Real-time auralization is essential in virtual reality (VR), gaming, and architecture to enable an immersive audio-visual experience. The audio rendering must be congruent with visual feedback and respond with minimal delay to interactive events and user motion. The wave nature of sound poses critical challenges for plausible and immersive rendering and leads to enormous computational costs. These costs have only increased as virtual scenes have progressed away from enclosures toward complex, city-scale scenes that mix indoor and outdoor areas. However, hard real-time constraints must be obeyed while supporting numerous dynamic sound sources, frequently within a tightly limited computational budget. In this chapter, we provide a general overview of VR auralization systems and approaches that allow them to meet such stringent requirements. We focus on the mathematical foundation, perceptual considerations, and application-specific design requirements of practical systems today, and the future challenges that remain.