Liver Transplant

What this procedure is

A liver transplant is a surgery to replace a liver that is no longer working correctly with a healthy liver from another person. The liver is a vital organ that performs hundreds of tasks, such as filtering toxins from your blood and helping you digest food.

Most transplants use a whole liver from a donor who has recently passed away. In some cases, a healthy living person can donate a portion of their liver. This is possible because the liver is the only organ in the body that can regrow. After a living-donor transplant, both the donor's and the recipient's liver sections usually grow back to a full, healthy size within a few weeks.

What it treats or fixes

This procedure is typically used when the liver has reached "end-stage" failure. This means the organ is so damaged that it can no longer support the body's needs. A common reason for this is cirrhosis, a condition where healthy liver tissue is replaced by permanent scar tissue.

Your clinician may also consider a transplant for conditions such as:

• Acute liver failure: This happens when a previously healthy liver suffers sudden, severe damage.
• Liver cancer: Certain types of cancer that start in the liver may be treated with a transplant.
• Metabolic diseases: These are conditions people are born with that prevent the liver from processing chemicals correctly.

The primary goal of the surgery is to restore liver function and improve your overall quality of life.

How common it is & where it's done

Liver transplants are a common and well-established medical procedure. Every year, thousands of people in the United States receive a new liver. Because it is a major surgery, it requires a highly coordinated team of experts.

Transplants are performed at specialized hospitals known as transplant centers. These centers have dedicated teams that include surgeons, liver specialists (hepatologists), and transplant coordinators. Your care team will guide you through a detailed evaluation to see if a transplant is the best option for your specific health needs.

Recovery: What to Expect

After your surgery, you will likely spend a few days in the intensive care unit (ICU) so your team can monitor you closely. Most people stay in the hospital for one to two weeks. During this time, your clinician may help you start walking and moving around to help your body heal and prevent blood clots.

Once you go home, you will need frequent checkups and blood tests. These visits help your care team make sure your new liver is working well. You will also begin taking anti-rejection medications, also called immunosuppressants. These are medicines that keep your immune system from attacking the new liver. You will likely need to take these for the rest of your life.

Risks & Possible Complications

Like any major surgery, a liver transplant has risks. Your care team will watch you closely for signs of complications, such as:

• Organ rejection: This happens when your immune system sees the new liver as "foreign." It is a common issue and is often managed by adjusting your medications.
• Infection: Because anti-rejection medicines weaken your immune system, you may get sick more easily.
• Bile duct problems: These are issues with the tubes that carry digestive fluid out of the liver, such as leaks or narrowing.

It is important to contact your clinician if you notice a fever, yellowing of the skin or eyes (jaundice), or unusual pain. Catching these signs early helps your team manage them effectively.

Outcomes & Long-Term Results

Most people who receive a liver transplant go on to live full, active lives. Many are able to return to work, travel, and enjoy their favorite hobbies within a few months. Your long-term health depends on taking your medications exactly as prescribed and attending all follow-up appointments.

A healthy lifestyle is also key to a good outcome. Your clinician may suggest eating a balanced diet and getting regular exercise to keep your new liver and your heart healthy. Avoiding alcohol is essential to protect the health of your new organ.

Emotional Support & Reassurance

It is normal to feel a mix of emotions, including anxiety or stress, during the transplant process. You are not alone in this journey. Most transplant centers have social workers, counselors, and support groups to help you and your family navigate these feelings.

Your transplant team is your partner. They are there to answer your questions and provide the care you need. Focusing on small goals each day can help you feel more in control as you recover and embrace your new start.

Why doctors recommend it

A liver transplant is a surgery to replace a diseased liver with a healthy one from another person. Your clinician may recommend this procedure if your liver can no longer perform its vital jobs, such as filtering toxins from your blood or helping your body digest food. This state is often called liver failure.

The most common reason for a transplant is cirrhosis, which is a condition where the liver becomes heavily scarred and cannot function properly. Other reasons include:

• Liver cancer: Certain types of tumors that have not spread outside the liver.
• Biliary diseases: Conditions that damage the tubes (bile ducts) that carry fluid out of the liver.
• Genetic conditions: Rare disorders that cause the liver to build up harmful substances.

Doctors typically suggest a transplant when other treatments, such as medications or minor procedures, are no longer enough to keep you healthy.

