European Journal of Endocrinology, 2025, 193, C1–C3

[Link]
Advance access publication 8 September 2025
Unsolicited Commentary

Harmonization of dynamic endocrine function tests:

a nationwide project in the Netherlands
Karlijn Koops,1,2,3 Esther Donga,4 Iris Wentholt,5 Ayş e Y. Demir,6 Murat Kiliçarslan,7
Titia M. Vriesendorp,8 Peter H. Bisschop,2,9,10 Annemieke C. Heijboer,1,2,3,11

Downloaded from [Link] by Research 4 Life user on 06 October 2025

and Jacquelien J. Hillebrand2,3,*
1
Department of Laboratory Medicine, Endocrine Laboratory, Amsterdam UMC, Vrije Universiteit Amsterdam, Boelelaan 1117, 1081 HV
Amsterdam, The Netherlands
2
Amsterdam Gastroenterology, Endocrinology & Metabolism Research Institute, 1105 AZ Amsterdam, The Netherlands
3
Department of Laboratory Medicine, Endocrine Laboratory, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam,
The Netherlands
4
Department of Internal Medicine, Elisabeth TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC Tilburg, The Netherlands
5
Department of Internal Medicine, OLVG Hospital, Oosterpark 9, 1091 AC Amsterdam, The Netherlands
6
Department of Laboratory for Clinical Chemistry and Hematology, Meander Medical Centre, Maatweg 3, 3813 TZ Amersfoort, The Netherlands
7
Department of Internal Medicine, Red Cross Hospital, Vondellaan 13, 1942 LE Beverwijk, The Netherlands
8
Department of Internal Medicine, Isala Hospital, Dokter van Heesweg 2, 8025 AB Zwolle, The Netherlands
9
Amsterdam Movement Sciences Research Institute, 1105 AZ Amsterdam, The Netherlands
10
Department of Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The
Netherlands
11
Amsterdam Reproduction & Development Research Institute, 1105 AZ Amsterdam, The Netherlands
*Corresponding author: Department of Laboratory Medicine, Endocrine Laboratory, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ
Amsterdam, The Netherlands. Email: [Link]@[Link]
Keywords: harmonization, standardization, dynamic testing, endocrine protocols

Dynamic endocrine function tests are frequently used in the use of uniform cutoff values, ultimately improving confidence
diagnosis and follow-up of endocrine diseases. However, there in test results. This article outlines the Dutch harmonization
is considerable interhospital variation in how these tests are efforts and aims to inspire similar initiatives internationally
conducted. Variations may exist in pretest conditions (eg, fast­ to improve dynamic endocrine testing and patient care.
ing status, medication use), the execution of the test (eg, intra­ The Dutch Endocrine Association (NVE) assembled a com­
venous vs intramuscular administration), and analytical mittee consisting of expert (pediatric) endocrinologists and
methods (eg, immunoassays vs LC-MS/MS, or similar meth­ clinical chemists from both general and university hospitals.
ods with differing assay standardization). Importantly, inter­ The process comprised (1) aligning test conditions and the exe­
pretation of dynamic endocrine tests is often rigid and based cution of the tests, (2) investigating and promoting analytical
on outdated literature, obsolete analytical methods, and in­ standardization, and (3) unifying the interpretation of test re­
consistent preanalytical procedures. This variability limits sults. We started with a priority list of 17 dynamic endocrine
the interchangeability of dynamic endocrine test results across tests, but many followed during the project. For every test, ex­
medical centers. The lack of harmonization of dynamic endo­ isting test protocols from different medical centers and avail­
crine tests often leads to uncertainty when patients are referred able literature on the topic were collected. Key preanalytical
to another medical center, prompting unnecessary test repeti­ factors (Table 1) were outlined, and through thorough discus­
tion. This causes patient dissatisfaction, delay in diagnosis and sion and literature review, harmonized test protocols were
treatment, and increased healthcare costs. developed. These test protocols were then reviewed by inde­
Between 2016 and 2023, the Dutch Endocrine Society initi­ pendent national experts, made available online to all mem­
ated one of the first national efforts to harmonize dynamic bers of NVE for final comments, and published open access
endocrine testing. This was prompted by the introduction of on the NVE website ([Link]). The protocols included
the Roche Elecsys Cortisol II immunoassay, which led to a contact options to encourage feedback and support to facili­
20%-30% decrease in plasma cortisol levels compared to tate implementation. We have also started harmonizing pa­
the cortisol I assay,1-3 causing confusion in test interpretation. tient information leaflets and published these online.
It highlighted broader issues with (cortisol) assay standardiza­ The second step was the harmonization of the analytical
tion and the use of outdated cutoff values for tests. Uniform phase. In Dutch laboratories, most hormone analyses are per­
procedures and analyses could reduce uncertainty in test inter­ formed using CE-marked (automated) immunoassays from
pretation, avoid unnecessary repeated testing, and support the different in vitro diagnostics (IVD) companies or in-house

Received: July 24, 2025. Revised: July 28, 2025. Editorial Decision: July 30, 2025
© The Author(s) 2025. Published by Oxford University Press on behalf of European Society of Endocrinology. All rights reserved. For commercial re-use, please
contact reprints@[Link] for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the
Permissions link on the article page on our site—for further information please contact [Link]@[Link].
C2 European Journal of Endocrinology, 2025, Vol. 193, No. 3

Table 1. Key factors to consider during the harmonization process.

