Norris Jackson is something of a hero around Detroit. He was the first security guard at the Detroit Symphony Orchestra and remained their security guard for 34 years until he retired in 2023.
Retirement didn’t slow him down. His Motor City Rams just won the Player Football Association Midwest Championship against their crosstown rivals, the Detroit Ravens.
But that wasn’t the Norris Jackson I knew. I knew the patient with severe hypertension and advanced chronic kidney disease.
I met Norris in 2019 when he was admitted with a blood pressure of 204/102, a creatinine of 5 mg/dL, and a potassium of 6.2. His prior creatinine from a year earlier was 3.4 (his whole story hinges on this earlier creatinine). We diagnosed him with hypertensive emergency, with AKI as the end-organ damage. We stabilized his blood pressure, but the kidney function never improved. Using the 2009 CKD-Epi race based formula his GFR was 13 ml/min. Using the current race-free 2021 formula it was 12 ml/min.
It is always hard to start the CKD journey in Stage 5. We were going to have speed run the advanced CKD playbook. He followed up in my clinic a couple of weeks after discharge and his blood pressure was improved to the 160s systolic. We referred him to transplant and cardiology for transplant clearance.
He returned a month later and his blood pressure was in the 140s. Cardiology started their work-up by scheduling an echo and a stress test with nuclear imaging. We increased his torsemide to 100 mg daily.
By June we had his blood pressure down to 127/60 on torsemide 100, chlorthalidone 25, nifedipine 60, and hydralazine 50 bid.
His transplant quest had the usual problems of collecting reports from other hospitals systems, dealing with a positive TB skin test, and completing multiple tests and imaging requests.
We also started him on epoetin and regular iron infusions. It was a lot but Norris did it all. Then a year after I met him, COVID hit and if navigating the health system seemed difficult before hand, it became near impossible during the pandemic. There will never be a full accounting how much damage was done by interrupting and delaying the care of everyone in the medical system.
Jackson wasn’t fully listed for a kidney transplant until November of 2022.
While he was navigating the world of transplant we were simultaneously preparing him for dialysis. Every visit we did modality education and discussion. He decided on home therapy and we referred to our general surgeon, Dr Meguid, who has really taken a deep interest in PD and become a valued partner. In June of 2021, Norris received a PD catheter and he began dialysis the following September. We did the whole process as an outpatient.
So by UNOS rules, even though he wasn’t listed until 2022, his wait time was backdated to the start of dialysis, September 2021.
But something else happened in 2021. The nephrology community abandoned race in the calculation of eGFR. While this change helped Black patients going forward, it did nothing for people whose transplant evaluations had already been delayed by the old race-adjusted equation. So in January 2023, the Organ Procurement and Transplantation Network (OPTN) required transplant programs to review Black kidney transplant candidates and determine whether earlier creatinine values would have made them eligible for listing using the race-free equation.
Norris had exactly that creatinine from a year before he presented to my service. This creatinine of 3.4 gave him a GFR of 21 by the 2009 formula, but with the 2021 race-free eGFR it was 19 ml/min. Low enough for him to be eligible for transplant listing.
With the stroke of a pen, his wait time moved from late 2021 to early 2018. An additional three years. This was enough to thrust him near to the top of the list.
In September of 2024, Norris got his kidney and three days later he was home with a falling creatinine, feeling better than he had in years.
A lot of people worked hard to remove race from eGFR equations. It can feel like an abstract policy debate.
But sometimes it looks like this.