Urgent vs planned treatment

The timing of a liver transplant depends on how quickly the liver is failing. Some people experience acute liver failure, which happens suddenly—sometimes in just a few days. This is often caused by a viral infection or a reaction to certain medications. In these cases, a transplant is considered an urgent, life-saving necessity.

Most transplants are planned for people with chronic liver failure. This is a slow process where the liver loses function over many years. If you have chronic failure, your care team will use a scoring system to track your health and place you on a national waiting list. The score helps ensure that the people who need a transplant most urgently are prioritized.

In some planned cases, a living donor transplant may be an option. This is a scheduled surgery where a healthy person donates a portion of their liver. Because the liver has the unique ability to regrow, both the donor's and the recipient's liver segments can grow back to a normal size within a few weeks.

Goals of treatment

The primary goal of a liver transplant is to extend your life and improve your overall health. When a transplant is successful, the new liver takes over all the essential functions that the old liver could no longer handle. This can resolve many of the uncomfortable symptoms of liver disease, such as extreme tiredness, yellowing of the skin (jaundice), and fluid buildup.

Success also means returning to a better quality of life. Most people find they have more energy and can return to their daily activities, work, and hobbies after they recover. While you will need to take daily medications for the rest of your life to help your body accept the new organ, the goal is for you to live a full and active life.

Who may benefit

A liver transplant is a surgery to replace a diseased liver with a healthy one from a donor. This procedure is often recommended for people with end-stage liver failure, which means the liver can no longer perform its vital jobs for the body. One common reason for a transplant is cirrhosis, a condition where the liver becomes heavily scarred and loses its ability to function properly.

Your clinician may also suggest a transplant if you have certain types of liver cancer that have not spread to other organs. In some cases, a transplant is needed for sudden (acute) liver failure, which can happen very quickly due to toxins or certain medications. Other conditions that may lead to a transplant include long-term diseases like chronic hepatitis or genetic disorders that damage the liver over time.

When it may not be the right option

While a transplant can be a life-saving treatment, it is not the right choice for everyone. Your care team will perform a detailed evaluation to see if the surgery is safe for you. For example, a transplant may not be recommended if you have a serious infection or a cancer that has spread outside of the liver.

Other factors that might make a transplant too risky include severe heart or lung disease that would make it difficult to survive a major surgery. Additionally, clinicians usually require that patients are able to follow a strict medical routine. This includes taking daily medications for the rest of your life to prevent rejection, which is when the body's immune system attacks the new organ. Active substance use, such as alcohol or drug abuse, may also prevent someone from being eligible for the procedure.

Questions to ask your care team

Deciding on a transplant is a major step, and it is helpful to bring a list of questions to your appointments. Your care team can help you understand the process and what to expect during the wait and recovery. You may want to ask:

• What is my MELD score (a system used to rank the urgency of a transplant), and how does it affect my place on the waiting list?
• Am I a candidate for a living donor transplant, where a healthy person donates a portion of their liver to me?
• What are the most common risks or complications I should be aware of?
• How long is the typical recovery time, and what kind of help will I need at home?
• What medications will I need to take after the surgery to keep the new liver healthy?

In the procedure room

When you enter the operating room, the surgical team will help you get settled on the procedure table. The room is kept very clean and cool to prevent infection. You will see various monitors and machines that the team uses to track your health throughout the surgery.

Nurses and specialists will place several intravenous (IV) lines in your veins. These tubes allow the team to give you fluids, nutrition, and medicine quickly. You may also have a catheter (a thin tube) placed to drain urine from your bladder during the long procedure.

High-level steps

The surgeon begins by making an incision (a surgical cut) across your upper abdomen. This allows the team to reach the liver and the surrounding blood vessels. The diseased liver is then carefully disconnected from the blood supply and removed from your body.

The healthy donor liver is placed into your abdomen. The surgeon then connects the new liver to your blood vessels and your bile ducts, which are the small tubes that carry digestive fluid to the intestines. Once the new liver is in place and blood is flowing through it, the surgeon will check for any leaks or bleeding before closing the incision with staples or stitches.

Anesthesia and pain control

You will be given general anesthesia, which is medicine that puts you into a deep sleep. This ensures you are comfortable and do not feel any pain or remember the surgery. An anesthesiologist—a doctor who specializes in managing pain and sedation—will stay by your side the entire time to monitor your comfort.

