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Federal Register / Vol. 86, No. 187 / Thursday, September 30, 2021 / Rules and Regulations condition. Nonetheless, to ensure that the full range of relevant factors is adequately addressed, VA intends to establish a work group that will consider this issue at a future time.
Upon consideration and assessment of the work groups findings, VA will determine whether any additional amendments to the criteria are necessary; if so, they would be addressed in a future proposal. At this time, however, VA makes no changes based on this comment.
Another commenter expressed concern that the proposed rule did not make clear how the stages of chronic kidney disease CKD translate into the proposed rating criteria for renal disfunction. To be clear, VA proposed 100, 80, 60, 30, and 0 percent evaluations based on the stages of CKD
according to most current clinical guidelines, specifically, those of the National Kidney Foundation. See KDIGO at 8. The National Kidney Foundation guidelines distinguish between patients with kidney failure that is, GFR value <15 or dialysis, severely decreased kidney function GFR value 15 to 29, moderately to severely decreased kidney function GFR value 30 to 44, mildly to moderately decreased kidney function GFR value 45 to 59, and mildly decreased kidney function GFR value 60 to 89. Id. VAs proposed and now final rating criteria for renal dysfunction provide the same staging.
VA makes no changes based on this comment.
Another commenter welcomed VAs decision to base its disability evaluations for renal dysfunction on GFR and ACR laboratory findings, but was concerned that VA would use only these laboratory findings without taking into consideration other available evidence in the claims file. By law, VA
must consider all available evidence when determining whether the criteria for a particular a disability evaluation are met. 38 U.S.C. 5107b. As noted above, the GFR and ACR laboratory findings are an objective, accurate, and standard method for measuring renal dysfunction. Other relevant evidence in the claims file may implicate broader issues such as separate ratings or secondary service connection in a given case but, for the renal dysfunction rating specifically, the GFR and ACR
laboratory findings will govern. VA
makes no changes based on this comment.
The same commenter referenced a National Institutes of Health NIH study and alleged that renal dysfunction due to cold injury-related venous congestion cannot be rated based on GFR values.

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VA disagrees. The NIH report does not appear to make such an allegation;
indeed, it used GFR values to measure renal impairment. Mullens et al., Importance of Venous Congestion for Worsening of Renal Function in Advanced Decompensated Heart Failure, 537 J Am Coll Cardiol. 589
596 2009, available at https
pubmed.ncbi.nlm.nih.gov/19215833/
last visited May 19, 2020. According to the National Kidney Foundation, GFR is widely accepted as the best overall index of kidney function, KDIGO at 19, and the commenter does not appear to present an alternative measure. VA
makes no changes based on this comment.
The same commenter stated that basing the renal dysfunction rating on GFR values would exclude combat veterans with warm water immersion foot and paddy foot injuries from receiving VA disability compensation.
VA disagrees. To the extent that these injuries cause renal dysfunction, that dysfunction can be measured through GFR, and compensation can be provided based on the GFR value. VA makes no changes based on this comment.
The same commenter proposed the addition of new diagnostic codes for kidney dysfunction due to the warm water immersion foot and paddy foot injuries. VA appreciates this comment.
To ensure that the full range of relevant factors is adequately addressed, VA
intends to establish a work group that will consider this issue at a future time.
Upon consideration and assessment of the work groups findings, VA will determine whether any additional amendments to the criteria are necessary; if so, they would be addressed in a future proposal. At this time, however, VA makes no changes based on this comment.
Based on its internal review, however, VA makes one change to the general rating formula for renal dysfunction:
Adding the word eligible to the 100
percent evaluation that describes a kidney transplant recipient. This addition is made to ensure that all veterans with service-connected renal disease who are eligible to receive a kidney transplant will be entitled to a 100 percent evaluation as soon as they are deemed eligible for a kidney transplant, whether or not the transplant has been scheduled.
III. Comments Regarding Diagnostic Codes 7520 Through 7522
VA received several comments regarding the proposed changes to DCs 7520 through 7522, which address removal and deformity of the penis.

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One commenter asked VA to provide a rationale for its decision to remove the ability to rate the removal of the penis or glans as voiding dysfunction. Under most circumstances, the removal of the penis or glans does not result in voiding dysfunction. Most commonly, the loss of penis or glans will affect the ability to void while standing, which is not considered a compensable functional impairment under the criteria for voiding dysfunction in 38 CFR 4.115a.
Santucci et al., Penile Fracture and Trauma, Medscape updated 2019, https emedicine.medscape.com/
article/456305-overview last visited May 15, 2020. Furthermore, if, in the course of penis or glans surgical removal, there is associated urethral trauma resulting in voiding dysfunction, it should be separately rated under DC
7518, which addresses the stricture of the urethra. For these reasons, VA does not find it appropriate to direct rating personnel to reference the voiding dysfunction criteria of 38 CFR 4.115a when evaluating DCs 7520 and 7521.
VA therefore makes no changes based on this comment.
The same commenter recognized that erectile dysfunction alone may not equate to a reduction in earning capacity, but nevertheless asserted that VA should acknowledge that erectile dysfunction could lead to mental distress, such as depression and anxiety, and could impact a veterans ability to work. The commenter recommended that VA grant compensation for any secondary condition that is related to erectile dysfunction that causes a reduction in earning capacity. VA agrees with the commenters assessment that a mental disorder related to serviceconnected erectile dysfunction could warrant secondary service connection.
That mental disorder would require its own diagnosis, service connection, and a disability evaluation under 38 CFR
4.130, which governs ratings for mental disorders. VA already recognizes this concept in 38 CFR 3.310a, which directs that any disability which is proximately due to or the result of a service-connected disability shall be service connected. VA makes no changes based on this comment.
Another commenter disagreed with the proposed changes to DC 7522, which addresses erectile dysfunction and penile deformity. The commenter expressed concern that, by removing a compensable evaluation for penis deformity, VA will unreasonably deprive certain veterans of benefits, specifically, veterans with Peyronies disease. The commenter listed several signs and symptoms of Peyronies disease to include scar tissue, a
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