Phase Factors Explanation

Preanalytical: test Indications for testing Rationale and implications for performing the test
conditions Contra-indications For example, allergies, comorbidities
Fasting Yes or no; duration; specific restrictions
Patient medication (Dis)continuation of what medication; duration of discontinuation; alternatives
Other relevant factors For example, avoiding brushing teeth, drinking, smoking
Preanalytical: execution of Sample collection Sample type (see Matrix); collection materials; storage conditions; processing time
the test Test medication (administered Route (intravenous, intramuscular, oral); dosage; administration speed
during test)
Timing Test timing (morning, evening), administration timing of test medication, blood
sampling time points

Downloaded from [Link] by Research 4 Life user on 06 October 2025

Resting time before sampling Yes/no; duration
Patient position For example, supine or sitting position
Potential complications Expected effects; necessary precautions
Other relevant variables
Analytical Matrix Blood (plasma/serum), urine, saliva
Blood container anticoagulants For example, K2EDTA, lithium-heparin
Method Immunoassay, LC-MS/MS (commercial or in house developed test)
Post-analytical: Reference intervals Specific for age/gender/other; source (local/published/international)
interpretation of test Cutoff values/decision limits Absolute concentrations or changes over time (delta); source (local/published/
results international)

developed LC-MS/MS methods. The quality of the techniques communicated to clinical chemists, (pediatric) endocrinolo­
used may vary.4 Hormone measurements often lack standard­ gists, and nurses via national conferences, newsletters, publi­
ization, leading to non-comparable results across assays of dif­ cations, and surveys. Draft and final protocols were
ferent IVD companies. Since laboratories are often committed published on the NVE website with opportunities for feed­
to specific IVD platforms, universal assay use is impractical. back, and shared via websites of the participating Dutch
Ideally, IVD manufacturers should improve standardization, Society for Clinical Chemistry and (NVKC) and Dutch
as seen with Roche’s efforts for plasma cortisol, but despite Society for Pediatrics (NvK). Two national surveys monitored
continuous assay improvements by IVD companies, standard­ implementation. In 2021, 97% of medical centers were aware
ization challenges persist. In response to significant discrepan­ of the project, and 71% had started implementation. Main
cies in GH and IGF-1 assays, Dutch laboratories themselves barriers included time needed for protocol adjustments and
introduced a commutable consensus reference serum, permit­ lack of cutoff values for some tests. By 2023, 84% had imple­
ting correction of each immunoassay’s result to a common mented (part of) the protocols. One persistent challenge was
scale for GH and IGF-1 assays several years ago, improving the need for more supporting documentation. Therefore,
comparability in GH stimulation tests.5 FAQs and additional background information will be added
As part of this project, we assessed whether further stand­ to the online protocols.
ardizing plasma cortisol assays in Dutch laboratories could Now that most endocrine tests have been harmonized, the
improve dynamic endocrine test interpretation. Therefore, committee continues its work by updating existing protocols
cortisol was measured in multiple laboratories using 4 immu­ and developing new ones based on emerging scientific evi­
noassays and various LC-MS/MS methods and results were dence. One of the main challenges during this project was to
compared. Similar approaches are planned for aldosterone generate sufficient support across all medical centers.
and renin. For some hormone assays, new reference methods Without broad participation, the (partial) harmonization pro­
or national correction factors may further improve interlabor­ cess would risk further ambiguity rather than clarity. To en­
atory comparability. gage busy professionals, the long-term benefits, such as
When dynamic endocrine test conditions, protocols, and la­ reduced repeated testing and less time needed for drafting
boratory analyses are aligned between different medical cen­ and writing local protocols, were clearly communicated.
ters, harmonized cutoff values for dynamic endocrine tests Active promotion helped to emphasize the importance, and
can be established. In our project, harmonized cutoff values professionals were invited to contribute throughout the pro­
based on recent literature were implemented for several tests. cess. After implementation, the committee was expanded to
For example, for the clonidine stimulation test, a peak include representatives from all Dutch regions to ensure na­
harmonized GH concentration of 20 mU/L (with IGF-1 be­ tional commitment and long-term continuity.
tween 0 and −2 SD) was set as cutoff value for GH deficiency Another notable challenge was that harmonization of cer­
in children and for the metyrapone test, a 11-deoxycortisol tain test protocols had to be postponed due to concurrent clin­
concentration of >200 nmol/L (measured using LC-MS/MS) ical research trials. Furthermore, medicine shortages resulted
defined the threshold to exclude central adrenal insufficiency. in the inability to carry out certain tests. For example, shortage
The current harmonized approach lays the foundation for es­ of growth hormone-releasing hormone (GHRH) prevented
tablishing more nationwide cutoff values in the near future. the performance of the GHRH-arginine stimulation test.
From the outset, healthcare professionals were informed This led to a joint decision to propose the macimorelin test
about the variability in dynamic endocrine test protocols as an alternative test for growth hormone deficiency. The ma­
and the aim of harmonizing them. Broad support was consid­ cimorelin test has recently been added to the arsenal of
ered essential; therefore, the project was actively harmonized protocols.
Koops et al. C3