After the surgery, your clinician may use a combination of IV medicines and local numbing agents to help manage soreness. You may feel some pressure or numbness around the incision site as you wake up, which is a normal part of the healing process.

Monitoring and safety steps

Safety is the top priority during a transplant. The surgical team constantly checks your heart rate, blood pressure, and the amount of oxygen in your blood. They also perform frequent blood tests during the operation to monitor how your body is handling the new organ.

Before finishing the surgery, the team carefully inspects the connections to the new liver. They use specialized tools to ensure that blood is flowing properly into and out of the organ. This step helps confirm that the new liver is ready to begin working right away.

Immediately after the procedure

Once the surgery is finished, you will be moved to the Intensive Care Unit (ICU). You will likely have a breathing tube in your throat for a few hours or a day to help you breathe while the anesthesia wears off. You will also have several small tubes, called drains, near your incision to help remove extra fluid and prevent swelling.

In some situations, your clinician may decide to leave the surgical wound open for a short time or use sterile packing (special bandages). This is done to manage any natural swelling that occurs after a major operation. This approach allows the team to ensure everything is stable before the final stitches are placed.

Typical procedure length

A liver transplant is a very detailed and complex operation. On average, the procedure takes between 6 and 12 hours. However, the exact time can vary depending on your specific medical history and the type of transplant being performed.

Your family and loved ones will be kept informed by the hospital staff throughout the day. While the surgery is long, the team works steadily to ensure every step is completed with the highest level of care.

Common approaches (open vs minimally invasive)

For the person receiving a new liver, the surgery is almost always an "open" procedure. This is because the liver is a large organ, and the surgical team needs enough space to remove the diseased liver and place the new one safely. Your surgeon will make a large incision (cut) across your abdomen to reach the liver. The shape of this incision often looks like a hockey stick or a boomerang.

Minimally invasive surgery, which uses smaller cuts and cameras, is generally not used for the transplant recipient. However, if you have a living donor, the doctors may use minimally invasive techniques to remove the portion of the liver from the donor. This helps the donor recover faster, even though the recipient still requires the standard open surgery.

Partial vs total

Most liver transplants are "orthotopic." This means the surgeon removes your entire diseased liver and replaces it with a healthy one in the same spot. If the new organ comes from a deceased donor, you will typically receive a whole liver.

In cases of living-donor transplants, you will receive a portion (or segment) of a healthy liver rather than the whole organ. This is possible because the liver has the unique ability to regenerate. Within a few months, the partial liver grows to normal size in your body, and the donor's remaining liver grows back to its full size as well.

Revision or repeat procedures

In some cases, a transplanted liver may not work as well as expected, or complications may arise. Common issues can include bile duct leaks or the body attempting to reject the new organ. Doctors can often treat these problems with medication or minor procedures to place a tube (stent) in the bile duct.

If the new liver fails to function or if the original liver disease returns over time, your care team may evaluate you for a second transplant (re-transplantation). This is not always an option and depends heavily on your overall health and the availability of donor organs.

Tests and imaging that may be done

Before you can be placed on the waiting list or scheduled for surgery, your transplant team needs a complete picture of your health. This evaluation helps ensure your body is strong enough for the operation and that the new liver has the best chance of working well.

• Blood tests: These check your blood type to find a matching donor. They also measure how well your kidneys and liver are working and check for infections.
• Imaging scans: Doctors may use ultrasound, CT scans, or MRI to look at the size and shape of your liver and the blood vessels around it.
• Heart and lung tests: An electrocardiogram (EKG) or stress test checks your heart health, while other tests measure how well your lungs work.
• General health screenings: Depending on your age and gender, you may need routine cancer screenings, such as a colonoscopy, mammogram, or Pap smear.
• Psychological evaluation: You may meet with a counselor to discuss your support system and ensure you are ready for the emotional aspects of recovery.

Medication adjustments

Your transplant team will review every medicine, vitamin, and supplement you currently take. Some medications can affect bleeding or react with anesthesia, so your plan may need to change briefly before surgery.

• Prescription drugs: Do not stop taking your regular medicines unless your clinician specifically instructs you to do so.
• Blood thinners: If you take aspirin or other blood thinners, ask your doctor exactly when to stop them before the procedure.
• Supplements: You may be asked to stop taking herbal supplements or vitamins, as these can sometimes interfere with the surgery or recovery.
• Lifestyle changes: If you smoke or drink alcohol, your team will require you to stop to help ensure the transplant is successful.

