This retrospective study was done to compare the infection-free and overall survival of first and subsequent tunneled cuffed hemodialysis catheters in children. Subsequent catheters were exchanged by two different methods (a) removal and replacement (R&R), or (b) wire-guided exchange (WGE) using the same tunnel and vessel. The study involved 59 children (27 male, 32 female; mean age 13.9 +/- 4.6 years) undergoing maintenance hemodialysis in a pediatric unit over a period of 60 months. From a total of 175 catheters (57 first catheters, 81 WGE, 37 R&R) and 38,888 catheter days, 74/175 (42%) catheters were exchanged because of catheter-related bacteremia (CRB) and 43/175 (25%) for malfunction or cuff extrusion. One-year survival rates for first and consecutive catheters was 26% and 21%, respectively. The overall survival of first catheters, and those exchanged by WGE and R&R for both infectious and non-infectious reasons, was not statistically different. However, infection-free survival of first catheters was significantly prolonged in comparison with that of subsequent catheters (P < 0.001). The infection-free survival and the overall survival were not affected by etiology of primary disease, gender, serum albumin, or hemoglobin. Overall catheter survival increased with age >10 years. There was a significant association between gram-negative and polymicrobial CRB and requirement for R&R (P < 0.02). Our findings suggest that WGE is safe in a clinically stable child if the tunnel and the exit site are not infected and has the potential benefit of preserving the vascular access site. The shorter infection-free survival in subsequent catheters suggests a cumulative disadvantage with prolonged catheter use.