To conclude, we harmonized dynamic endocrine testing in editing [equal]), Murat Kiliçarslan (Conceptualization [equal],
the Netherlands. The protocols of all harmonized tests are Project administration [equal], Writing—review & editing
freely accessible to all practitioners nationwide. Although [supporting]), Titia M. Vriesendorp (Conceptualization
the harmonization process is still ongoing for some tests, this [equal], Writing—review & editing [supporting]), Peter
initiative has already improved efficiency for both patients H. Bisschop (Conceptualization [equal], Writing—review & ed­
and healthcare workers, by reducing unnecessary repetition iting [supporting]), Annemieke C. Heijboer (Conceptualization
of tests, simplifying result interpretation, and enabling the [equal], Writing—review & editing [equal]), and Jacquelien
use of uniform cutoff values without requiring center-specific J. Hillebrand (Conceptualization [equal], Funding acquisition
validation. While the harmonization process required an ini­ [lead], Methodology [equal], Project administration [equal],
tial investment of time and effort, it has proven to be a sustain­ Supervision [lead], Writing—original draft [equal], Writing—
able and valuable advancement in healthcare quality. We review & editing [equal])
recommend that healthcare professionals in other countries

Downloaded from [Link] by Research 4 Life user on 06 October 2025

Conflict of interest: None declared.
consider adopting a similar approach. This article may serve
as a reference for those undertaking comparable endeavors.
References
Acknowledgments
1. Kline GA, Buse J, Krause RD. Clinical implications for biochemical
We thank all healthcare professionals (clinical chemists, [pedi­ diagnostic thresholds of adrenal sufficiency using a highly specific
atric] endocrinologists) involved in the Dutch Endocrine cortisol immunoassay. Clin Biochem. 2017;50(9):475-480. https://
Society committee harmonizing dynamic testing for their valu­ [Link]/10.1016/[Link].2017.02.008
able contribution. AI tool Bing Copilot was used for shorten­ 2. Raverot V, Richet C, Morel Y, Raverot G, Borson-Chazot F.
ing the self-written text. Establishment of revised diagnostic cut-offs for adrenal laboratory
investigation using the new Roche Diagnostics Elecsys(®) Cortisol
II assay. Ann Endocrinol (Paris). 2016;77(5):620-622. [Link]
Funding org/10.1016/[Link].2016.05.002
This project was founded by the SKMS (Stichting 3. Grassi G, Morelli V, Ceriotti F, et al. Minding the gap between cor­
Kwaliteitsgelden Medisch Specialisten), grant 20190904, as tisol levels measured with second-generation assays and current diag­
nostic thresholds for the diagnosis of adrenal insufficiency: a
part of a broader effort to improve healthcare quality.
single-center experience. Hormones (Athens). 2020;19(3):425-431.
[Link]
Authors’ contributions 4. Hillebrand JJ, Wickenhagen WV, Heijboer AC. Improving science by
Karlijn Koops (Conceptualization [equal], Writing—original overcoming laboratory pitfalls with hormone measurements. J Clin
Endocrinol Metab. 2021;106(4):e1504-e1512. [Link]
draft [lead], Writing—review & editing [equal]), Esther
1210/clinem/dgaa923
Donga (Conceptualization [equal], Methodology [equal],
5. Ross HA, Lentjes EW, Menheere PM, Sweep CG; Endocrinology
Project administration [equal], Writing—review & editing Section and project group “Calibration 2000” of the SKML (Dutch
[equal]), Iris Wentholt (Conceptualization [equal], Funding Foundation for Quality Assessment in Clinical Laboratories).
acquisition [equal], Project administration [equal], Writing— Harmonization of growth hormone measurement results: the empir­
review & editing [equal]), Ayş e Y. Demir (Conceptualization ical approach. Clin Chim Acta. 2014;432:72-76. [Link]
[equal], Project administration [equal], Writing—review & 1016/[Link].2014.01.008