Day-before and day-of instructions

If you are waiting for a deceased donor liver, you must be ready to go to the hospital immediately when you get the call. If you are receiving a living donor transplant, your surgery will be scheduled in advance. In either case, preparation is key.

• Packing: Have a "go-bag" ready with your ID, insurance card, a list of your medications, and personal items like glasses or a phone charger. Leave jewelry and valuables at home.
• Eating and drinking: You will likely be told not to eat or drink anything (including water) after midnight the night before surgery. This helps prevent complications during anesthesia.
• Hygiene: Your team may ask you to shower with a special antiseptic soap to reduce the risk of infection.
• Support: Bring a family member or friend who can listen to instructions and support you during the admission process.

General surgical risks

Liver transplant is a major surgery. Like any significant operation, there are standard risks involved. Your surgical team takes many precautions to lower the chance of these problems occurring.

• Bleeding: This may happen during or after the surgery.
• Infection: This can occur at the incision site or internally.
• Blood clots: Clots can sometimes form in the legs or lungs.
• Anesthesia risks: Some patients may have reactions to the medicine used to put them to sleep.

Procedure-specific complications

There are also risks specific to receiving a new liver. One of the most significant is rejection. This happens when the body’s immune system sees the new liver as foreign and tries to attack it. Rejection is common, but it does not mean the transplant has failed.

Other specific complications may include:

• Bile duct issues: The tubes that carry bile can sometimes leak or become blocked (strictures).
• Blood vessel problems: The artery supplying blood to the new liver may become blocked or narrowed.
• Graft failure: In some cases, the new liver does not start working immediately after surgery.

How complications are treated

Most complications can be managed effectively, especially when caught early. Your transplant team will monitor you very closely during your recovery to look for signs of infection or rejection.

Treatments often include:

• Medication adjustments: If rejection occurs, your doctor may change the dose or type of your anti-rejection medicines.
• Antibiotics: These are used to treat bacterial or viral infections.
• Minimally invasive procedures: If a bile duct becomes narrow, a doctor may place a small tube (stent) to keep it open without needing major surgery.

In rare cases where the new liver does not function well, a second transplant may be considered.

Pain control medicines

After your liver transplant, your care team will focus on keeping you comfortable so you can begin moving and healing. Initially, your clinician may provide pain relief through an IV (intravenous) line, which delivers medicine directly into a vein. As you recover and begin eating, they will likely switch you to oral pills.

Your medical team will carefully choose which medicines to use. They often avoid or limit certain over-the-counter pain relievers that could affect your new liver or kidneys. It is important to tell your clinicians about any allergies you have or if you have had bad reactions to pain medicine in the past.

Antibiotics

Because a liver transplant is a major surgery, your clinician may give you antibiotics to prevent infections. These medicines help protect your body while it is healing. Since you will also be taking medicines to prevent your body from rejecting the new liver (immunosuppressants), your immune system will be less able to fight off germs on its own.

In addition to standard antibiotics, your team might prescribe medicines to prevent viral or fungal infections. Your clinician will tailor this plan based on your specific health needs and the type of transplant you received. Always let your team know if you develop a fever or notice redness near your incision.

Blood thinners and clot prevention

Preventing blood clots is a vital part of recovery. Clots can sometimes form in the legs or in the blood vessels that lead to your new liver. To help prevent this, your clinician may use "blood thinners" (anticoagulants). These medicines help keep your blood flowing smoothly through the new organ.

Your care team may also use other methods to prevent clots, such as:

• Compression boots: Sleeves worn on the legs that gently squeeze to keep blood moving.
• Early walking: Getting out of bed as soon as it is safe to do so.
• Low-dose aspirin: A common medicine that helps prevent platelets from sticking together.

Because these medicines can increase the risk of bleeding, your team will monitor you very closely with regular blood tests. They will adjust the type and amount of medicine to find the safest balance for your body.

