of this Act, the Secretary of Veterans Affairs shall award retroactive claims for a condition under section 1116(a)(2)(M) of title 38, United States Code, as added by subsection (c) of this section, only to claimants for dependency and indemnity compensation under chapter 13 of such title described in subparagraph (A)(i) of this paragraph." VA's manual, as its own practice, lists August 10, 2022 as the date hypertension "became subject to presumptive SC based on herbicide exposure" and, for retroactive payment, points to 38 CFR 3.114(a) (M21-1 Part VIII, Subpart i, Chapter 1, Section C, Block 1.f). Under 3.114(a) the criteria must have been met on that date and continuously until the claim; a request received within 1 year of that date can reach back to it, and one received later can reach back no more than 1 year before the request.

38 CFR 3.309(e), at the eCFR issue of August 27, 2026, lists 14 diseases and no hypertension, kidney disease or nephritis; its Note 2 excludes hypertension from ischemic heart disease. The presumption's source is the statute. In A25005255 (2025) the Board said hypertension "is not a listed condition" there and granted it on a direct herbicide basis, "without application of presumptive service connection pursuant to the PACT Act"; the February 2024 VA hypertension examination gave no etiology opinion, and the Board relied on the National Academies' November 2018 move of hypertension to the category of "sufficient" evidence of an association. 25000681 (2025) granted hypertension "on a facts-found basis, for purposes of accrued benefits" after the veteran's death, for the period before the PACT Act, with a VA examiner's April 2024 advisory opinion in favor. Both are binding only with regard to the specific case decided (38 CFR 20.1303).

Kidney disease is on neither list. In 23005461 (2023), entered below, the Board could not grant kidney disease secondary to hypertension that was not service connected. Once the hypertension is granted, the kidney claim runs under 38 CFR 3.310; in A25035038 the Board held that veteran's kidney grant could be dated no earlier than his hypertension's service connection. These decisions are binding only with regard to the specific case decided (38 CFR 20.1303).

The chronic-disease presumption

38 CFR 3.309(a) lists "Cardiovascular-renal disease, including hypertension." with this parenthetical: "(This term applies to combination involvement of the type of arteriosclerosis, nephritis, and organic heart disease, and since hypertension is an early symptom long preceding the development of those diseases in their more obvious forms, a disabling hypertension within the 1-year period will be given the same benefit of service connection as any of the chronic diseases listed.)" This is the regulation's reason for a presumption, not a finding about any veteran's kidneys. It also lists "Nephritis." Such a claim is direct, not secondary: under 3.307(a)(3) the disease must be "manifest to a degree of 10 percent or more within 1 year" of separation, and 3.307(b) excepts intercurrent causes such as "active nephritis or acute endocarditis due to intercurrent infection". The renal table has no 10 percent row, and we do not work out how the window applies to it.

Former prisoners of war

For any former prisoner of war, 38 CFR 3.309(c)(1) presumes "Atherosclerotic heart disease or hypertensive vascular disease (including hypertensive heart disease) and their complications (including myocardial infarction, congestive heart failure, arrhythmia)." Whether 'complications' reaches nephrosclerosis is not stated in the regulation or in the manual section we read; we make no claim either way.

Chained claims through PTSD or sleep apnea

A kidney claim can end a chain, PTSD or sleep apnea to hypertension to kidney disease, each link with its own support; under the manual's causation block, quoted above, the hypertension need not be service connected when the kidney disease begins. 18142125 (2018) granted both links in one decision; 23005461 (2023) could not grant the kidney link without service-connected hypertension. Both are binding only with regard to the specific case decided (38 CFR 20.1303).

Through heart disease

In A22025743 (2022) a VA examiner found the kidney disease less likely due to hypertension but listed coronary artery disease as a risk factor. The Board granted coronary artery disease secondary to hypertension on a private physician assistant's opinion, and the kidney disease secondary to it. The decision does not address rating, and it is binding only with regard to the specific case decided (38 CFR 20.1303). On the regulation's own text, not the decision's, 4.115's heart-and-nephritis sentence would bear on rating a veteran in this position if the kidney disease is a form of nephritis, the open question above.

When diabetes is the cause on the record

DC 7541, "Renal involvement in diabetes mellitus type I or II", reads "Rate as renal dysfunction." The manual adds: "Important: When the renal impairment is a form of nephritis, 38 CFR 4.115 applies as discussed in M21-1, Part V, Subpart iii, 7.2.f." (Chapter 7, Block 2.b). In 18146719 (2018) a VA opinion resting on biopsy-proven diabetic nephropathy defeated the hypertension theory, which only the veteran's own statement supported; in 18144383 (2018), under the table in force before November 14, 2021, diabetic kidney disease and hypertension stayed in one rating (both binding only with regard to the specific case decided, 38 CFR 20.1303). For today's table, VA's manual says 4.115 applies where the renal impairment is a form of nephritis and that other types of nephropathy may be evaluated separately (Chapter 7, Blocks 2.b and 2.c); this page does not say which a given diabetic kidney disease is.

What a kidney grant can lead to

A service-connected kidney disease can support later claims, such as sleep apnea secondary to it, or anemia, each needing its own medical support and its own decision.

The first link of a PTSD chain has its own guide: hypertension secondary to PTSD.

So does the sleep apnea version: hypertension secondary to sleep apnea.

And once the kidney disease is service connected: sleep apnea secondary to kidney disease.

What Board Decisions on Kidney Disease and Hypertension Show

We opened 45 Board decision files, read each ORDER block, and rely on the 17 decisions this page cites: 13 below, A25005255, 25000681 and A22025743 in the routes section, and A23032816 in the rating section. The Board's own search was not reachable from our research tools, so the set came from web searches; the newest decision found is from April 2025. Read the lists as examples, never as rates. None of the 2023 to 2025 decisions we found grants or denies service connection for chronic kidney disease secondary to hypertension on the merits. Of those cited on this page, the ones that take up kidney disease and hypertension together are remands, effective-date decisions and a rating decision; the rest decide hypertension with no kidney issue, a polycystic kidney disease claim on service and herbicide exposure, or a kidney rating after a renal infarct. None we found applies DC 7507, or rates kidney disease beside hypertension under the table in force since November 14, 2021.

Under 38 CFR 20.1303, "Although the Board strives for consistency in issuing its decisions, previously issued Board decisions will be considered binding only with regard to the specific case decided." Each entry below is described only for the issue it decided.

Service connection granted

Citation Nr 22003375 (decided January 24, 2022)

Granted: service connection only, for "chronic kidney disease, including hypertensive nephropathy and hypertensive nephrosclerosis".

A March 2018 "private medical opinion", in the Board's words, was one of the four supports it named. A June 2017 VA questionnaire citing, in the Board's paraphrase, "multiple risk factors, especially his age" "lacks significant probative value" "given the established diagnosis of chronic kidney disease", "including hypertensive nephropathy and hypertensive nephrosclerosis", and because the examiner "failed to discuss or reconcile the medical article cited" and "did not acknowledge that nephrosclerosis (hardening of the kidney) may be due to hypertension of the renal arterioles". On literature, the Board cited Wallin v. West and Sacks v. West: article or treatise evidence alone can meet the nexus requirement where, under a case's facts, it shows "at least plausible causality", but not "solely by generic information in a medical journal or treatise". The record showed a right nephrectomy for a Bosniak 4 renal tumor and, by July 2018, "stage 5 chronic kidney disease due to hypertension".

Why it matters. A late-stage example; 4.115 and DC 7507 are not discussed.