Emergency warning signs

After a liver transplant, serious complications are rare but require immediate attention. You should seek emergency care or call 911 if you experience life-threatening symptoms. While your transplant team will give you a specific list of emergencies, general warning signs often include:

• Trouble breathing: Shortness of breath or chest pain, which could signal a blood clot or heart issue.
• Severe bleeding: Bleeding from your incision that does not stop with pressure, or vomiting blood.
• Sudden confusion: A sudden change in mental state or seizures.

Call your surgeon or clinic if…

It is important to catch signs of infection or rejection early. Rejection happens when your immune system attacks the new liver. This is common and can often be treated with medicine if found quickly. Contact your transplant team right away if you notice:

• Fever: A temperature higher than 100.4°F (38°C), often accompanied by chills.
• Incision changes: Redness, swelling, warmth, or fluid draining from your surgery site.
• Digestive changes: Nausea, vomiting, diarrhea, or pain over the area where your liver is located.
• Signs of liver trouble: Yellowing of your skin or the whites of your eyes (jaundice), dark-colored urine, or clay-colored stools.
• Itching: Severe or persistent itching of the skin.

Expected vs concerning symptoms

Recovery takes time, and it can be hard to tell what is normal healing and what is a problem. Most people feel tired and sore, but certain changes warrant a call to your doctor.

• Pain: It is normal to have some soreness around the incision as you heal. However, you should call your doctor if you have severe pain over your liver or abdominal pain that gets worse instead of better.
• Fatigue: Feeling tired is expected after major surgery. However, if you feel sudden, extreme fatigue or "flu-like" body aches, this could be a sign of rejection.
• Swelling: Some mild swelling can happen, but sudden swelling in your belly or legs should be reported to your care team.

Non-surgical treatments

Before suggesting a transplant, your clinician may try other ways to manage liver disease. These treatments often focus on the cause of the damage. For example, medications can help treat viruses like hepatitis or manage autoimmune issues. Lifestyle changes, such as eating a healthy diet and avoiding alcohol, are also important steps to protect the liver from further harm.

Other non-surgical options focus on managing symptoms. Your care team might use medications to reduce fluid buildup in the body or to lower the risk of bleeding in the digestive tract. These steps aim to keep the liver working for as long as possible without the need for major surgery.

Watchful waiting

If your liver is still functioning well enough, your doctor may use a "watchful waiting" approach. This involves regular check-ups to monitor your health. During these visits, you will likely have blood tests and imaging scans to see if the liver disease is staying the same or getting worse.

Clinicians often use a tool called the MELD score (Model for End-Stage Liver Disease) to track your progress. This score uses blood test results to measure how well your liver is filtering waste. A stable score may mean you can continue with non-surgical care, while a rising score helps the team decide if it is time to consider a transplant.

When surgery becomes the best option

A liver transplant is usually the best option when the liver reaches "end-stage failure." This means the organ can no longer perform vital tasks, like cleaning toxins from your blood or making proteins that help your blood clot. When these functions fail, it can lead to serious health problems that medications alone cannot fix.

Your clinician may recommend a transplant if complications become frequent or life-threatening. These might include severe jaundice (yellowing of the skin and eyes), intense itching, or confusion caused by toxins reaching the brain. At this stage, the goal of surgery is to replace the failing organ with a healthy one to improve your long-term health and quality of life.

Hospital services that commonly perform this surgery

Liver transplants take place at specialized medical facilities called transplant centers. These centers have a multidisciplinary team, which is a group of experts from different medical fields who work together. This team usually includes hepatologists (liver specialists), transplant surgeons, and transplant coordinators who manage your care from start to finish.

Many of these hospitals have dedicated intensive care units (ICU) and recovery floors specifically for transplant patients. Some centers also have living-donor programs. This is where a healthy person donates a part of their liver to a patient. Because the liver has the unique ability to grow back, both the donor's and the recipient's liver pieces can grow into full-sized organs.

Patient resources and support services

Transplant centers offer many resources to help you manage the physical, emotional, and financial parts of the process. A transplant coordinator will guide you through the testing and waiting period. You may also work with a financial coordinator who helps you understand what your insurance covers and how to plan for medical costs.

Common support services include:

• Social workers: They provide emotional support and help with practical needs, like finding local lodging if you live far from the hospital.
• Support groups: These meetings allow you to connect with others who have gone through the transplant process.
• Nutritionists: These experts help you plan a diet that keeps you as healthy as possible before and after surgery.
• Psychologists or counselors: They help you and your family cope with the stress of a major medical procedure.

Questions for choosing where to have surgery

When deciding where to have your transplant, it is helpful to compare different centers. Your clinician may provide a list of recommended hospitals, but you can also look at public data regarding how many surgeries a center performs and how well their patients do afterward.

Consider asking these questions when choosing a facility:

• How many liver transplants does this center perform each year?
• What are the patient survival rates at this hospital compared to the national average?
• Does the center have a living-donor program if that is an option for me?
• Is this hospital in my insurance network?
• What kind of support is available for my caregivers and family members?
• How often will I need to return to this location for check-ups after I go home?

Conditions commonly treated by this procedure

A liver transplant is a surgery to replace a liver that no longer works correctly with a healthy liver from a donor. This procedure is often considered when other treatments are no longer enough to keep the liver functioning and healthy.

Clinicians may recommend a transplant for several conditions, including:

• Cirrhosis: This is a late stage of scarring of the liver. It can be caused by many things, such as chronic hepatitis, metabolic issues, or long-term alcohol use.
• Liver Cancer: Certain types of tumors that start in the liver may be treated with a transplant to remove the diseased organ and prevent the cancer from spreading.
• Bile Duct Diseases: Conditions like primary biliary cholangitis can damage the tubes that carry bile, a fluid that helps the body digest fats.
• Genetic Conditions: Some inherited disorders, such as Wilson’s disease or hemochromatosis, can cause substances to build up and damage the liver over time.
• Sudden Liver Failure: Also called acute liver failure, this happens very quickly and may be caused by certain medications, toxins, or sudden infections.

Related symptoms people search for

When the liver is not working properly, it can cause a variety of symptoms throughout the body. While these signs can be associated with many different health issues, they are often the reason a person begins a conversation with their medical team about liver health.

Common symptoms that people may search for include:

• Jaundice: This is a yellowing of the skin or the whites of the eyes. It happens when the liver cannot process a substance called bilirubin.
• Abdominal Swelling: Also known as ascites, this is a buildup of fluid in the belly area that can cause discomfort or a feeling of fullness.
• Confusion: When the liver cannot filter toxins from the blood, it can lead to mental changes, forgetfulness, or changes in sleep patterns.
• Itching: Severe, persistent itching of the skin (pruritus) is a common symptom when bile flow is blocked.
• Easy Bruising: Because the liver helps the blood to clot, a damaged liver may lead to bruising or bleeding more easily than usual.
• Fatigue: Feeling very tired or weak is one of the most common signs that the liver is struggling.

If you are experiencing these symptoms, your clinician can perform tests to find the cause and help you understand your care options.

Evidence overview

Liver transplantation is a well-established treatment for people with liver failure whose condition cannot be controlled by other treatments. It is widely recognized by medical organizations as a life-saving procedure for those with end-stage liver disease or acute liver failure. The goal of the surgery is to replace a diseased liver with a healthy one to extend life and improve overall health.

Medical evidence supports two main types of transplants: deceased donor transplants and living donor transplants. In a living donor transplant, a portion of a liver is removed from a healthy person and placed into the recipient. Studies show that the liver regenerates (grows back) to full size in both the donor and the recipient shortly after surgery. Specialized transplant centers follow strict protocols to ensure these complex procedures are performed safely.

Safety notes and individualized care

Because a liver transplant is a major surgery, it carries significant risks. Your transplant team will discuss potential complications with you, which may include bleeding, blood clots, infection, or issues with the bile ducts. A specific concern in transplantation is rejection, where the body’s immune system recognizes the new liver as foreign and tries to attack it.

To prevent rejection, you will need to take anti-rejection medications, also known as immunosuppressants, for the rest of your life. While these medicines are essential for keeping the new liver healthy, they can make you more susceptible to infections. Your clinician will help you manage the dosage to balance preventing rejection with minimizing side effects.

Safety also relies on a thorough evaluation process before surgery. You will undergo various tests—including blood work, heart exams, and psychological screenings—to ensure your body is strong enough for the procedure. After the transplant, care is highly individualized. You will have frequent follow-up appointments to monitor your recovery and liver function.

Sources used

The information presented here is based on patient education materials and clinical overviews from reputable academic medical centers and transplant programs in the United States. These sources reflect the current standard of care and medical consensus regarding liver transplantation procedures, risks, and recovery expectations.